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Vol. 95 (2001) 766^767

c 2001 Harcourt Publishers Ltd
doi:10.1053/rmed.2001.1075, available online at http://www.idealibrary.com on

CASE REPORT

Pneumonia as the sole presentation of brucellosis

F. ABU-EKTEISH AND K. KAKISH

Department of Paediatrics, Jordan University of Science and Technology, Irbid, Jordan

INTRODUCTION
Brucellosis remains a world-wide public health problem
(1). Although it has disappeared in many developed coun-
tries, it is still common in the Mediterranean and Middle
Eastern countries (2,3), including Jordan. The disease af-
fects various parts of the body with wide clinical mani-
festations. Pulmonary involvement in brucellosis is
infrequent (4,5), however we report a 4 -year-old boy
who presented with fever and cough only, which proved
to be due to brucellosis. However, to our knowledge
there is no description of similar case in the literature.

CASE REPORT FIG. 1. Right upper lobe consolidation.

A 4 -year-old boy was admitted to hospital due to history
of fever and productive cough for 4 days. There was no
and widal titre. All these tests were within normal limits.
history of joint pain, loss of weight, backache, fatigue or
Blood culture was done once before antibiotics were
abdominal symptoms, and no de¢nite history of raw milk
started and repeated again later, using an automated
ingestion. Physical examination of the child on admission
Bact/Alert system. Brucella serum agglutination titre,
revealed an ill-looking child, with a temperature of
repeated twice, was 51: 20, using the standard tube-ag-
39?58C rectally, a respiratory rate of 25 min71, and a
glutination technique. The antibiotic was changed to in-
heart rate of 110 min71. Chest examination revealed
travenous vancomycin and augmentin. The patient
crackles on auscutation over the right upper zone of
continued to have spikes of fever for another week de-
the lung. Other physical ¢ndings were normal.
spite the new antibiotics regimen. Chest radiography re-
Laboratory ¢nding included blood leukocytes of
peated for a third time showed the same initial ¢ndings.
9600 mm73 with a di¡erential count of 62% neutrophils,
Brucella serum agglutination test titre was repeated and
35% lymphocytes and 3% monocytes.Chest radiography
showed 1: 320 for Brucella melitensis. The antibiotic was
showed right upper consolidation (Fig.1). He was started
shifted to oral co-trimoxazole and gentamicin intramus-
on intravenous ceftriaxone and azithromycin orally. The
cularly.Fever disappeared within 48 h of the new antibio-
child showed no response after 4 days of therapy and
tics and cough improved dramatically. Chest X-ray was
continued to have spikes of high fever up to 40?38C rect-
normal after 3 weeks of treatment of brucellosis.
ally with cough.Repeated physical examination and chest
X-ray con¢rmed the previous ¢ndings. The following la-
boratory investigations were carried out: complete
DISCUSSION
blood count, blood culture, urine culture serum electro-
lytes level, kidney function, liver function, Mantout test Although inhalation is a recognized route of acquiring
brucellosis (6), pulmonary manifestations remain uncom-
Received 7 December 2000 and accepted 6 March 2001.
mon (4,5). The following pulmonary manifestations of
Correspondence should be addressed to: Dr Faisal Abu-Ekteish, P.O.
Box 3030, Paediatric Department, Faculty of Medicine, Jordan brucellosis have been reported: bronchitis, bronchop-
University of Science and Technology, Irbid, Jordan. neumonia, pleural e¡usion, lung abscess, pulmonary no-
Fax:+962-2-7102149; E-mail: faisal@just.edu.jo dules and hilar lymphadenopathy (4,9).
CASE REPORT
In a prospective study of 400 adults by Lulu et al. (5),
respiratory symptoms including cough and dyspnoa with
normal chest radiography were present in 16% of cases.
Pulmonary complications in the form of pleural e¡u-
sion and pneumonitis were present in 1% of cases. Pul-
monary involvement in children seems more unusual,
with only four out of 1300 children with brucellosis re-
ported from Kuwait having pulmonary disease (4,10).
Our patient presented with fever and productive cough
only with no other signs or symptoms, which makes the
diagnosis of brucellosis a remote possibility initially. The
lack of response of the patient to a multiple antibiotics
regimen and persistence of high fever with right upper
lobe consolidation make unusual infection a possibility.
The standard tube-agglutination technique was used in
our laboratory to con¢rm the diagnosis. The serum ag-
glutination titre was 1: 320 which was signi¢cant because
the initial two tests were negative.This method has been
extensively evaluated, yielding the highest degree of re-
producibility and accuracy (11). However, very often
false-positive agglutination reactions exist due to cross-
reactivity with Francisella tularensis,Vibrio cholera orYersi-
nia enterocolitica (12), but the patient had no other symp-
toms consistent with the previous diagnosis. Lubani et al.
(4) analysed1500 patients (adults and children) and found
four children with pulmonary involvement and only one
of them (an 8 -year-old) with consolidation. To our
knowledge this is the youngest child presenting with
pneumonitic consolidation as the only manifestation of
brucellosis.
767
We conclude that brucellosis should be added to the
list of causes of pneumonia which is resistant to di¡erent
antibiotics, even in the absence of other associated
symptoms of brucellosis.
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