Indian Journal of Dermatology
  Publication of IADVL, WB
  Official organ of AADV
Indexed with Science Citation Index (E) , Web of Science and PubMed
 
Users online: 8434  
Home About  Editorial Board  Current Issue Archives Online Early Coming Soon Guidelines Subscriptions  e-Alerts    Login  
    Small font sizeDefault font sizeIncrease font size Print this page Email this page


 
Table of Contents 
CASE REPORT
Year : 2011  |  Volume : 56  |  Issue : 3  |  Page : 339-340
Cutaneous manifestations in Brucellosis


Department of Internal Medicine, Haseki Training and Research Hospital, Millet caddesi, 34096 Haseki, Istanbul, Turkey

Date of Web Publication30-Jun-2011

Correspondence Address:
Zeynep Karaali
Department of Internal Medicine, Haseki Training and Research Hospital, Millet caddesi, 34096 Haseki Istanbul
Turkey
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.82505

Rights and Permissions

   Abstract 

Brucellosis is a common worldwide zoonotic disease. Cutaneous manifestations are not specific and affect 1-14% of patients with brucellosis. Here, we describe 49-year-old female with fever and a diffuse maculopapular rash due to Brucella melitensis infection. Histopathology of skin biopsy revealed leukocytoclastic vasculitis; positive blood cultures for B. melitensis established the diagnosis of brucellosis. We provide a review of the relevant literature.


Keywords: Brucellosis, cutaneous manifestations,leukocytoclastic vasculitis


How to cite this article:
Karaali Z, Baysal B, Poturoglu S, Kendir M. Cutaneous manifestations in Brucellosis. Indian J Dermatol 2011;56:339-40

How to cite this URL:
Karaali Z, Baysal B, Poturoglu S, Kendir M. Cutaneous manifestations in Brucellosis. Indian J Dermatol [serial online] 2011 [cited 2020 Aug 5];56:339-40. Available from: http://www.e-ijd.org/text.asp?2011/56/3/339/82505



   Introduction Top


 Brucellosis More Details is an infection caused by bacteria of the genus  Brucella More Details. There are four species of Brucella that cause infection in humans. The most pathogenic is Brucella melitensis. Human infection results from occupational contact with an infected animal or by ingestion of infected milk products or tissues. Person-to-person transmission rarely, if ever, occurs. After invading the body, Brucella is phagocytized by polymorph nuclear leukocytes and macrophages. Organisms spread via lymphatics to regional lymph nodes and, if not contained, to the bloodstream. Bacteremia may result in foci in cells of the reticuloendothelial system in the liver, spleen, and bone marrow, and the other organs such as the kidneys. [1]

Brucellosis may be asymptomatic with only serologic evidence of infection. The manifestation of symptomatic brucellosis may be divided into acute brucellosis, localized disease, and chronic brucellosis. Localized disease may occur at almost any anatomic location, but osteomyelitis, splenic abscess, genitourinary tract infection, pulmonary disease, and endocarditis are among the more common. [1] Cutaneous manifestations are nonspecific and their prevalence is reported to range between 1 and 14% of patients with brucellosis. [2],[3]

Here, we describe 49-year-old female with cutaneous manifestation (leukocytoclastic vasculitis) as an unusual presentation of brucellosis.


   Case Report Top


A 49-year-old woman was admitted to hospital after a 3-week period of an intermittent fever, fatigue, and nausea and vomiting. The physical examination revealed high fever and splenomegaly which was confirmed by an abnormal ultrasound scan. Laboratory tests showed the following values: hematocrit 28%; WBC 2650 cells/mm 3 , platelet count 52,000 mm 3 . Serological and blood cultures were obtained on admission. Bone marrow biopsy was planned but as disseminated urticarial and maculopapular lesions developed [Figure 1], bone marrow biopsy was delayed and biopsy from skin lesions was done. Histopathology of a skin biopsy revealed supporting results with infectious process. Excisional skin biopsy results were assessed as leukocytoclastic vasculitis. Serological tests for  Salmonellosis More Details, Epstein-Barr virus (EBV), HIV and hepatitis B were negative. Brucella agglutinin titer was positive at 1/200 titration (4+). Blood cultures are positive, that means Brucella reproduced. After a diagnosis of brucellosis was made, the patient was administered doxycycline 100 mg per os twice daily for 6 weeks, and rifampicin 600 mg per os once daily, beginning on the 10th day of hospitalization. Six days after treatment, the fever came down and the skin lesions vanished.
Figure 1: Maculopapular lesions on the abdomen and knee

Click here to view



   Discussion Top


Brucellosis is a systemic infection in which any organ or system of the body can be involved. Cutaneous lesions occur in about 5-10% of patients with brucellosis. [4] The cutaneous manifestations of brucellosis can be multiple and are due to direct inoculation, hypersensitivity phenomena, deposition of immune complexes and direct invasion by the organism reaching the skin hematogenously. [2],[3],[4],[5]

Ariza et al., in a review of 436 cases of brucellosis, reported that about 6% of the patients had cutaneous lesions probably caused by the disease and described disseminated violet erythematous, papulonodular eruption, and erythema nodosum-like lesions as the most frequent eruptions observed, which appear during the initial episode of the disease or in relapse. [2] Chronic ulcerations and subcutaneous abscesses have also been described in brucellosis. [6] Al Abdely et al. described a case of female patient with a breast abscess caused by B. melitensis, which was successfully treated with co-trimoxazole plus doxycycline for 3 months. [7]

The patient in our case had fever, splenomegaly and pancytopenia. Her blood and urine cultures were negative; however, Brucella agglutinin titer was positive at 1/200. Maculopapuler rash developed after 2 days of her admission. Skin lesions were nonpruritic, and there was no clinical or laboratory evidence of a hypersensitivity reaction (e.g. eosinophilia). Histological examination of skin biopsy with immune-fluorescence revealed infectious process and assessed the condition as a leukocytoclastic vasculitis.

