Pancytopenia As the Initial Manifestation of Brucellosis in Children

Abstract

Presenting with severe thrombocytopenia and pancytopenia is rare in children with brucellosis, and at the beginning it can be misdiagnosed as a hematological or a viral hemorrhagic disease. The follow-ups of 52 patients diagnosed with brucellosis from January, 2008, to December, 2013, in our clinic have shown the following results. Eleven out of these 52 patients revealed the fact that they had pancytopenia at the admission phase. Anemia and leukopenia were defined as hemoglobin levels and leukocyte counts below the standard values in terms of ages, thrombocytopenia as thrombocyte counts below 150,000/mm³, and severe thrombocytopenia as thrombocyte counts below 20,000/mm³. The most frequent admission symptoms and findings of the patients with pancytopenia were fever (75%), fatigue (50%), splenomegaly (75%), and hepatomegaly (41%). Laboratory results were hemoglobin 9.3±0.96 gram/dL, white blood cell count 2226±735.9/mm³, and thrombocyte count 70,090±47,961/mm³. The standard tube agglutination test was positive for all patients, and Brucellosis spp. were isolated in the blood cultures of six (54%) patients. Three of the 11 patients had severe thrombocytopenia, and they were admitted with complaints of epistaxis, gingival bleeding, petechiae, and purpura. At the beginning, two of three cases were misdiagnosed as Crimean–Congo hemorrhagic fever (CCHF), another zoonotic endemic disease in Turkey. Pancytopenia improved with treatment of brucellosis on all patients. In conclusion, brucellosis can show great similarity with hematologic and zoonotic diseases like CCHF. Brucellosis should be considered in the differential diagnosis of pancytopenia, treatment-resistant immune thrombocytopenia, and viral hemorrhagic disease, especially in countries where brucellosis is endemic.

Introduction

Brucellosis today is still the most common of the zoonotic diseases in the world, with a figure of more than 500,000 yearly reported cases. Specifically in endemic regions, the ratio of brucellosis incidence is more than 10/100 000. In fact, in some Mediterranean countries, such as Turkey, Spain, Greece, Portugal, and France, it is even considered as hyperendemic, as it is in Arabia and India (Pappas et al. 2006). Turkey, however, is regarded as endemic with restrictions to areas in East, Southeast, and Central Anatolia only (Buzgan et al. 2010).

In children, the disease is most frequently contracted through consumption of unpasteurized dairy products (Buzgan et al. 2010). A great number of systems, such as the osteoarticular system, gastrointestinal system, and central nervous system, can be affected by brucellosis. The most frequent clinical symptoms are fever, weight loss, night sweating, and fatigue. Ciftdogan's study shows that in epidemic countries the underlying reason for unknown fever is generally related to the incidence of brucellosis (Ciftdoğan et al. 2011). This state mimics a great number of diseases and causes difficulties in diagnosis. Brucellosis also causes various hematological symptoms. Mild anemia and leukopenia are frequent in brucellosis, whereas severe thrombocytopenia and pancytopenia are less frequently observed (Akbayram et al. 2011, Karsen et al, 2012, El-Koumi et al. 2013). In this study, 11 pediatric cases that were found to have pancytopenia on admission and diagnosed at a later phase with brucellosis are discussed.

Materials and Methods

The records of 52 patients with brucellosis who were followed up in our clinic between January, 2008, and December, 2013, were examined. Patients with symptoms of pancytopenia were analyzed retrospectively from the hospital's files. There were no patients with chronic systemic diseases. The diagnosis of brucellosis was made by the standard tube agglutination test (SAT) with a titer ≥1/160 and/or isolation of Brucella spp. in a sterile body fluid sample from the patients with clinical findings, such as fever, arthralgia, fatigue, or weight loss.

The following elements were analyzied: Patients' demographic features; complaints on admission; findings of the physical examinations; results of laboratory investigations, such as complete blood counts, liver function tests, erythrocyte sedimentation rates, C-reactive protein (CRP), SAT, sterile body fluid culture, and bone marrow aspiration results; and approaches to the treatment. Anemia and leukopenia were defined as hemoglobin levels and leukocyte counts below the standard values in terms of age; thrombocytopenia was defined as thrombocyte counts below 150,000/mm³; and severe thrombocytopenia was defined as thrombocyte counts below 20,000/mm³. Pancytopenia was defined as low hemoglobin, thrombocytes, and white blood cell rates in the same patient. Bone marrow aspiration was performed on eight patients.

Results

Of the 52 patients who were hospitalized and monitored with the diagnosis of brucellosis, 11 (21%) cases found to have pancytopenia were included in the study. Six of the patients were male, whereas five were female. The median age was 12.9±3.4 years. Seven (63.6%) patients had a history of consuming unpasteurized milk and dairy products and/or their families were raising stock.

