Dear Label_Name,

Greetings! I hope you are well.

I am writing on behalf of an international publishing house, Science and Education Publishing, USA (http://www.sciepub.com).

Science and Education Publishing (SciEP) is a multidisciplinary open access publisher of Journals covering the fields of Science, Technology and Medicine. All SciEP publications are subject to high-quality peer review, editorial and production processes and are freely available online.

Welcome to the April, 2013 edition of SciEP newsletter, providing monthly summaries of articles on science & education related topics of interest to scientist and professionals. The mission of our journals is to provide an open access forum for publishing new findings on issues pertinent to scientific and academic field. We also invite you to submit original research papers, review articles, short reports, or case studies are considered for publication in our Multidisciplinary Journals.

American Journal of Public Health Research
DOI: 10.12691/ajphr-1-1-3

The Implementation of a Tele-Homecare System with Service Oriented Architecture and HL7 Message Transmission Standard
Ching-Sung Wang

American Journal of Medical and Biological Research
DOI: 10.12691/ajmbr-1-1-2

The Influence of Ethanol on Pyruvate Kinases Activity in Vivo, in Vitro, in Silico
Lelevich Sergey Vladimirovich, Khrustalev Vladislav Victorovich, Barkovsky Eugene Victorovich, Shedogubova Tatyana Aleksandrovna

American Journal of Medical Sciences and Medicine
DOI: 10.12691/ajmsm-1-1-1

Clinical and Histological Features in Wegener Granulomatosis
Li Cavoli Gioacchino, Passantino Rita, Bono Luisa, Tortorici Calogera, Ferrantelli Angelo, Giammarresi Carlo, Rotolo Ugo

American Journal of Infectious Diseases and Microbiology
DOI: 10.12691/ajidm-1-1-2

The Curse of Lymphatic Filariasis: Would the Continual Use of Diethylcarbamazine Eliminate this Scourge in Papua New Guinea?
Anne Lanham, Lillian Mwanri

We have released issues of some journals on February 2013.
American Journal of Public Health Research
American Journal of Medical Sciences and Medicine
American Journal of Medical and Biological Research
American Journal of Pharmacological Sciences
American Journal of Clinical Medicine Research
American Journal of Nursing Research
American Journal of Cancer Prevention
American Journal of Medicine Studies
American Journal of Infectious Diseases and Microbiology
American Journal of Cardiovascular Disease Research
American Journal of Biomedical Research
American Journal of Mechanical Engineering
American Journal of Microbiological Research
Journal of Preventive Medicine
American Journal of Food and Nutrition
American Journal of Hypertension Research
American Journal of Sports Science and Medicine
Journal of Cancer Research and Treatment
American Journal of Zoological Research
Journal of Biomedical Engineering and Technology
American Journal of Microbiological Research
Biomedical Science and Engineering

We are pleased to announce that submissions are now being accepted for peer review for all the journals across all our subject areas in SciEP.

Please submit your manuscript via our online submission system:
http://www.sciepub.com/author/signin

To unsubscribe from our mailing list, please click on the following link: unsubscribe

I am looking forward to hearing from you.

Kind regards,

David Rain
Email:join@sciepub.com
Science and Education Publishing (http://www.sciepub.com)

Cutaneous Leuckocytoclastic Vasculitis Revealing Acute Brucellosis: A Case Report

Salem Bouomrani*, Houcine Mrad, Saoussan Ben Teber

Department of Internal Medicine, Military Hospital of Gabes, Gabes 6000, Tunisia

Abstract: The clinical presentations of human brucellosis are very polymorphic, representing a real challenge for clinicians. Among the unusual manifestations of this infection, vasculitis is particularly uncommon with only few sporadic cases in the world literature. We report an original observation of isolated cutaneous leuckocytoclastic vasculitis revealing acute brucellosis in a 44-year-old Tunisian man who was admitted for a rash with fever that had been evolving for two days. Somatic examination noted fever at 38°C, red-purple infiltrated and tender petechial lesions on feet, legs, and hands, small periungual necrotic lesions, and subungual splinter hemorrhages. The basic biological tests showed a biological inflammatory syndrome with an erythrocyte sedimentation rate of 82mmH1 and a C-reactive protein at 62mg/l. The skin biopsy concluded in leukocytoclastic vasculitis, without signs of malignancy and with a negative direct immunofluorescence. The specific etiological assessment of this vasculitis was negative. Wright's serology was positive at 1/1,280 confirming the diagnosis of acute septicemic brucellosis with brucellian vasculitis. The patient was treated with the combination: Doxycycline 200mg/d and Rifampicin 600mg/d with a rapidly favorable evolution. Healthcare professionals should be aware of the possibility of brucellosis in front of any unproven vasculitis, especially in endemic countries. This better knowledge will make it possible to avoid diagnostic delay and improve the prognosis of this infection.

