CASE RECORDS OF TH E MASSACH USET TS GENERA L H OS PITA L

Case Records of the Massachusetts General Hospital

The temperature was 37.1°C, the pulse was 60,

and the respirations were 18. The blood pressure was
100/60 mm Hg.
Physical examination showed no abnormalities ex-
cept for the presence of a grade 2 systolic murmur
Weekly Clinicopathological Exercises along the upper sternal border on the right side. The
FOUNDED BY RICHARD C. CABOT urine was positive (++) for protein; the sediment con-
tained 0 to 2 red cells, 3 to 5 white cells, and 0 to
R O B E R T E . S C U L L Y , M. D. , Editor 2 hyaline casts per low-power field. Other laboratory
E U G E N E J. M A R K , M. D. , Associate Editor tests were performed (Tables 1 and 2). An electrocar-
W I L L I A M F. M C N E E L Y , M. D. , Associate Editor
J O - A N N E O. S H E P A R D , M. D. , Associate Editor
S A L L Y H . E B E L I N G , Assistant Editor
S T A C E Y M. E L L E N D E R , Assistant Editor
TABLE 1. HEMATOLOGIC LABORATORY VALUES
C H R I S T I N E C . P E T E R S , Editorial Staff
ON ADMISSION.
Case 20-2001
VARIABLE VALUE
PRESENTATION OF CASE
Hematocrit (%) 36.7
A 64-year-old man was admitted to the hospital
Mean corpuscular volume (µm3) 77
because of fever and bacteremia. Erythrocyte sedimentation rate (mm/hr) 58
The patient had had hypertension for 20 years, White-cell count (per mm3) 8,200
type 2 diabetes mellitus for 16 years, and coronary dis- Differential count (%)
ease for 7 years, with a history of myocardial infarc- Neutrophils 41
Lymphocytes 48
tion and congestive heart failure. He also had protein- Atypical lymphocytes 1
uria (+++) and mild, chronic renal insufficiency. Eosinophils 2
He had otherwise been well until three weeks be- Platelet count (per mm3) 253,000
fore admission, when he was traveling in the Middle Prothrombin time Normal
East and began to have fever (peak temperature, Partial-thromboplastin time Normal
39.0°C), with fatigue and weight loss. Ten days before
admission, treatment with ciprofloxacin (500 mg
daily) was begun. Three days later, a physician heard a
soft systolic murmur on physical examination; the tem-
TABLE 2. BLOOD CHEMICAL VALUES
perature was normal, and the erythrocyte sedimen- ON ADMISSION.*
tation rate was 59 mm per hour. A chest radiograph
was unremarkable; an abdominal ultrasonographic
examination revealed a gallstone, without evidence VARIABLE VALUE

of thickening of the gallbladder wall, and a cyst in the Urea nitrogen (mg/dl) 33
left kidney. A malarial smear was negative. The fever Creatinine (mg/dl) 2.1
recurred, and the administration of ciprofloxacin for Glucose (mg/dl) 139
six days and additional treatment with metronida- Sodium (mmol/liter) 137
zole (400 mg twice a day) did not relieve it. A cul- Potassium (mmol/liter) 4.7
ture of a blood specimen, obtained three days after Chloride (mmol/liter) 98
Carbon dioxide (mmol/liter) 29.8
the initiation of treatment with ciprofloxacin, yielded
Magnesium Normal
gram-negative bacilli, which were identified as b-lac- Calcium Normal
tamase–negative Moraxella phenylpyruvica. The micro- Phosphorus Normal
organisms were sensitive to amoxicillin, cefuroxime, Bilirubin
ciprofloxacin, gentamicin, and tetracycline and were Total Normal
resistant to trimethoprim. The patient was admitted Conjugated Normal
Enzymes Normal
to this hospital.
The patient’s weight had dropped from 93 to 78 kg *To convert the value for urea nitrogen to milli-
during the year before admission. He reported that moles per liter, multiply by 0.357. To convert the val-
ue for creatinine to micromoles per liter, multiply by
he had not ingested unpasteurized milk and had con- 88.4. To convert the value for glucose to millimoles
sumed little meat. per liter, multiply by 0.05551.