The most frequent symptoms were fever in nine (81.8%) cases and fatigue in six (54.5%) cases. One of the cases was admitted to hospital with the complaint of nose bleeding and two cases were admitted with gingival bleeding. Seven (63.6%) cases were found to have splenomegaly and six (54.5%) cases were found to have hepatomegaly. Two cases had petechiae and purpura (Table 1).

Table 1.

Symptoms and Findings in Brucellosis Cases That Are Found to Have Pancytopenia

Patient	Age (years)/sex	Complaint	Physical examination	Treatment
1	10/M	Fever, gingival bleeding, rash	Hepatosplenomegaly. petechia, purpura	Ribavirin, i.v. Ig, pulse steroid, thrombocyte suspension, FFP AB
2	12/F	Fever, nose bleeding, rash	Petechia, purpura	i.v. Ig, thrombocyte suspension, AB
3	17/M	Fever, gingival bleeding	Normal	Ribavirin, thrombocyte suspension, TDP, AB
4	15/M	Fever, fatigue, leg pain	Normal	AB
5	15/M	Fever, abdominal pain, hip pain	Hepatosplenomegaly	AB
6	11/M	Fever, fatigue	Hepatosplenomegaly	AB
7	11/F	Fever, fatigue	Hepatosplenomegaly	AB
8	17/F	Fever, fatigue	Hepatosplenomegaly	AB
9	7/M	Fatigue, weight loss	Hepatosplenomegaly	AB
10	17/F	Fatigue	Normal	AB
11	10/F	Fever	Splenomegaly	AB

M, male; F, female; FFP, fresh frozen plasma; AB, antibrucella treatment; i.v. Ig, intravenous immune globulin.

When the laboratory results were analyzed, hemoglobin was 9.3±0.96 gram/dL, white blood cell count was 2226±735.9/mm³, absolute neutrophil count was 1023±293/mm³, and thrombocyte count was 70,090±47,961/mm³. Three of the cases were found to have severe thrombocytopenia and they were investigated for coagulopaties.

A standard tube agglutination test was performed on all patients; it was found to be ≥1/160 in eight patients, and 1/160 in three patients. Brucellosis spp. were isolated in the blood cultures of six (54.5%) patients (Table 2).

Table 2.

Laboratory Findings of Brucellosis Cases Monitored for Pancytopenia

Patient number	Hb g/dL	WBC/mm³	Neutrophils/mm³	Platelets/mm³	Agglutination titers	Blood culture
1	8.9	2200	1300	3000	1/2560	Brucella spp.
2	10.2	1900	1000	2000	1/5120	Brucella spp.
3	9.8	990	490	19,000	1/160–1/1280	B. melitensis
4	7.2	1970	790	103,000	1/320	B. melitensis
5	9.9	2600	1100	51,000	1/1280	No
6	10.5	2500	1000	117,000	1/320	No
7	8.5	2100	800	88,000	1/1280	No
8	9.5	2500	1400	90,000	1/160	B. melitensis
9	9.3	4000	1500	53,000	1/640	No
10	8.5	1830	880	146,000	1/160	No
11	10	1900	1000	99,000	1/160	B. melitensis

Hb, hemoglobin; WBC, white blood cells.

Of the 11 patients who were admitted with the complaint of pancytopenia, bone marrow aspiration was performed on eight patients. Examination of bone marrow aspiration findings showed no malignancy; four cases were found to have mild hemophagocytosis. Cases 1 and 2, which presented with bleeding, were found to have increases in megakaryocytes in bone marrow aspiration; however, these cases were found to have negative direct Coombs test results that indicated immune thrombocytopenia. Trimethoprim sulfamethoxazole and rifampicin treatment was given to children younger than 8 years of age, and doxycycline and rifampicin treatment was given to children older than 8 years for 6 weeks (Schutze et al. 2011).

We experienced difficulties in diagnosis of three patients with severe thrombocytopenia. For two cases, the initial diagnosis was CCHF because the patients were admitted in the summer and they were working as farmers. For the other patient, the initial diagnosis was idiopathic thrombocytopenic purpura. For this reason, these three patients are presented in detail.

Cases with severe thrombocytopenia

Case 1

A 10-year-old male patient was admitted with nose bleeding and rash in the lower extremities. His physical examination revealed a fever of 38.5°C, active mucosal bleeding in the mouth, hepatosplenomegaly, general petechiae, and purpura in the lower extremities. His hemoglobin was 8.9/dL, white blood cell count was 2200/mm³, and thrombocyte count was 3000/mm³ (mean platelet volume [MPV], 9.3 fL). Because the case was from the countryside and he had a history of contact with animals, CCHF diagnosis was considered initially. Ribavirin was started. The patient, who had active bleeding, was given thrombocyte suspension several times. In the bone marrow aspiration, which was performed to exclude malignancy, the bone marrow was cellular; all three series had normal appearance, and one hemophagocytosis with increased megakaryocyte was observed. No atypical cell was found. Because the thrombocyte levels were about 3000/mm³, the patient was given intravenous gamma globulin (IVIG) three times. Direct Coombs tests were negative, activated thromboplastin time tests (PTT) were 41 s (normal, 22–35), prothrombin time (PT) was 13 s (normal, 10–14), international normalized ratio (INR) was 1.24 (normal, 0.8–1.15), ferritin was 1265 ng/mL (normal, 21–274), and fibrinogen, d-dimer, and triglycerides levels were found to be normal.

