An Unusual Presentation of Brucellosis – A Case of Rare Illness

A 4-year-old boy was admitted to Max Smart Super Speciality Hospital, Saket, at the end of March 2022 with a right-sided upper cervical swelling for 25 days and fever for 20 days. He was treated with medications as an outpatient with a provisional diagnosis of Staphylococcal Lymphadenitis. But his fever and neck swelling did not reduce. In the hospital, he was started on a combination of medicines for an  anticipated synergistic action on Staphylococci.

The fever subsided, but the cervical nodes stayed unchanged. Medications were changed since he developed a drug rash. He completed the course of 14 days of intravenous antibiotics and got discharged. At home, his fever relapsed, and there was an increase in the size and number of conglomerated lymph nodes in the neck, and there were new lymph nodes in the right axilla and left inguinal region. Considering a differential diagnosis of Tuberculosis and Lymphoma, he was readmitted to have a chest X-ray & a Mantoux test, which were both normal.

His physical examination was unremarkable. An FNAC of the node was done, which showed only Reactive Hyperplasia and negative for Gene expert for TB. The results of all standard investigations, including a CBC, Blood culture, Typhoid screen, KFT, and LFT, were normal. A USG of the abdomen showed a horseshoe kidney and multiple small splenic granulomas. The granulomas were in the spleen in the abdomen ultrasound, which is diagnostic. A test for Brucella antibody IgM fraction showed a high reading (positive).

He was then switched to an intravenous antibiotic for two weeks, along with oral antibiotic to be given for six weeks at home. It turned out that the child liked cottage cheese, not always pasteurised from where he probably caught the infection. At the follow-up after two weeks of discharge, he had no fever and a 30% decrease in swelling in the lymph nodes.

"This patient taught a lesson that though doctors treat common illnesses, there are other unusual causes of fever of unknown origin with lymphadenopathy. The doctors could avoid an excisional lymph node biopsy  to rule out Lymphoma in this child."

Brucellosis is a disease quite widespread in the Middle East, but cases occur sporadically in South Asia too. It is caused by a gram-negative bacillus from the unpasteurised milk of camel, goats and cattle and, if untreated, can be fatal.