There is little information in the literature on the clinical progress of brucellosis in patients affected by other non-infectious diseases; however, the infection can often trigger an exacerbation of existing underlying conditions in certain target organs. In this report we present four cases of brucellosis complicating previous diseases, and the difficulties in relation to their diagnosis and treatment. The study involved four patients with the following disorders: polycythaemia vera, pulmonary fibrosis, cirrhosis of the liver and arthritis of the knee. Brucellosis was diagnosed by classical serological and bacteriological methods. The strains involved could be isolated only in three of the four patients: two strains were Brucella abortus biovar 1 and one was Brucella suis biovar 1. Two patients relapsed 10 and 7 months after admission, another presented chronic brucellosis and received various therapy schemes, and one died. Since the best selection of antibiotics and the optimal duration of therapy remain unknown for patients having brucellosis complicated by previous pathologies, these remain at the discretion of the attending physician. Management of our patients was controversial in terms of the selection of antibiotics, duration of treatment and decision regarding surgery. IntroductionThe clinical features of human brucellosis make diagnosis difficult because of their protean manifestations; in addition to non-specific symptoms, another characteristic of the disease is the paucity of physical signs. However, fever may spike and be accompanied by rigors if bacteraemia is present, and may be relapsing, mild or protracted. This disease may lead to changes in haematological parameters, although it has been stated that routine laboratory tests are generally not helpful for diagnosis, except that the white blood cell count is often normal or low (Young, 1995). Physical signs are generally nonspecific, although lymphadenopathy, hepatomegaly or splenomegaly is often found (Pappas et al., 2005). Common presentations such as osteoarticular (Ariza et al., 1993;Solera et al., 1999) and hepatosplenic involvement have been described (Cervantes et al., 1982;Akritidis & Pappas, 2001). Some authors have considered abscess production to be exceptional (Ariza et al., 2001), while respiratory system complications are acknowledged but considered to be rare (Pappas et al., 2003). Bone and joint involvement includes arthritis, spondylitis, osteomyelitis, tenosynovitis and bursitis (Weil et al., 2003).There is little information in the literature regarding the clinical progress of brucellosis in patients affected with other diseases; however, this infection can often trigger an exacerbation of existing underlying conditions in certain target organs (Akritidis & Pappas, 2001). The objective of this report is to present four cases where brucellosis complicated previous diseases that were followed up over an extended period of time, and to discuss the difficulties in relation to treatment, as well as diagnostic problems. Case repo...
Clinically significant hematologic abnormalities are common in persons with human immunodeficiency virus infection(HIV). None the less aplastic anemia (AA) is an unusual entity associated with HIV infection. We want to communicate the case of an HIV infected patient whit acquired AA and the good results obtained with peripheral blood stem cell trasplantation (PSCT) from an histoidentical twin brother. A 31 years old man presented with epistaxis and weakness. No physical abnormalities were observed. Blood counts showed: Hb:8,5g/dL;absolute neutrophil count(ANC)1000/mm3;platelets10.000/mm3 and absolute reticulocyte count (ARC)25.000/uL. Bone marrow (BM) aspiration showed severely depressed BM cellularity. There was no morphological evidence of hypocellular myelodysplastic syndrome. Flow cytometric analysis of red cells and granulocytes was performed and there was no evidence of paroxysmal nocturnal hemoglobinuria clone. In the BM biopsy the hematopoietic cells represented 15% of the residual cells. The karyotype was normal. The enzyme immunoassay to detect increases in titers of antibodies against HIV was positive and was confirmed by western blot. Initial CD4+ T cells count: 424/mm3. Initial serum HIV RNA level : 30.000 copies /ml. HIV RNA copies in BM were not detected. Others serologic assays:hepatitis(H) A:(−);HB(−);HC(−). Specific IgM e IgG against parvovirus B19(−)VDRL(−). IgM VCA Epstein-Barr virus (EB)(−) IgG(VCA)E:B(+1/250). Detection of CMV antigens(pp65) was negative in four opportunities during the course of the illness. Blood cultures for Bartonella spp and Histoplasma capsulatum (−) Fetal Hb normal. Direct Coombs test (−). Chest and abdominal computed tomography were normal. Drug/toxin exposure were ruled out. He began highly active antiretroviral therapy (HAART) with zidovudine(AZT), lamivudine(3TC)and efavirenz. While HLA typing was ordered he received supportive treatment with platelet concentrates from single donor and packed red cells leucodepletated on account of his transfusion- dependent anemia, both irradiated. Recombinant erythopoietin 4.000UI 3 times/week during a month was useless to diminish the red cells transfusion requirements. Granulocyte colony-stimulating factor15UI/day increased the (ANC) to 2.500/mm3. The twin brother showed to be an histocompatible donor. Complementary studies were done and they demonstrated that they were monocorial twins.(Identity index is II=1,37×1022). CD4+T cell count pretransplantation:383/mm3. HIVRNAcopies < 50/ml. Conditioning regimen : cyclophosphamide 5000mg /day for 4 days. The 4th day he also received intravenous immunoglobulin (20000mg). PSCT was selected because of its more rapid blood count recovery(platelets and neutrophils)It was infused 11,7×106 CD34/kg. G-CSF was not administered. Neutrophil and platelet engrafment was obtained on day +11. Ten red cell packed units were administered post(PSCT). The only complications were light mucositis and fever during the neutropenic phase which requires broad spectrum antibiotics. 26 days after (PSCT) CD4+T count were 318/mm3 and the viral load was < of 50 copies. It was reinstituded HAART (3TC, efavirenz and abacavir). Eight months after the(PSCT) the blood counts are:Hb:14,2 g/dl; ANC:5.330/mm3 and platelets:290.000/mm3. We conclude that in the HAART era the HIV patients are able to receive intensive treatments with low morbidity.
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