Keywords: brucellosis, cutaneous vasculitis, leuckocytoclastic vasculitis, angiitis

Received February 10, 2021; Revised March 16, 2021; Accepted March 25, 2021

Citation: Salem Bouomrani, Houcine Mrad, Saoussan Ben Teber, Cutaneous Leuckocytoclastic Vasculitis Revealing Acute Brucellosis: A Case Report. American Journal of Medical Case Reports, 9 (6). 335-338. January 2021. doi:10.12691/ajmcr-9-6-8

1. Introduction

Brucellosis is the most common bacterial zoonosis [1,2]. Also human brucellosis is frequent and still endemic in many countries with an incidence of more than 500,000 cases annually worldwide [1,2,3]. It represents a real major public health problem with significant economic repercussions and heavy morbidity [4].

It is characterized, moreover, by a great clinical polymorphism making its diagnosis a real challenge for clinicians even in endemic areas [1,2,3,5,6].

Certain clinical presentations are exceptional and uncommon during this infection, particularly in the acute forms; they are thus qualified as “unusual” by several authors [5,6,7,8]. Among these unusual manifestations of brucellosis were: uveitis, neurobrucellosis, peritonitis, orchitis, epididymitis, pericarditis, pancytopenia, myocarditis, and vasculitis [5,6,7,8,9].

We report the original observation of isolated cutaneous vasculitis revealing acute brucellosis.

2. Case Presentation

44-year-old Tunisian man, with no notable pathological history, was admitted to our department for a rash with fever that had been evolving for two days. Somatic examination noted fever at 38°C, red-purple infiltrated and tender petechial lesions on feet, legs, and hands (Figure 1), small periungual necrotic lesions (Figure 2), and subungual splinter hemorrhages (Figure 3). The remainder of the somatic examination was without abnormalities. The basic biological tests showed a biological inflammatory syndrome with an erythrocyte sedimentation rate of 82mmH1 and a C-reactive protein at 62mg/l. The other tests were within normal limits (leukocytes, hemoglobin, platelets, creatinine, serum calcium, transaminases, muscle enzymes, serum protein electrophoresis, fast glycemia, plasma ionogram, thyroid hormones, and urinalysis). Electrocardiogram and chest X-ray were without abnormalities. The skin biopsy concluded in leukocytoclastic vasculitis, without signs of malignancy, and direct immunofluorescence was negative. The specific etiological assessment of this vasculitis was negative: specialized ENT examination with sinus X-ray, trans-thoracic cardiac ultrasound, abdominal ultrasound, thoraco-abdomino-pelvic tomodensitometry, anti-nuclear antibodies, anti-soluble antigen antibodies, anti-neutrophil cytoplasmic antibodies (ANCA, anti-PR3 and anti-MPO), cryoglobulins, immunoglobulin subclass levels, blood cultures, HLA B51 typing, quantiferon, and myelogram. Likewise, no recent drug intake, toxic exposure, or infection was noted. Considering the notion of consumption of unpasteurized milk revealed in the interrogation and the endemic character of our country for brucellosis, Wright's serology was requested and was positive at 1/1,280.

Figure 1. Petechial rash on feet and legs

Figure 2. Periungual necrotic lesions

Figure 3. Subungual splinter hemorrhages

Thus the diagnosis of acute septicemic brucellosis with brucellian vasculitis was retained. The patient was treated according to the protocol of the World Health Organization with the combination: Doxycycline 200mg/d and Rifampicin 600mg/d with a rapidly favorable evolution. The patient was afebrile on the second day of treatment. The lesions of cutaneous vasculitis disappear completely after one week of antibiotic therapy. The C-reactive protein was 5mg/l on the tenth day of treatment. Wright's serology was negative at the third month control, and no recurrence of vasculitis has been noted for a year now.