The patient, whose mucosal bleeding continued, was started on high-dose methylprednisolone (1×500 mg) intravenously (i.v.). On the fifth day of his hospitalization, the patient's brucellosis tube agglutination test was found to be 1/2520 and Crimean–Congo hemorrhagic fever (CCHF) polymerase chain reaction (PCR) and antibody tests were negative. The patient was started on rifampicin and doxycycline treatment and ribavirin treatment was stopped. Methylprednisolone treatment was stopped after 7 days. The results of the laboratory tests on the 15th day of the patient's hospitalization showed that his white blood cell count was 5520/mm³, his hemoglobin level was 10.5 grams/dL, and his thrombocyte count was 79,000/mm³. The patient was discharged. In his checkup 10 days later, his thrombocyte count was found to have increased to 160,000/mm³.

Case 2

A 12-year-old female patient was admitted with nose bleeding and rash. Her family was raising stock and she consumed unpasteurized dairy products. Her complaints were nose bleeding, 39°C fever, generalized petechiae, and purpura on the lower extremities and the body. She had no organomegaly. Her hemoglobin level was 10.2/dL, her white blood cell count was 1900/mm³, and her thrombocyte count was 2000/mm³ (MPV, 10.3 fL). Direct Coombs tests were negative, and PT, PTT, INR, ferritin, and triglycerides levels were found to be normal. In bone marrow aspiration, an increase was found in megakaryocytes, and the patient IVIG for 2 days. Her diagnosis was idiopathic thrombocytopenic purpura. She was given thrombocyte suspension for nose bleeding. However, doxycycline and gentamicin were started on the sixth day of her hospitalization because her thrombocyte count was still 2000/mm³ and the brucellosis agglutination test result was found to be 1/5120. The patient, whose thrombocyte level increased to 118,000/mm³ on the sixth day of treatment, was discharged.

Case 3

A 17-year-old male patient who was living in the village and working as a shepherd was admitted to the hospital with complaints of fever, fatigue, and gingival bleeding. His physical examination showed 39°C of fever. The patient was hospitalized with a diagnosis of CCHF. His hemoglobin level was 9.8 grams/dL, his white blood cell count was 990/mm³, his thrombocyte count was 19,000/mm³ (MPV, 13.4 fL), and his activated PTT was 48 s. The patient's INR was 1.4, and his bone marrow aspiration showed mild hemophagocytosis. Ribavirin was started, and because he had intermittent gingival bleeding, he received thrombocyte suspension and fresh frozen plasma support. The examinations made for hemophagocytosis showed that his ferritin level was 7600 ng/mL, triglycerides level was 328 mg/dL (normal, 0–200), and cholesterol level was 134 mg/dL (normal, 0–200). No increase was found in thrombocyte levels, and CCHF PCR and antibody tests were negative. The test result was SAT 1/160, and Brucella melitensis was isolated in his blood culture. Thus, the patient was diagnosed with brucellosis. His control SAT level rose to 1/1280 titer. Doxycycline and streptomycin treatment was started. On the sixth day of the brucellosis treatment, his thrombocyte count went up to 78,000/mm³ and his fever started to decline. On the 16th day of the treatment, his thrombocyte and blood values reached normal levels.

In all cases, pancytopenia improved within 10.5±4.8 days after the brucellosis treatment.

Discussion

Hematologic complications are frequent in brucellosis, which can cause multisystem involvement, and they can be confused with hematological and zoonotic diseases (Karakukcu et al. 2004, Citak et al. 2010, El-Koumi et al. 2013). In a large study conducted mostly with adults in our country, hematologic laboratory anomalies had a rate of 44%, whereas the rate of symptomatic findings was 1.7% (Buzgan et al. 2010).

Pancytopenia has frequently been reported in adults, but data related to children is limited (Shalev et al. 1994, Citak et al. 2010, El-Koumi et al. 2013). The frequency of pancytopenia varies between 3% and 21% in various studies; in our study, it was 21%. Although its pathogenesis is not clear, hypersplenism, developing hemophagocytosis during infection, or bone marrow suppression may be the cause of pancytopenia and thrombocytopenia. The direct inhibitor effect of bacteria on bone marrow cells and inhibition of hematopoiesis by mediators released from activated lymphocytes can also be responsible for pancytopenia (al-Eissa et al. 1993, Akdeniz et al. 1998). The mechanism of thrombocytopenia in our cases was related to brucellosis destruction of cells in peripheral blood by mediators. The increased megakaryocytes in bone marrow and MPV values possibly show peripheral destruction of platelets.

