|Year : 2013 | Volume
| Issue : 2 | Page : 130-131
A case of pediatric systemic brucellosis presenting with urinary symptoms
Varun Goel, Sumati A Hogade, Shankar G Karadesai
Department of Microbiology, Jawaharlal Nehru Medical College, Karnataka Lingayat Education University, Belgaum, Karnataka, India
|Date of Web Publication||10-Sep-2013|
Division of Clinical Microbiology and Molecular Medicine, Department of Laboratory Medicine, All India Institute of Medical Sciences, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
Human brucellosis is a multisystem and potentially lethal disease of zoonotic origin with highly variable and non-specific clinical presentation. We report here on a 4-year-old pediatric patient who was presented with fever, chills, frequency, urgency of urine, and pain in lower abdomen. Blood cultures yielded slow-growing gram-negative coccobacilli that were later identified as Brucella melitensis. To the best of our knowledge, this is one of the few rare case reports of Brucellosis with symptoms of urinary tract infection in a female child.
Keywords: Brucellosis, child, urinary tract infection, zoonoses
|How to cite this article:|
Goel V, Hogade SA, Karadesai SG. A case of pediatric systemic brucellosis presenting with urinary symptoms. Saudi J Health Sci 2013;2:130-1
| Introduction|| |
Brucellosis More Details is a serious bacterial zoonosis caused by members of the genus, Brucella More Details. The disease is caused by facultative intracellular, gram-negative, coccobacilli that are catalase, oxidase, and urease positive. It affects people of all age groups and of both sexes. Human brucellosis is a multisystem disease that may present with a broad spectrum of clinical manifestations, and its focal complications are often troublesome in making a clinical diagnosis. One of the important reasons for missing the diagnosis is lack of awareness of the existence of the disease on part of medical men concerned. Involvement of testis and urinary tract in animals is well documented.  However, such manifestations of brucellosis in humans have not been adequately stressed. Uncu H et al., have reported a case presenting with symptoms of acute urinary tract infection.  Genitourinary (GU) localization of brucellosis is rarely documented in the medical literature with most cases presenting as epididymo-orchitis. 
| Case Report|| |
A 4-year-old female was admitted to the pediatric emergency service of J. N. Medical College, Belgaum, India with complaints of high grade fever with chills for three days duration, increased frequency and decreased amount (only few drops at a time) of urination, and with history of diffuse and dull aching type pain in lower abdomen. Her complaints were persisting for three days before admission. On further elicitation of history, the mother recalled of her daughter having handling cow placenta in her house two months prior to the onset of symptoms, and there was history of consumption of raw milk. Also, she was from an endemic area. Milestones were appropriate for age. Physical examination revealed pallor with a temperature of 38°C and associated with chills. Per-abdomen on palpation revealed tenderness, costovertebral angle tenderness, and mild splenomegaly. There was no vomiting, diarrhea, hypertension, abdominal mass, abnormal genitalia, lymphadenopathy or skin rash. Rest of the systemic examination was normal. Clinical diagnosis of urinary tract infection was made on admission. She was treated with amoxicillin. Laboratory tests showed urine was pale yellow, clear, acidic, and no albumin or sugar. In urine microscopy, 7-8 white blood cells per high power field (HPF) in centrifuged urine were found with no RBCs, epithelial cells, cast or crystals. Hemoglobin was 11 mg/dl, erythrocyte sedimentation rate was 24 mm/hour, and white blood cell count was 9200/mm 3 with a 70% of lymphocyte ratio. Blood glucose and liver function tests were normal. Widal test was negative. Abdominal ultrasound was normal. Rose Bengal plate agglutination test (RBPT) [Figure 1] was found positive, and standard tube agglutination test (SAT) was positive at a titre of 1/5,120 (10,240 IU/ml) and 2-mercaptoethanol (2-ME) titre of 1/2560. Antigen for RBPT, SAT and 2ME test were obtained from the Division of Biological Products, Indian Veterinary Research Institute, Izzatnagar-243122,(Uttar Pradesh), India. Blood culture in Castaneda biphasic BHI medium was positive after 14 th day. Oxidase, catalase, and urease test were positive. There was no H 2 S production and it was resistant to dye inhibition. , The organism was confirmed as Brucella melitensis. Urine culture on Blood agar and MacConkey agar showed 200 CFU/ml which was insignificant. We also tried to do culture of urine in Castaneda biphasic BHI medium but we could not isolate any organism. All manipulation of live Brucella cultures and antigens were performed in a biological safety cabinet. We also performed milk ring test (MRT)  from the milk of the cow suspected with brucellosis which was in the house of the patient. MRT was found to be positive. The patient treatment was changed to doxycline (100 mg P.O. bid) for six weeks and her signs and symptoms improved. On follow-up after two months, serum titres of SAT had decreased to dilutions of 1:80 and RBPT and 2-ME tests were negative.
|Figure 1: Rose Bengal plate test. The test was read as positive on noting any degree of agglutination or negative when no agglutination was noted|
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| Discussion|| |
Brucellosis is a zoonotic disease that occurs by contact with infected meat or the placenta of infected animals, or ingestion of unpasteurized milk and dairy products, or by inhaling airborne agents, and rarely by transplantation and sexual course. Human brucellosis is found to have significant presence in rural/nomadic communities where people live in close association with animals. In endemic disease areas reported incidence of human brucellosis varies widely, from <0.01 to >200 per 100,000 population around the world.  B. melitensis has been isolated in a large number of pediatric cases of brucellosis in different countries: Reports from India, Iran, Greece and Saudi Arabia indicate that the ingestion of raw milk or dairy products is the main source of infection. ,
Dunea has classified renal involvement into three clinical types: (1) Chronic brucellosis with renal involvement resembling renal tuberculosis or chronic non-specific pyelonephritis; (2) renal involvement associated with Brucella endocarditis; and (3) acute nephritis or acute pyelonephritis-like features seen during the acute stage of brucellosis. These features are usually transient. 
In humans, reports of unusual manifestations with atypical lesions in brucellosis are on the rise due to availability of diagnostic facilities and awareness. In this case, contact with infected cow placenta was the most likely source of infection.
In conclusion, it is important to consider the possibility of brucellosis presenting with urinary symptoms, especially in endemic region. Further confirmation has to be done by culture of organisms from urethral discharges and urine.
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