|Year : 2015 | Volume
| Issue : 3 | Page : 367-369
A rare case report of Brucellosis in human immunodeficiency virus infected patient from rural Uttar Pradesh
Shewtank Goel1, Shelesh Goel2, Ruhi Pathania3, Abhishek Singh4, Deepak Pathania5, Nand Kishore Singh4
1 Department of Microbiology, Major S. D. Singh Medical College, Fathehgarh, Farrukhabad, Uttar Pradesh, India
2 Department of Community Medicine, GFIMS&R, Ballabgarh, Faridabad, India
3 Department of Microbiology, Maharishi Markandeshwar Institute of Medical Sciences, Mullana, India
4 Department of Community Medicine, Shaheed Hasan Khan Mewati Government Medical College, Nalhar, Mewat, Haryana, India
5 Department of Community Medicine, Maharishi Markandeshwar Institute of Medical Sciences, Mullana, India
|Date of Web Publication||15-May-2015|
Department of Community Medicine, Shaheed Hasan Khan Mewat Government Medical College, Nalhar, Mewat, Haryana
Source of Support: None, Conflict of Interest: None
We report a case of brucellosis in a patient infected with the human immunodeficiency virus (HIV), who came to seek medical care at a tertiary care center in rural Uttar Pradesh. A 26-year-old male patient, milk salesperson by occupation who also used to rear his cattle as a routine, presented with complaints of longstanding fever accompanied with vomiting, giddiness, myalgia, and headache. No significant abnormality was detected on routine physical and laboratory investigations except reactive HIV antibodies. It was decided to conduct the serological tests for the evidence of brucellosis as clinical symptoms continued to persist. He had high titers of Brucella agglutinin, and responded to treatment with tetracycline and streptomycin. The isolates were confirmed at Indian Veterinary Research Institute, Izatnagar.
Keywords: Brucella , brucellosis, human immunodeficiency virus
|How to cite this article:|
Goel S, Goel S, Pathania R, Singh A, Pathania D, Singh NK. A rare case report of Brucellosis in human immunodeficiency virus infected patient from rural Uttar Pradesh. Med J DY Patil Univ 2015;8:367-9
| Introduction|| |
Worldwide Brucellosis More Details is considered as an important re-emerging zoonotic disease.  It is an important co-infection in human immunodeficiency virus (HIV) infected patients, as HIV leads to the susceptibility of such patients to several bacterial opportunistic infections including brucellosis. Some studies have reported more severe forms and high prevalence of brucellosis including relapses, when it is associated with HIV and other immunocompromised conditions. ,,
The clinical manifestations of brucellosis among human beings are inconsistent and only if a high index of suspicion is maintained, will the disease be identified. The laboratory aid is essential because it is next to impossible to diagnose it clinically. Therefore, the present case is being reported for the rare occurrence of brucellosis in a patient infected with HIV.
| Case Report|| |
A 26-year-old male patient presented with complaints of fever with chills and rigors - on and off in nature over a period of 20 days, associated with vomiting, giddiness, myalgia, and headache. He was milk salesperson by occupation and used to rear his cattle as a routine, general physical examination did not reveal any abnormality, except for tenderness in the right hypochondrium. On examination of the abdomen, liver was palpable. Routine hematological examination showed, mild leukopenia with a relative lymphocytosis (total leukocyte count: 3600/cu.mm, differential leukocyte count: Neutrophil - 35%, lymphocyte -60%, eosinophil -1%, monocyte -4%, basophil -0%). Urine examination was found to be within normal limits. Peripheral smear for malarial parasites was negative. HIV antibody (Tridot method) was reactive which was confirmed by enzyme-linked immunosorbent assay. Western blot confirmed the diagnosis. Routine blood culture did not show any bacterial growth even after 8 weeks of incubation. Titers of Widal test were not significant (manufacturer for Tridot & Western Blot Kit - J. Mitra & Co. Pvt. Ltd., manufacturer for Widal Test Kit - Bio Lab Diagnostics India Private Limited, Mumbai).