Hemophagocytosis can be seen during a great number of viral, bacterial, and parasitic infections. Nonadaptive T lymphocyte and macrophage activation will be changed into hemophagocytosis that can be the result of extreme cytokine release (Larroche and Mouthon 2004). In our study, of the 11 cases that were admitted with pancytopenia, eight received bone marrow aspiration for exclusion of malignancy. Four cases were found to have mild hemophagocytosis, and two cases were found to have increases in megakaryocytes. Similar bone marrow activation results were found in the study of Akbayram et al. (2011). In our study, hemophagocytosis was found in the bone marrow aspiration of four cases. None of the cases met the other criteria of hemophagocytic syndrome.

In the literature, the frequency of thrombocytopenia in brucellosis varies between 2.4% and 33% and mild thrombocytopenia is more common. Severe thrombocytopenia that can cause mucosal bleeding is very rare (al-Eissa et al. 1993, Gür et al. 2003). Thrombotic thrombocytopenic purpura and disseminated intravascular coagulation have also rarely been reported (Young et al. 2000, Turunc et al. 2008). Brucellosis is known to be a disease with a benign course, and mortality is seen rarely in the involvement of specific organs, such as in endocarditis (Schutze et al. 2011). However, there are patients in the literature who have died because of bleeding due to thrombocytopenia (Young et al. 2000). In critical patients, diagnostic tests should be made quickly, and in the meantime, supporting treatment should be started. Thus, intense thrombocyte and fresh frozen plasma support were given to the patients who were admitted with the symptoms of severe thrombocytopenia and bleeding. The patients recovered with antimicrobial treatment and hematologic support.

In cases with brucellosis, immune mechanisms can also be responsible for thrombocytopenia. In their study, Benecos et al. (1998) reported that a 9-year-old patient who was admitted with nose bleeding was given steroid and gamma globulin therapy, considering immune thrombocytopenia. Initially, thrombocytes went up; however, 2 weeks later thrombocytopenia recurred and the patient was reexamined and diagnosed with brucellosis. Initial response to corticosteroid treatment brings to mind that the mechanism of thrombocytopenia may be immune mediated (Benecos et al. 1998, Sevinc et al. 2000). Some authors recommend the use of treatments such as i.v. gamma globulin and steroid therapy in patients who are found to have hemophagocytosis as well as for brucellosis (Young et al. 2000). In our study, two of the cases that were monitored for severe thrombocytopenia were given a treatment of i.v. gamma globulin and high-dose steroids before the diagnosis of brucellosis. However, no increase was observed in thrombocytes, and after the treatment for brucellosis, one of the cases reached normal laboratory levels in 10 days, whereas another one reached normal levels in 14 days. All patients recovered clinically and hemotologically with treatment of brucellosis. In the literature, while investigating the etiology of pancytopenia, patients with malignancy were found to be determined (Sari et al. 2008).

Hemorrhagic symptoms, such as nose bleeding, are very rare in brucellosis cases; they are frequently associated with B. melitensis (Citak et al. 2010, Karsen et al. 2012). In our study, B. melitensis was isolated in the blood culture of one of three cases with hemorrhagic symptoms. In two cases, Brucella spp. were also isolated, but they could not typed.

CCHF is another endemic zoonotic disease in Turkey that presents with fever and bleeding manifestations. Our hospital is a reference center for CCHF cases in the central Black Sea Region (Belet et al. 2014). Therefore, we started ribavirin treatment in two cases with severe thrombocytopenia and hemorrhagic symptoms at the beginning. These patients were dealing with stock breeding, and they had been admitted to the hospital in the summer months. However, their PCR and serological tests for CCHF diseases were negative, and Brucella spp. were isolated in the blood cultures. These patients were diagnosed with brucellosis. In the literature, Almış et al. also reported that a patient with a severe thrombocytopenia was initially thought to have CCHF, but the definitive diagnosis turned out to be brucellosis (Almiş et al. 2012).

Conclusions

Brucellosis can mimic a great number of hematologic and zoonotic diseases like CCHF. In countries where brucellosis is endemic, brucellosis should be considered in the differential diagnosis of pancytopenia, treatment-resistant immune thrombocytopenia, and CCHF. In cases that are admitted with hemorrhagic symptoms and with severe thrombocytopenia, supportive treatment should be started, tests for a possible diagnosis of brucellosis should be run, and doctors should be alert for complications.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

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