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CASE REPORT
Year : 2022  |  Volume : 11  |  Issue : 5  |  Page : 9-11

An interesting case of glomerulonephritis and rhabdomyolysis


Department of General Medicine, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India

Date of Submission31-Mar-2020
Date of Decision15-May-2020
Date of Acceptance04-Sep-2020
Date of Web Publication30-Aug-2022

Correspondence Address:
Mallikarjuna Shetty
Associate Professor, Department of General Medicine, Department of General Medicine, Nizam's Institute of Medical Sciences, Panjagutta, Hyderabad 500 082, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JCSR.JCSR_33_20

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  Abstract 


A 19-year-old male from a rural background with no prior co-morbidities came with chief complaints of fever for 4 days, associated with chills, rigors, myalgias and high coloured urine. On general examination, pallor was present. Vitals and systemic examination were normal. Routine blood investigations were sent, and two sets of blood cultures were sent. The patient was empirically started on ceftriaxone. Complete urine examination showed >20 red blood cells (RBCs)/high-power field (HPF) with four to five RBC casts/HPF. Initial creatine phosphokinase was 3216 U/L. The patient's fever spikes continued, and antibiotic was changed to piperacillin-tazobactam after 48 h and then to meropenem. Fever spikes continued. The patient developed pancytopenia and acute respiratory distress syndrome. Final blood culture report grew Brucella melitensis. The patient was started on streptomycin and doxycycline. The patient improved clinically and discharged in clinically stable condition.

Keywords: Brucella melitensis, creatine phosphokinase, pancytopenia


How to cite this article:
Babu KN, Reddy D A, Shetty M, Rao M N. An interesting case of glomerulonephritis and rhabdomyolysis. J Clin Sci Res 2022;11, Suppl S1:9-11

How to cite this URL:
Babu KN, Reddy D A, Shetty M, Rao M N. An interesting case of glomerulonephritis and rhabdomyolysis. J Clin Sci Res [serial online] 2022 [cited 2022 Oct 2];11, Suppl S1:9-11. Available from: https://www.jcsr.co.in/text.asp?2022/11/5/9/355152




  Introduction Top


Brucellosis is a zoonotic infection transmitted to humans from infected animals (cattle, sheep, goats, camels and pigs) by ingestion of food products or by contact with tissue or fluids. It is the most common zoonosis worldwide and is an important public health problem in many developing countries.[1],[2],[3] Consumption of unpasteurised dairy products (especially raw milk, soft cheese and butter) is the most common means of transmission.[1],[4]

We present this case because brucellosis is endemic in India and it should be considered in the differential diagnosis of any acute febrile illness in the relevant clinical setting.


  Case Report Top


A 19-year-old male student from a rural background with no prior co-morbidities came with chief complaints of high-grade fever for 4 days associated with chills, rigors, myalgias and associated with high coloured urine. There was no history of cough, breathlessness and jaundice. On general physical examination, pallor was present. Blood pressure was 130/70 mmHg and pulse rate was 106 beats/min. Systemic examination was normal.

On evaluation, haemogram showed anaemia and thrombocytopenia. Urinalysis revealed red blood cells (RBCs) >20/high-power field (HPF). On day 1 serum creatinine was 2.6 mg/dL. Serum aspartate aminotransferase was elevated; alanine aminotransferase was normal [Table 1]. Viral markers were negative. Creatine phosphokinase was elevated. Smear and strip tests for malarial parasite were negative. Dengue, scrub immunoglobulin M (IgM) and Leptospira IgM serology were sent and were negative. Two sets of blood cultures were sent.
Table 1: Laboratory data

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During hospital stay, fever of 104 °F was recorded on day 1. The patient was treated with intravenous normal saline and empirically started on intravenous ceftriaxone 1 g twice-a-day. Fever spikes continued. The patient's blood pressure increased to 160/100 mmHg the next day. Serum procalcitonin was 18.18 ng/mL. Chest radiograph obtained on the first day was normal. Urine for myoglobin was negative. Repeat urinalysis showed 90–100 RBCs/HPF with occasional dysmorphic RBCs and four to five RBC casts/HPF. Blood cultures after 48 h of admission were sterile. Two-dimensional echocardiography was normal. Antibiotic was changed to piperacillin-tazobactam on day 3 in view of persisting fever spikes. The 24-h urinary protein was 800 mg. Antinuclear antibody was negative. On day 4, the patient's haemoglobin was 7.8 g/dL, total leucocyte count was 2200/mm3 and platelet count was 40,000/mm3. In view of pancytopenia, bone marrow aspiration and biopsy were done. Bone marrow aspiration was reported as normal. The patient developed shortness of breath on day 4. Chest radiograph was suggestive of bilateral lower lobe infiltrates. The ratio of arterial oxygen saturation PaO2 to fraction of inspired oxygen (FIO2) was 166 suggestive of moderate acute respiratory distress syndrome (ARDS). High-resolution computed tomography (HRCT) of the chest was suggestive of interstitial thickening and ground-glass opacities in bilateral lower lobes. Antibiotic was changed to meropenem and oxygen supplementation given. Fever spikes continued.

