A 39 y/o Hispanic man presented with 1 week of fever, headache, photophobia, and mild confusion. His complaints and physical examination were consistent with possible meningitis, so empiric treatment with vancomycin, ceftriaxone and acyclovir was initiated following blood cultures. Laboratory data was significant for mild hyponatremia, transaminases 3-4X normal, monocytosis, and surprisingly normal CSF studies. Antibiotics were discontinued, the patient’s symptoms seemed to abate, and he was discharged on the 3rd hospital day with symptomatic treatment for a possible viral syndrome. Three days after discharge, the patient’s blood cultures grew Brucella species so he was summoned back to the hospital for further evaluation and definitive treatment.
Upon return, the patient was still febrile with mild head and backache. Further history was obtained from the patient’s wife that she bought Mexican goat cheese from a street peddler, which she served to the patient and other family members. Appropriate precautions were taken and doxycycline and rifampin were initiated. After three days of treatment, the patient’s symptoms resolved. He was discharged with plans for 6 weeks treatment and weekly follow-up in our resident clinic.
Brucellosis is caused by Gram negative, non-spore forming, intracellular coccobacilli that gain access to the human body via ingestion or inhalation. Over the years, this infection has been called by many names: undulant fever, Mediterranean fever, and Malta fever amongst others. Although there are eight total Brucella species, only four carry risk of human infection – B. melitensis, B. suis, B. abortus and B. canis.
The organism infects the reproductive organs of animals and is shed into their body fluids, including breast milk. The most common mode of transmission is eating unpasteurized milk or cheese products from infected animals. Mode of transfer via inhalation of aerosols most often affects laboratory technicians, veterinarians, and slaughterhouse employees. These groups of people are also susceptible to infection via contact if there is a breakdown in skin or mucus membranes. Human to human transmission, although rare, has been reported with breastfeeding, blood transfusion and sexual transmission.
Worldwide, there are 500,000 reported cases annually, but only around 100 per year in the US due to aggressive animal vaccination and pasteurization programs. The prognosis is excellent if the infection is diagnosed and treated within the first few months. Mortality rates between 2-5% can be seen with the main causes being endocarditis/arteritis and meningitis, which can manifest immediately or many years after onset of symptoms. This organism is also under close scrutiny due to its potential as an agent of bioterrorism.
Physicians in Texas and other border states have the opportunity to diagnose and treat diseases that are otherwise never seen in a developed country. Such diseases are rare and diagnosis and treatment may be delayed with unnecessary laboratory worker exposure if physicians are not aware and knowledgeable. We report a 39 year-old man who presented with several days of fever, headache, and constitutional symptoms who was subsequently diagnosed with Brucella melitensis. We will review his laboratory findings, clinical course, and diagnostic and therapeutic modalities for brucellosis. We will also review protocols to prevent accidental transmission to laboratory workers.