Clinically, patient did not improve as the clinical symptoms continued to persist. Hence, serological tests for the evidence of brucellosis were done after obtaining informed expressed written consent from the patient. The serum samples were subjected to tests such as Rose Bengal plate test (RBPT) and standard tube agglutination test (STAT). The serum was subjected to RBPT with a drop of Brucella More Details abortus plain antigen. RBPT antigen was obtained from Indian Veterinary Research Institute (IVRI), Izatnagar. The presence of agglutination was assessed by naked eye examination. Positive agglutination was further subjected to the standard agglutination test (SAT) by tube dilution method. , The patient had high-agglutinin titers of 1:640, which is considered as significant. Source of SAT antigen is IVRI, Izatnagar.
A volume of 10 ml of blood was aseptically collected from antecubital fossa of patient who showed the presence of anti-Brucella antibodies by STAT. A volume of 5 ml of blood was added to each of the two bottles containing 50 ml of brain heart infusion (BHI) broth (Himedia). One bottle was incubated at 37°C, and other was incubated in CO 2 incubator to provide 5% of CO 2 .
Subcultures were made onto BHI agar plates (Himedia) in duplicate every 4 th day of incubation. Simultaneously, smears were made from the broth and stained by modified cold Ziehl-Neelsen (ZN) stain. Presence of acid-fast Gram-negative coccobacillary forms on 19 th day from BHI broth from CO 2 incubator was considered to be suggestive of Brucella. Thus, it was cultured on BHI agar plates, isolated, and confirmed. The isolates were identified based on colony morphology, gram stain, modified "ZN" staining, CO 2 requirement, biochemical tests such as oxidase and urease, H 2 S production for 4 days and growth in the presence of basic fuchsine (1:50,000 and 1:100,000) and thionin (1:25,000, 1:50,000, and 1:100,000). Provisional confirmation and bio-typing of the isolate were done by performing slide agglutination test using B. abortus and Brucella melitensis monospecific antisera (Murex Biotech). The patient was put-on tetracycline 250 mg, orally 4 times a day for 6 weeks along with streptomycin, 1 g/day intramuscular for 3 weeks. The patient responded very well to the treatment as fever, malaise, vomiting, giddiness, myalgia, and headache subsided and cell count started coming within the normal limits. These isolates were then sent to IVRI, Izatnagar for further confirmation.
| Discussion|| |
Brucellosis is a disease of worldwide distribution and it has been reported from almost all the states of India.  Human beings are susceptible hosts and acquire the infection by consuming raw infected milk and unpasteurized milk products. It has been estimated that the true incidence may be 25 times higher than the reported incidence due to misdiagnosis and underreporting.  The diagnosis of chronic brucellosis is frequently difficult to prove. Brucellosis has been described rarely in patients with HIV. Despite the fact that the clearance of intracellular Brucellae is largely dependent on cell-mediated immunity, these patients have relatively preserved immunity. 
Brucella spp. infects not only their preferred hosts, but also other domestic and wild animal species, which in turn can act as reservoirs of the disease for other animal species and humans. Brucellosis is, therefore, considered to be a major zoonosis transmitted by direct contact with animals and/or their secretions, or by consuming milk and dairy products. People living in rural areas are at a higher risk for acquisition of Brucella infection, while living in cities has a greater risk for exposure to HIV.
Association of brucellosis and HIV is a rare occurrence. Presentation of this case was not atypical, and the case had a relatively preserved immunity according to the presenting symptoms and findings. Patient was a milk vendor by profession coming in contact with infected raw milk and the body fluids of infected cattle thus, showing clear epidemiologic correlates for acquisition of brucellosis. The results of SAT for brucellosis correlated with epidemiological data (time, place, and person distribution), clinical data, and other laboratory information. He presented with high titers of Brucella agglutinins and responded to treatment with tetracycline and streptomycin.
Findings of our study mimic the findings presented by another study from Spain.  Author observed that most cases of brucellosis occur in asymptomatic patients with relatively preserved immunity. The epidemiology, clinical presentation, diagnosis, response to therapy, and outcome are similar to those observed in non HIV-infected patients.
Similar picture of brucellosis in patients with HIV infection has been reported by other authors from different parts of the globe. ,,
The triad of clear-cut epidemiologic correlates, consistent clinical features, and raised levels of Brucella antibodies confirms the diagnosis of brucellosis. Brucellosis has to be considered as a firmly significant differential diagnosis in any HIV positive patient with myalgia, fever, or other unexplained conditions, particularly in brucellosis endemic regions of the world.
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