3. Discussion

Due to the large clinical polymorphism and misleading unusual presentations, the diagnosis of brucellosis is often missed, and it is estimated that fewer than 10% of cases of human brucellosis may be clinically recognized [11].

The overall frequency of these unusual clinical presentations was estimated at less than 5% [7,10]. Among these presentations, cardiovascular damage remains exceptional, occurring in less than 1% of cases [1,9].

The vascular involvement itself (vascular brucellosis) is very uncommon [1,12]. This involvement can be such as: endarteritis, arterial ulcers, aortitis, arterial and venous thrombosis, arterial aneurysms, and vasculitis [1,9,12,13,14,15].

Brucellian vasculitis is particularly unusual with only a few sporadic cases reported in the world literature [6,16,17,18,19,20].

This vasculitis can be localized: cutaneous, renal, and cerebral [1,16,17,18,19,21,22,23,24] or systemic [6,20]. Histologically, leukocytoclastic vasculitis is the most frequent [16,17,18]; more rarely, cases of granulomatous vasculitis [19] or Henoch-Schönlein purpura [20] have been reported.

The pathogenesis of brucellosis-associated vascular involvement is still unclear; two mechanisms can be discussed:

- Direct mechanism: the invasion of endothelial cells by the bacteria causing a sustained pro-inflammatory response (infectious vasculitis) [1,12,18],

- Indirect mechanism: induction by the bacteria of an immunological dysregulation with production of circulating immune complexes, immunoglobulins, cryoglobulins or autoantibodies causing immunological vasculitis [16,18,22,25].

Usually this vasculitis has a good prognosis with a rapidly favorable outcome under appropriate systemic antibiotic therapy [26]; more rarely, relapsing forms [3,6,7,8] as well as exceptional forms with fatal outcome [16] have been reported.

4. Conclusion

Healthcare professionals should be aware of the possibility of brucellosis in front of any unproven vasculitis, especially in endemic countries. In our observation, the concordance over time, the negativity of the etiological investigation, as well as the good response to specific antibiotic therapy, and the absence of subsequent recurrences make it possible to confirm the direct causal link between leukocytoclastic vasculitis and brucellosis. This better knowledge will make it possible to avoid diagnostic delay and improve the prognosis of this very simulating infection.

