On July 10, 2022, a 40-year-old woman was admitted to the first affiliated hospital of Xi'an Jiaotong University due to intermittent fever for 2 months. Two months prior, her temperature fluctuated between 37.4 and 38.4 C in the afternoons, and chills and a dry cough accompanied this symptom. She had previously undergone examination and symptomatic treatment at a regional hospital. However, the treatment was ineffective. Furthermore, arthralgia and fatigue gradually appeared, with no chest pain and tightness, or rash. A month and a half prior, she was diagnosed with depression and treated with escitalopram oxalate, and magnesium valproate sustained-release tablets at a hospital. The symptoms slightly improved after treatment. Half a month prior, a B-ultrasonic examination showed lymphadenopathy throughout her body. Therefore, lymphoma was suspected but she did not get any treatment. One day prior to her arrival at our hospital, the patient suddenly developed hemoptysis of approximately 2 ml, which occurred four times for no reason. Past medical history revealed that she was diagnosed with chronic hepatitis B (CHB) in 2014 and developed cirrhosis a year later. Her CHB was well-controlled by a long-term oral antiviral treatment with Entecavir. In addition, she had lost 5 kg over the past 3 months.
On admission, her temperature was 37 C, respiratory rate was 19 breathe min-1, heart rate was 70 beat min-1, and blood pressure was 103/72 mmHg. The liver, spleen, lymph nodes of the neck, and axillary lymph nodes were enlarged with moderate activity and no tenderness. Rough breath sounds were detected in both lungs with dry and wet rales. All other clinical examination results were negative.
Laboratory examination revealed inflammation and liver dysfunction: red cell count, 4.27 x 1012/L (4-4.5 x 1012/L); white cell count, 4.87 x 109/L (5-12 x 109/L); platelet count 89 x 109/L (125-350 x 109/L), hypersensitive C-reactive protein 9.81 mg/L (0-3 mg/L), direct bilirubin 6.2 mumol/L (0-3.4 mumol/L), aspartate aminotransferase, 54 U/L (13-45 U/L); alanine aminotransferase, 20 U/L (7-40 U/L); alkaline phosphatase, 164 U/L (35-100 U/L); gamma-glutamyl transpeptidase, 82 U/L (7-45 U/L), albumin 33.8 g/L (40-55 g/L).
B-scan ultrasonography revealed bilateral cervical and axillary lymphadenopathies. Chest computed tomography (CT) revealed multiple pulmonary nodules in both lungs, with a small amount of pleural effusion (Figure 1) and enlarged lymph nodes in the bilateral axilla. To effectively confirm the nature of the lesion, we performed needle biopsies of pulmonary nodules and lymph nodes. The results implied an infectious disease, while the detection of T cells in tuberculosis infection was negative. Therefore, suspicions of tumors and tuberculosis were excluded.
Interestingly, we noticed that the patient came from Ningxia province, which is famous for animal husbandry. The patient reluctantly informed us that she raised cattle and had come into contact with neighboring sheep without vaccination. Consequently, Brucella infection was suspected. On the fourth day of admission, the serum agglutination test (SAT) result was 1:800, and the rose-bengal plate agglutination test (RBPT) result was positive. Furthermore, the blood culture for Brucella melitensis was positive on the tenth day after admission. Characteristic rod-shaped gram-negative bacteria could be observed under a microscope. Subsequently, the patient was definitively diagnosed with brucellosis.
Following the brucellosis diagnosis, she received antibiotic therapy with rifampicin (600 mg/dose, once a day) and doxycycline (100 mg/dose, twice a day) for 3 months from the fourth day of the course. Furthermore, due to the poor medical conditions of the patient's residence and excessive complications, including multipulmonary nodules, arthralgia, hepatosplenomegaly, and lymphadenopathy, moxifloxacin and ceftriaxone sodium were added from the sixth day of the course to prevent the possibility of developing drug-resistant brucellosis after discharge. During treatment, the patient and her family were highly cooperative. At discharge, fever, cough, arthralgia, depression and fatigue were relieved. After 2 months of follow-up, the fever and cough were gone, as was fatigue and arthralgia. In addition, the number of multiple nodules in both lungs was reduced. At the same time, liver function test results also indicated that the patient was recovering well. After 3 months of follow-up, her weight had increased and her depression symptoms were alleviated. The entire process of diagnosis, treatment, and outcomes is shown in Figure 2.