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 The Ne w E n g l a nd Jo u r n a l o f Me d ic i ne

diogram showed nonspecific ST-segment and T-wave material, revealed multiple, calcified left-sided hilar and
abnormalities; the findings were otherwise normal. subcarinal lymph nodes; the lungs appeared normal.
Thoracic radiographs showed no abnormalities. A A CT scan of the abdomen and pelvis, obtained after
transrectal ultrasonographic study of the prostate the oral administration of contrast material, showed
gland showed no evidence of an abscess. a gallstone.
Urine and three samples of blood were obtained for On the fifth hospital day, a radionuclide bone scan
culture. Cefuroxime (750 mg every eight hours) was showed small foci of increased uptake in the cervical
administered. During the next several days, the peak spine, right foot, and right knee; these findings were
temperature each day ranged from 36.9° to 37.6°C. most consistent with the presence of degenerative
The urine culture and an assay for Clostridium diffi- changes. There was no evidence of osteomyelitis. On
cile toxin were negative. the sixth hospital day, one of the three blood-culture
On the second hospital day, an ultrasonographic specimens obtained on admission yielded gram-neg-
examination of the kidneys revealed bilateral cysts and ative rods.
a hyperechoic stone on the left side, without evidence A diagnostic procedure was performed.
of hydronephrosis. A transthoracic cardiac ultrason-
ographic study showed thickening of both mitral leaf- DIFFERENTIAL DIAGNOSIS
lets, calcification of the posterior mitral annulus, left DR. DIMITRIOS P. KONTOYIANNIS*: May we re-
atrial dilatation, thickened aortic leaflets, symmetric view the pertinent radiographic findings?
left ventricular hypertrophy, and segmental left ven- DR. CONSTANTINO S. PEÑA: A CT examination
tricular dysfunction. The estimated ejection fraction of the thorax (Fig. 1), performed after the oral admin-
was 60 percent. A transesophageal cardiac ultrason- istration of contrast material, showed small, calcified
ographic examination showed no evidence of vegeta- subcarinal and left-sided hilar lymph nodes that were
tions or paravalvular abscesses; there was moderate consistent with prior granulomatous disease.
atheromatous disease of the descending thoracic aorta DR. KONTOYIANNIS: A traveler returning from the
with several protruding plaques, including one that Middle East who presents with a nonspecific, pro-
appeared ulcerated. tracted febrile illness may have any one of a variety of
On the third hospital day, a tuberculin skin test bacterial, parasitic, rickettsial, fungal, viral, or non-
(purified protein derivative, 5 TU) was positive, with infectious diseases (Table 3).1-15
an induration that was 16 mm in diameter. (The pa-
tient had received bacille Calmette–Guérin vaccine in Bacterial Infections
the past and a booster dose more recently; a tubercu- Enteric fevers, especially typhoid fever, often have
lin skin test with purified protein derivative, performed no distinctive clinical and laboratory features and
after the booster dose, was negative.) Additional blood should therefore be considered in all febrile patients
and urine specimens were obtained for culture, and who have traveled to areas where enteric fevers are
a single dose of vancomycin was given. A computed endemic, such as the Middle East, even if there are no
tomographic (CT) examination of the thorax (Fig. 1), gastrointestinal symptoms.2 The ineffectiveness of cip-
performed after the oral administration of contrast rofloxacin in this patient, however, is evidence against
infection with various salmonella species that cause
enteric fever.3 Also, this patient had no gastrointesti-
nal symptoms suggestive of an enteric infection caused
by nontyphoidal salmonella species, Shigella flexneri,
enteroinvasive strains of Escherichia coli, or various
campylobacter or noncholera vibrio species.2 Finally,
none of the aforementioned gram-negative bacteria
have ever been misidentified as M. phenylpyruvica.
Another bacterial possibility is leptospirosis, a cosmo-
politan zoonosis,4 but it is very unlikely in the ab-
sence of a history of exposure to the causative organ-
ism and a biphasic presentation with an influenza-like
illness and conjunctivitis, followed by meningitis, uvei-
tis, rash, or hepatorenal dysfunction. I shall return to
two other bacterial diseases that are more likely to
have caused this patient’s illness and choose one of
them as the almost certain diagnosis.

*Assistant professor of medicine, assistant internist, and director of clin-

ical mycology, Department of Infectious Diseases, Infection Control, and
Figure 1. CT Scan of the Thorax at the Level of the Hila, Showing Employee Health, University of Texas M.D. Anderson Cancer Center,
Calcified Left-Sided Hilar and Subcarinal Lymph Nodes (Arrows). Houston.