References

[1]   | Herrick JA, Lederman RJ, Sullivan B, Powers JH, Palmore TN. Brucella arteritis: clinical manifestations, treatment, and prognosis. Lancet Infect Dis. 2014; 14(6): 520-6.
[2]   | Zheng R, Xie S, Lu X, Sun L, Zhou Y, Zhang Y, et al. A Systematic Review and Meta-Analysis of Epidemiology and Clinical Manifestations of Human Brucellosis in China. Biomed Res Int. 2018; 2018: 5712920.
[3]   | Franco MP, Mulder M, Gilman RH, Smits HL. Human brucellosis. Lancet Infect Dis. 2007; 7(12): 775-86.
[4]   | Ulu-Kilic A, Metan G, Alp E. Clinical presentations and diagnosis of brucellosis. Recent Pat Antiinfect Drug Discov. 2013; 8(1): 34-41.
[5]   | Bouomrani S, Belgacem N, Ben Hamad M, Regaïeg N, Baïli H, Lassoued N, et al. Bilateral Panuveitis Revealing Acute Septicemic Brucellosis. EC Ophthalmology. 2018; 9. 6: 437-441.
[6]   | Bouomrani S, Dey M, Ahmed A. Acute Renal Failure Complicating Septicemic Brucellosis. J Pathol Infect Dis. 2019; 2(2): 1-2.
[7]   | Hatipoglu CA, Yetkin A, Ertem GT, Tulek N. Unusual clinical presentations of brucellosis. Scand J Infect Dis. 2004; 36(9): 694-7.
[8]   | Türksoy O, Tokgöz H, Toparli S. Unusual clinical presentations of brucellosis. Scand J Infect Dis. 2005; 37(10): 784.
[9]   | Gatselis NK, Makaritsis KP, Gabranis I, Stefos A, Karanikas K, Dalekos GN. Unusual cardiovascular complications of brucellosis presenting in two men: two case reports and a review of the literature. J Med Case Rep. 2011; 5: 22.
[10]   | Starakis I, Mazokopakis EE, Bassaris H. Unusual manifestations of brucellosis: a retrospective case series in a tertiary care Greek university hospital. East Mediterr Health J. 2010; 16(4): 365-70.
[11]   | Mantur BG, Amarnath SK, Shinde RS. Review of clinical and laboratory features of human brucellosis. Indian J Med Microbiol. 2007; 25(3): 188-202.
[12]   | Ferrero MC, Bregante J, Delpino MV, Barrionuevo P, Fossati CA, Giambartolomei GHet al. Proinflammatory response of human endothelial cells to Brucella infection. Microbes Infect. 2011; 13(10): 852-61.
[13]   | Tosatto V, Boattini M, Nascimento P, Barata Moura R. Lymphadenitis and aortitis due to Brucella melitensis infection. Infection. 2020; 48(2): 313-314.
[14]   | Anantha T, Chittaragi VB, Karthik MK, Kumar J, Kumar BS, Sai BS. A fatal, rare case of bilateral, upper, lower limbs and abdominal gangrene associated with brucellosis. J Lab Physicians. 2019; 11(4): 388-390.
[15]   | Wang M, Zhu Q, Yang Q, Li W, Wang X, Liu W, et al. Intestinal brucellosis associated with celiac artery and superior mesenteric artery stenosis and with ileum mucosa and submucosa thickening: A case report. Medicine (Baltimore). 2017; 96(2): e5893.
[16]   | Dizbay M, Hizel K, Kilic S, Mutluay R, Ozkan Y, Karakan T. Brucella peritonitis and leucocytoclastic vasculitis due to Brucella melitensis. Braz J Infect Dis. 2007; 11(4): 443-4.
[17]   | Massasso D, Gibson K. Brucellosis mimicking Henoch-Schönlein purpura. Med J Aust. 2007; 186(11): 602-3.
[18]   | Karaali Z, Baysal B, Poturoglu S, Kendir M. Cutaneous manifestations in brucellosis. Indian J Dermatol. 2011; 56(3): 339-40.
[19]   | Franco Vicario R, Balparda J, Santamaria JM, Alvaro C, Arizaga C, de la Villa FM, et al. Cutaneous vasculitis in a patient with acute brucellosis. Dermatologica. 1985; 171(2): 126-8.
[20]   | Akgun C, Akbayram S, Guner S, Aktar F, Temel H, Basaranoglu M. Brucellosis as a trigger agent for Henoch-Schönlein purpura. Bratisl Lek Listy. 2012; 113(8): 506-7.
[21]   | Elzouki AY, Akthar M, Mirza K. Brucella endocarditis associated with glomerulonephritis and renal vasculitis. Pediatr Nephrol. 1996; 10(6): 748-51.
[22]   | Yrivarren JL, Lopez LR. Cryoglobulinemia and cutaneous vasculitis in human brucellosis. J Clin Immunol. 1987; 7(6): 471-4.
[23]   | Catakli T, Arikan FI, Acar B, Dallar Y. Cutaneous vasculitis in a patient with acute brucellosis. Clin Exp Dermatol. 2009; 34(7): e387-8.
[24]   | Kim EJ, Lee SJ, Ahn EY, Ryu DG, Choi YH, Kim TH. Relapsed Brucellosis Presenting as Neurobrucellosis with Cerebral Vasculitis in a Patient Previously Diagnosed with Brucellar Spondylitis: A Case Report. Infect Chemother. 2015; 47(4): 268-71.
[25]   | Hermida Lazcano I, Sáez Méndez L, Solera Santos J. Mixed cryoglobulinemia with renal failure, cutaneous vasculitis and peritonitis due to Brucella melitensis. J Infect. 2005; 51(5): e257-9.
[26]   | Nagore E, Sánchez-Motilla JM, Navarro V, Febrer MI, Aliaga A. Leukocytoclastic vasculitis as a cutaneous manifestation of systemic infection caused by Brucella melitensis. Cutis. 1999; 63(1): 25-7.
[27]   | Perez C, Hernandez R, Murie M, Vives R, Guarch R. Relapsing leucocytoclastic vasculitis as the initial manifestation of acute brucellosis. Br J Dermatol. 1999; 140(6): 1177-8.