Brucellosis infection presenting with cholestasis

Brucellosis is a relatively common disease in the Mediterranean area and may present with prolonged fever without focus, however it remains an important diagnostic challenge to most pediatricians. We report the case of a 10-year-old male patient who presented with fever without a focus of 10-day duration, hepatomegaly, ascites, a small elevation in transaminases and acute-phase reactants indicating cholestasis, leukopenia, and thrombocytopenia. Imaging tests showed many small, rounded, hypodense focal lesions in the liver and spleen. After eliminating a wide range of diseases, positive results for the Rose Bengal test and indirect immunofluorescence assay for Brucella melitensis made it possible to establish a diagnosis of hepatosplenic brucellosis. A review of the family history revealed direct contact with farm animals. The patient made good progress on treatment with doxycycline and streptomycin, with complete resolution of both clinical symptoms and imaging signs. The prevalence of brucellosis is gradually increasing, mainly due to migratory movements. It should always be eliminated as a source of unknown fever in endemic areas and should also be taken into account in other geographical areas where it is not common whenever a patient presents with prolonged fever and unspecific symptoms. Standard therapy is highly effective, even in relapse cases, and early diagnosis leads to a rapid recovery and favorable outcome. The unusual presentation in the case reported here reminds us that it is possible to encounter a Brucella infection in a case of fever without a focus, irrespective of the existence of a clear epidemiological history, which is very often omitted by the family. All differential diagnostic protocols for fever without a focus should include a diagnostic test for Brucella in order to achieve early detection of the disease and initiate therapy promptly.