Objective: Brucellosis is a zoonotic disease caused by Brucella spp. bacteria that is transmitted to humans through contact with animal products and body fluids of animals. It is a multisystemic disease associated with variable clinical symptoms. Although cutaneous symptoms can rarely be encountered at presentation and during the course of the disease, the occurrence of cutaneous vasculitis is extremely rare. Here, we present a case that presented with purpuric eruptions and was diagnosed with brucellosis-induced leukocytoclastic vasculitis.
Case report: A 62-year-old female presented to our clinic with fatigue, tiredness, and eruptions on the anterior aspects of both legs that had persisted for two weeks. On physical examination, there were diffuse, non-palpable maculopapular eruptions on the anterior surfaces of both tibias. Detailed patient history revealed complaints of myalgia and arthralgia, lumbar pain, fatigue, and eruptions that had persisted for approximately one month. The patient was a farmer and worked in animal husbandry. Laboratory tests were as follows; hemoglobin level, 12.3g/dL (range, 12–16g/dL); white blood cell count, 5.92×109/L (range, 4–10×109/L); platelet count, 115×109/L (range, 150–400×109/L); lactate dehydrogenase, 240IU/L (range, 120–246IU/L); total bilirubin, 0.8mg/dL (range, 0–1.1mg/dL); creatinine, 1.23mg/dL (range, 0.6–1.2mg/dL); alanine aminotransferase, 12U/L (range, <31U/L); erythrocyte sedimentation rate, 86mm/h (range, 0–15mm/h); C-reactive protein, 26.3mg/L (range, <5); prothrombin time (PT), normal; and activated partial thromboplastin time (aPTT), normal. HBsAg was negative, Anti-HCV was negative, Anti-HIV was negative, anti-nuclear antibody (ANA) was negative, rheumatoid factor was 19 IU/ML (range, 0–15), p-ANCA and c-ANCA were negative. Rose Bengal test performed due to clinical suspicion was positive. Brucella standard tube agglutination (STA) test was performed twice and was positive at a titer of 1/1280. A skin biopsy was taken from the purpuric lesions on the anterior aspect of the tibia. On histological examination; vascular structures in the dermis showed diffuse inflammation and neutrophilic and lymphocytic infiltration. On immunofluorescence examination; IgA: (–), IgM: (–), IgG: (–), C3: (–) and the results were consistent with leukocytoclastic vasculitis. Leukocytoclastic vasculitis could not be explained by medication use or infective endocarditis, and cryoglobulin tests were negative. The clinical picture was considered to be induced by acute brucellosis. The patient was started on rifampicin (600mg/day PO), doxycycline (100mg PO, q 12h) as brucellosis treatment. Vasculitic lesions showed significant improvement after two weeks of follow-up. Complete recovery was achieved with 6 weeks of antimicrobial treatment for brucellosis and Brucella SAT titres declined to 1:40 after the treatment.
Conclusion: Brucellosis is associated with a wide variety of cutaneous symptoms. Various cutaneous lesions such as maculopapular lesions, papules, petechia, purpura, and papulonodular lesions can be observed. Cutaneous symptoms encountered at presentation or during the course of the disease, particularly vasculitic eruptions, are extremely rare. Further, these eruptions can sometimes resemble subcutaneous bleeding induced by a hemostatic defect. However, in regions where brucellosis is endemic, such as Turkey, brucellosis should certainly be considered in the differential diagnosis when vasculitis is unexplained and classic brucellosis symptoms are concomitant.
