Acute Brucellosis with Myelodysplastic Syndrome Presenting as Pancytopenia and Fever of Unknown Origin

Objective: To report a rare case of brucellosis with myelodysplastic syndrome (MDS). Clinical Presentation and Intervention: A 70-year-old woman presented with pancytopenia and fever of unknown origin (FUO). The initial diagnosis was brucellosis; the woman was treated with doxycycline and rifampin against Brucella melitensis but was later diagnosed as suffering from MDS. She was immediately transferred to the Department of Hematology for further evaluation. Conclusion: This study highlights the rarity of brucellosis with MDS, and we recommend that brucellosis with MDS be considered in patients presenting with pancytopenia and FUO. Copyright © 2011 S. Karger AG, Basel Received: June 5, 2011 Accepted: September 21, 2011 Published online: December 1, 2011 Ji-Fang Sheng Department of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, School of Medicine Zhejiang University , Qingchun Road 79, Hangzhou 310003 (China) Tel. +86 571 8723 6759, E-Mail jifangsheng9200 @ 163.com © 2011 S. Karger AG, Basel 1011–7571/12/0212–0183$38.00/0 Accessible online at: www.karger.com/mpp D ow nl oa de d by : 54 .7 0. 40 .1 1 11 /7 /2 01 7 2: 08 :5 1 A M Li /Sheng /Tu /Bi /Shen /Sheng Med Princ Pract 2012;21:183–185 184 of taking toxic drugs or receiving immunosuppressive treatment. Detailed physical examination and extensive investigations for FUO were performed. Physical examination revealed that she was quite exhausted, with pallor of the skin and a high-grade fever (40.5 ° C). Her blood pressure was 112/64 mm Hg and the pulse rate was 65 beats/min. The laboratory examination results were as follows: complete blood count with white blood cells 2.0 ! 10 9 /l (50.5% lymphocytes, 15.8% monocytes, 33.7% neutrophils), hemoglobin 70 g/l, platelets 34 ! 10 9 /l; C-reactive protein 94.20 mg/l; erythrocyte sedimentation rate 101 mm/h; total protein 57.1 g/l; albumin 29.7 g/l; international normalized ratio 1.16; fibrinogen 5.1 g/l; partial thromboplastin time 44.2 s; prothrombin time 13.3 s. The liver and the renal function tests were normal. Antinuclear antibodies were within the normal range. Serological tests were negative for hepatitis B and C virus, Epstein-Barr virus, Coxsackie, echovirus, HIV, cytomegalovirus, Mycoplasma and Salmonella . In the local community hospital, the examination of pulmonary computed tomography (CT) revealed bronchitis with infection whereas blood cultures were negative in both the local and our hospital. In order to further investigate the cause of FUO and to exclude a neoplasm, fluorine-18 fluorodeoxyglucose positron emission tomography/CT was performed, the images of which suggested hypermetobolism in the spine, sternum and pelvis. Bone marrow examination revealed slight myelofibrosis with hypercellularity, and MDS was not excluded due to a slight increase in blasts. Although the antibiotic agents and transfusion were performed, the fever and pancytopenia were still out of control, with deteriorating condition. On day 15 after admission, the rose bengal plate agglutination test was positive, and the standard tube agglutination test for Brucella was positive at a titer of 1/160. The patient lived in a rural area and had a history of direct contact with her pet dog, which was a potential source of infection. Thus, brucellosis was diagnosed and then the patient was treated with oral rifampin 300 mg twice a day plus oral doxycycline 100 mg twice a day. Three weeks later, there was a slight clinical improvement. Due to the progressive pancytopenia (white blood cells 2.0 ! 10 9 /l, hemoglobin 53 g/l, platelets 8 ! 10 9 /l) and the persistence of high-grade fever, weight loss and paleness, a hematological malignancy was strongly suspected. Therefore, another bone marrow aspiration and biopsy were performed. A moderate myelofibrosis bone marrow coexisting with hypercellularity was noted, and an increase in the proportion of blasts (8.5%) with morphological abnormalities which suggested MDS with a subtype of refractory anemia with excess of blasts I (RAEB-I), according to the World Health Organization classification for MDS, was found [5] . Thus, MDS RAEB-I was diagnosed. Then she was transferred to a local hospital for further evaluation and management, and unfortunately she died due to persistent pancytopenia and high-grade fever.