Vicaro et al. reported a 29-year-old woman suffering from brucellosis, who developed maculonodular and purpuritic lesions. The skin biopsy showed granulomatous vasculitis with no deposition of immunoglobulins and complement of vessels. Maculonodular eruption was associated with purpura, secondary to Brucella abortus infection. [8] Like our case, Nagore et al. described a 22-year-old man presenting with brucellosis, with leukocytoclastic vasculitis as a cutaneous manifestation. Skin lesions resolved 48 hours after starting treatment tetracycline and rifampicin. [9] Our patient was treated with doxycycline 100 mg per os twice daily for 6 weeks, plus rifampicin 600 mg. Two days after the treatment had been initiated, the skin lesions vanished.

Brucellosis remains an important public health problem in Turkey. In a study by Akcalύ et al ., they determined the types and rates of cutaneous lesions that occur in patients with brucellosis. A total of 140 patients who had been diagnosed with brucellosis were prospectively observed in the dermatology clinic. Cutaneous findings related to brucellosis were observed in 8 (5.71%) of the 140 cases. Maculopapular eruptions were observed in 2 patients (25%), erythema nodosum-like lesions in 2 (25%), psoriasiform lesions in 1 (12.5%), palmar erythema in 1 (12.5%), malar eruption in 1 (12.5%), and palmar eczema in 1 (12.5%) patient. The investigators concluded that although cutaneous findings encountered in brucellosis are generally not specific to this disease, the presence of these findings may be useful in diagnosing brucellosis in persons who live in, or used to live in, endemic regions. [10]

In conclusion we emphasize that cutaneous lesions are not specific to brucellosis and may be seen in a variety of other dermatologic diseases caused by many agents; therefore, these agents should be kept in mind in the differential diagnosis in a country where the disease is endemic.

 
   References Top

1.Kaye D. Brucellosis. In: Wilson JD, Braunwald E, Isselbacher KJ, Petersdorf RG, Martin JB, Fauci AS, editors. Harrisons's Principles of Internal Medicine. 12 th ed. Vol. 1. New York: McGraw-Hill, Inc; 1991. p. 625-6.  Back to cited text no. 1
    
2.Ariza J, Servitje O, Pallarés R, Fernández Viladrich P, Rufí G, Peyrí J, et al. Characteristic cutaneous lesions in patients with brucellosis. Arch Dermatol 1989;125:380-3.  Back to cited text no. 2
    
3.Metin A, Akdeniz H, Buzgan T, Delice I. Cutaneous findings encountered in brucellosis and review of the literature. Int J Dermatol 2001;40:434-8.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Berger TG, Guill MA, Goette DK. Cutaneous lesions in brucellosis. Arc Dermatol 1981;117:40-2.  Back to cited text no. 4
    
5.Milionis H, Christou L, Elisaf M. Cutaneous manifestations in brucellosis: Case report and review of the literature. Infection 2000;28:124-6.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.Christianson HB, Pankey GA, Applewhite ML. Ulcers of the skin due to Brucella suis: report of a case. Arch Dermatol 1968;98:175-6.  Back to cited text no. 6
[PUBMED]  [FULLTEXT]  
7.Al Abdely HM, Halim MA, Anim TM. Breast abscess caused by Brucella melitensis. J Infect 1996;33:219-20.  Back to cited text no. 7
    
8.Vicario RF, Balparda J, Santamaria JM, Alvaro C, Arigaza C, Villa FM, et al. Cutaneous vasculitis in a patient with acute brucellosis. Dermatologica 1985;171:126-8.  Back to cited text no. 8
    
9.Nagore E, Sanchez-Motilla JM, Navarro V, Febrer MI, Aliaga A. Leukocytoclastic vasculitis as a cutaneous manifestation of skin infection caused by Brucella melitensis. Cutis 1999;63:25-7.  Back to cited text no. 9
    
10.Akcali C, Savas L, Baba M, Turunc T, Seckin D. Cutaneous manifestations in brucellosis: a prospective study. Adv Ther 2007;24:706-11.  Back to cited text no. 10
[PUBMED]    


    Figures

  [Figure 1]

This article has been cited by
1 Revista Chilena de Infectologia
Martínez, P.
Brucelosis humana: Situación epidemiológica en Chile, 2001-2010 | [Human brucellosis: Epidemiological situation in Chile, 2001-2010]. 2013;
[Pubmed]
2 Document Clinical presentations and diagnosis of brucellosis
Authors of Document Kilic, A.U., Metan, G., Alp, E.
Recent Patents on Anti-Infective Drug Discovery. 2013;
[Pubmed]



 

Top
Print this article  Email this article
 
 
  Search
 
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Article in PDF (419 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
    Introduction
    Case Report
    Discussion
    References
    Article Figures

 Article Access Statistics
    Viewed5222    
    Printed144    
    Emailed2    
    PDF Downloaded78    
    Comments [Add]    
    Cited by others 2    

Recommend this journal