Pediatric Brucellosis Presenting with Necrotizing-Like Skin Involvement

Brucellosis is the most common zoonosis worldwide and is a significant public health issue in many resource-limited settings. Complications of brucellosis include infection involving one or more focal areas; any organ system can be affected (Pappas et al., 2005).

We present a case of a previously healthy 13-year-old male patient who presented to our clinic with a 3-day history of testicular pain and discoloration. He was referred to us with a preliminary diagnosis of vasculitis. He had complained of fever and cough 1 week prior and had lost 2 kg of weight in the last week. He had no gastrointestinal or musculoskeletal complaints, and his medical history was unremarkable. On physical examination, the body temperature was 37°C, and blood pressure was 115/90 mmHg. bilateral scrotal tenderness, erythema, and a widespread necrotic appearance of the scrotal skin were observed (Fig. 1A). The patient had no herpetic lesions on any part of the body. There were no pathological findings in other areas of the body. Laboratory tests revealed a hemoglobin level of 14 g/dL, a platelet count of 184 × 10³/μL, a white blood cell count of 7.46 × 10³/μL (neutrophils 41%), an erythrocyte sedimentation rate of 35 mm/h, and a C-reactive protein level of 44.6 mg/L. Biochemical and urinalysis were normal. The patient was started on teicoplanin (12 mg/kg), piperacillin-tazobactam (300 mg/kg), and clindamycin (30 mg/kg/day) with a preliminary diagnosis of necrotizing fasciitis. Scrotal Doppler ultrasound revealed normal testicular size and vascularity bilaterally, with increased thickness of the skin and subcutaneous tissue in both hemiscrotums. No growth was observed in routine blood and urine cultures (extended culture requested). A respiratory multiplex PCR panel was negative, as were tests for mumps IgM, rubella IgM, and parvovirus IgM. Streptococcal serology was not performed. Tests for non-infectious causes of vasculitis were negative. Although the patient had no history of consuming unpasteurized dairy products, serological tests sent for the etiology of epididymo-orchitis and weight loss in a rural resident included a positive Brucella Coombs Gel test with a titre of 1/320, 3 days after the onset of symptoms. Repeat serology was not performed. Treatment with teicoplanin, piperacillin-tazobactam, and clindamycin was discontinued. The patient was started on doxycycline (4.4 mg/kg/day) and rifampicin (15 mg/kg/day). Treatment was completed in 6 weeks. The skin findings resolved after treatment (Fig. 1B).

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FIG. 1.

(A) Bilateral scrotal skin with hyperemia and necrotic appearance. (B) Scrotal skin after treatment.

Genitourinary involvement is the second most common form of focal brucellosis, occurring in up to 10% of cases (Artuk, 2019). Orchitis and epididymitis are the most common presentations in male patients, while prostatitis and testicular abscesses are less frequent (Bosilkovski et al., 2007). Dermatological findings, which can also occur in up to 10% of cases, include macular, maculopapular, scarlatiniform, papulonodular, erythema nodosum-like rashes, ulcerations, petechiae, purpura, granulomatous vasculitis, and abscesses (Korkmaz and Kartal, 2016).

In most cases the rash associated with brucellosis is minor and non-specific and is often diffuse or maculo-papular, rather than the more florid vasculitic rash illustrated here (Korkmaz and Kartal, 2016). The definitive diagnosis of Brucella infection relies on bacterial isolation, but culture sensitivity is limited, especially if cultures are not processed correctly or for long enough (Yagupsky et al., 2019). Serum agglutination tests are commonly used, but may yield false-positive results due prior exposure or cross-reactivity with other Gram-negative organisms, or yield false-negative results if not performed correctly. A high Brucella Coombs Gel titre as in our patient is more likely to signify a true positive result, but a single result must still be interpreted with caution in an endemic area (Yagupsky et al., 2019). While initial symptoms may mimic other conditions such as necrotic skin lesions, a high index of suspicion for brucellosis should be maintained in regions where the disease is endemic or in patients with rural exposure, even in the absence of a clear source of infection. Early diagnosis and appropriate treatment are crucial to prevent further complications and achieve complete resolution of symptoms. This case underscores the importance of considering brucellosis in the differential diagnosis of genitourinary and dermatological symptoms, especially in patients with atypical presentations and risk factors.