Hepatic brucelloma with initially negative antibodies: Diagnostic challenges in an endemic region

Hepatic abscess secondary to Brucella infection is an exceptionally rare clinical entity, accounting for approximately 1.7% of patients with brucellosis. Since its first description in 1904, hepatic abscess is reported as a rare complication of chronic brucellosis with a limited number of cases presented in the literature. Brucellosis itself most often follows an indolent or subclinical course, typically manifesting with low-grade fever, weight loss, malaise, myalgias, and arthralgias. Here, we report the case of a 44-year-old farmer from a rural endemic region who was presented with persistent low-grade fever over a period of approximately 2.5 months, characterized by evening exacerbations, associated with fatigue, sweating, and significant weight loss (15-20 kg). Initial serological testing for Brucella antibodies was negative. Due to ongoing diagnostic uncertainty, the patient underwent extensive evaluation across multiple levels of care, including imaging, abscess aspiration, and comprehensive laboratory testing (including tumor markers, cultures, and PCR), without establishment of a definitive diagnosis. He was treated empirically for presumed intra-abdominal infection but showed no clinical improvement. Following further deterioration, repeat serological testing demonstrated seroconversion. In the context of epidemiological exposure and clinical evolution, a diagnosis of probable brucellar hepatic involvement was made. Targeted therapy was initiated, resulting in clinical improvement. This case highlights the diagnostic challenges of brucellosis with initially negative serology and underscores the importance of repeated testing and sustained clinical suspicion in endemic settings.