Acute Brucella Hepatitis in an Urban Patient

A 35-year-old man was referred to our center because of low grade fever, vomiting, yellow sclera, and tenderness inthe upper-right quadrant of his abdomen. Laboratory tests showed a white blood cell (WBC) of 7100/μL, a platelet of184,000/μL, an erythrocyte sedimentation rate (ESR) of 4 mm/h, an alanine aminotransferase (ALT) of 525 U/L, an aspartateaminotransferase AST of 142 U/L, a total bilirubin level of 4.23 mg/dL, and a direct bilirubin level of 3.16 mg/dL. Viral hepatitis markers, immunoglobuline M antibody to cytomegalovirus (anti-CMV IgM), Ebstein-Barr virus (EBV)IgM, and immunologic markers of autoimmune hepatitis were negative. The patient was diagnosed with acute hepatitis.Alkaline phosphatase was in the normal range throughout the course of the disease. Because of the patient’s occupationas a butcher and his history of eating semi-cooked sheep testes, serologic tests of brucellosis were conducted; the testscame out positive. We were concerned about the hepatotoxicity of standard regimens; therefore, we started treatmentwith streptomycin and ciprofloxacin regimens. Although liver enzyme had fallen and fever discontinued, the total anddirect bilirubin concentrations in the patient’s serum both increased in spite of using 2 weeks of the abovementioneddrug regimen. The elevation of bilirubin could have been due to drug hepatotoxicity. Alternatively, a regimen containingciprofloxacin may have not have been efficient enough and may have had effects on the direct bilirubin concentration.Fortunately, within 8 weeks, progressive recovery was noticed. Brucellosis should be considered in the differential diagnosisof fever and hepatitis for those who live in endemic areas, especially if his/her job was at high risk for acquiringbrucellosis. We recommend taking a careful occupational and behavioral history for patients with acute hepatitissyndrome. We assumed that ciprofloxacin was not suitable for brucella hepatitis treatment and also it may cause liverdamage. The most appropriate treatment is a standard regimen containing doxycycline.