In view of rural background and history of myalgias, Brucella standard agglutination test was sent which came positive with titres of 1: 640. On the 5th day of admission, final blood culture report came and was suggestive of growth of Brucella melitensis in two sets. A final diagnosis of infection-related glomerulonephritis, rhabdomyolysis with acute kidney injury (AKI), pancytopenia and ARDS secondary to B. melitensis sepsis was made.

The patient was started on intramuscular streptomycin 1 g once-a-day and oral doxycycline 100 mg twice-a-day. The patient's fever spikes subsided and shortness of breath and myalgias resolved. Pancytopenia recovered gradually. AKI resolved. The patient was discharged and followed on an outpatient basis. The patient improved completely after treatment with intramuscular streptomycin for 21 days and tablet doxycycline for 6 weeks.


  Discussion Top


The prevalence of brucellosis has been increasing due to growing international tourism and migration.[5] Brucellosis typically presents with insidious onset of fever, malaise, night sweats and arthralgias.[1],[4] Brucellosis can affect any organ system.[6]

Osteoarticular disease is the most common form of focal brucellosis; it occurs in up to 70% of patients with brucellosis.[7] Genitourinary involvement is the second most common form of focal brucellosis; it occurs in up to 8% of cases.[8]

Laboratory findings of brucellosis may include elevated transaminases and haematologic abnormalities including anaemia, leucopenia or leucocytosis with relative lymphocytosis and thrombocytopenia.[4] A presumptive diagnosis of brucellosis is made via either of the following:[3] (i) Brucella total antibody titre ≥1:160 by standard tube agglutination test (SAT) in serum specimen obtained after onset of symptoms; and (ii) detection of Brucella deoxy ribonucleic acid (DNA) in a clinical specimen by polymerase chain reaction assay.

In general, positive SAT titres consist of >1:160 outside endemic regions and >1:320 within endemic areas.[1] The sensitivity and specificity of SAT are high (95% and 100%, respectively). The sensitivity of blood culture for the diagnosis of brucellosis is 15%–70%.[9] Most blood cultures are positive between 7 and 21 days; subcultures should be performed for at least 4 weeks.[1]

Bone marrow culture is more sensitive than blood culture and is considered the gold standard for the diagnosis of brucellosis.[1] Bone marrow culture has a shorter time to detection than blood culture, and its sensitivity is not diminished by prior antibiotic use.[10] Regimens for the treatment of adults with brucellosis (in the absence of focal disease due to spondylitis, neurobrucellosis or endocarditis) include:[2] (i) doxycycline (oral) for 6 weeks plus streptomycin (parenteral) for the first 14–21 days; (ii) doxycycline (oral) for 6 weeks PLUS gentamicin (parenteral) for the first 7–10 days; and (iii) doxycycline (oral) plus rifampicin (oral), both for 6 weeks.

Brucellosis is the most common zoonosis worldwide and is an important public health problem in many developing countries.[1],[2],[3] Correct diagnosis and treatment will result in cure in most of the cases. Our case highlights the fact that although Brucella typically has an insidious onset, it should be considered in the differential diagnosis of any acute febrile illness in the relevant clinical setting.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Pappas G. Akritidis N, Bosilkovski M, Tsianos E. Brucellosis. N Engl J Med 2005;352:2325-36.  Back to cited text no. 1
    
2.
Corbel MJ. Brucellosis in humans and animals. World Health Organization; 2006.  Back to cited text no. 2
    
3.
Alay H, Can FK, Yılmaz EP. A very rare case of brucellosis-related tubo-ovarian abscess. Rev Soc Bras Med Trop 2020;53: e20190501.  Back to cited text no. 3
    
4.
Bosilkovski M, Krteva L, Dimzova M, Vidinic I, Sopova Z, Spasovska K. Human brucellosis in macedonia–10 years of clinical experience in endemic region. Croat Med J 2010;51:327-36.  Back to cited text no. 4
    
5.
Pappas G, Panagopoulou P, Christou L, Akritidis N. Biological weapons. Cell Mol Life Sci 2006;63:2229-36.  Back to cited text no. 5
    
6.
Mantur BG, Amarnath SK, Shinde RS. Review of clinical and laboratory features of human brucellosis. Indian J Med Microbiol 2007;25:188.  Back to cited text no. 6
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7.
Al Shaalan M, Memish ZA, Al Mahmoud S, Alomari A, Khan MY, Almuneef M, et al. Brucellosis in children: Clinical observations in 115 cases. Int J Infect Dis 2002;6:182-6.  Back to cited text no. 7
    
8.
Araj GF. Human brucellosis and its complications. In: Neurobrucellosis. Springer, Cham: 2016. p. 7-12.  Back to cited text no. 8
    
9.
Memish Z, Mah MW, Al Mahmoud S, Al Shaalan M, Khan MY. Brucella bacteraemia: Clinical and laboratory observations in 160 patients. J Infect 2000;40:59-63.  Back to cited text no. 9
    
10.
Gotuzzo E, Carrillo C, Guerra J, Llosa L. An evaluation of diagnostic methods for brucellosis–the value of bone marrow culture. J Infect Dis 1986;153:122-5.  Back to cited text no. 10
    



 
 
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