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 CASE RECORDS OF TH E MASSACH USET TS GENERA L H OS PITA L

TABLE 3. DIFFERENTIAL DIAGNOSIS OF FEVER IN A PATIENT WHO HAS RECENTLY TRAVELED

TO THE MIDDLE EAST.

FINDINGS DISORDERS

Gastroenteritis Infection due to enterotoxigenic Escherichia coli, enteroinvasive E. coli, salmo-

nella species, shigella species, campylobacter species, Norwalk virus, Giardia
lamblia, Vibrio cholerae (rare), Strongyloides stercoralis, Entamoeba histolytica
Cutaneous lesions Anthrax, cutaneous leishmaniasis, hemorrhagic rash due to West Nile fever
(rare), bejel, filariasis
Meningitis or encephalitis West Nile fever, Rift Valley fever, Neisseria meningitidis infection, cerebral ma-
laria, rabies (rare), leptospirosis (rare)
Acute hepatitis Hepatitis A, B, C, D, or E, Crimean–Congo hemorrhagic fever, Rift Valley
fever, Q fever, leptospirosis
Hepatic lesions Amebiasis, tuberculosis, brucellosis, histoplasmosis
Pneumonia Tuberculosis, histoplasmosis, Q fever
Fever without focal findings Brucellosis, tuberculosis, typhoid fever, visceral leishmaniasis, sandfly fever, ty-
phus (endemic or epidemic), Q fever, malaria, typhoid, Katayama fever, his-
toplasmosis, acute human immunodeficiency virus infection (rare)
Infections or other conditions mim- Upper respiratory tract infection, bacterial pneumonia, Epstein–Barr virus in-
icking infection fection, urosepsis, drug-related fever, vasculitis, cancer

Parasitic and Rickettsial Infections East, where tuberculosis is a serious health problem.10
Visceral or viscerotropic leishmaniasis, acute schis- In view of the patient’s age, a reactivated infection is
tosomiasis, malaria, and Mediterranean fever due to more likely. Extrapulmonary tuberculosis in an older
Rickettsia conorii, all of which are seen in the Middle patient can easily be overlooked, since the clinical
East, are ruled out in this case by the absence of clin- findings are frequently nonspecific and insidious, and
ical or laboratory evidence of these diseases.5,6 In a pa- they may accompany coexisting diseases, masking the
tient with unexplained, recurrent gram-negative bac- tuberculosis.11,12
teremia, the possibility of a hyperinfection syndrome This patient probably does not have isolated skel-
due to Strongyloides stercoralis, a cosmopolitan intes- etal or genitourinary tuberculosis, since in such cases
tinal nematode, should be considered. In that disor- the overall clinical picture tends to reflect the main
der, however, the bacteremia is always due to common focus of infection.13,14 In addition, he does not have
enteric gram-negative bacteria, the clinical manifes- any evidence of miliary tuberculosis. Nevertheless, the
tations are severe, and risk factors (e.g., corticoster- available data do not entirely rule out the possibility
oid use) are usually present.7 of tuberculosis.

Fungal Infections Brucellosis

Although endemic fungal infections are uncommon The distinctive constellation of findings in this case
in the Middle East,8 chronic pulmonary histoplasmo- suggests the diagnosis of infection with Brucella me-
sis should be considered in this case because of the litensis. There are several important clues to this di-
finding of calcified intrathoracic lymph nodes.8 How- agnosis: the patient’s recent travel to the Middle
ever, the patient had no risk factors for the develop- East, an area where B. melitensis, an enzootic disease,
ment of histoplasmosis, and his clinical presentation is highly endemic1; a clinical picture that is very sug-
was not characteristic of it. gestive of brucellosis15-19; the initial identification of
the gram-negative bacillus as M. phenylpyruvica, which
Mycobacterial Infection is often confused with B. melitensis by laboratories
In a patient with an involuntary weight loss of 15 kg, using rapid, automated commercial methods 20-22; and
a subacute, nonspecific febrile illness, a newly posi- the fact that moraxella species other than M. catar-
tive tuberculin test, a mild monocytosis, and intratho- rhalis rarely infect humans.22 Since I have found no re-
racic lymphadenopathy, a diagnosis that merits serious ports of cases of systemic infections caused by M. phen-
consideration is concomitant or antecedent myco- ylpyruvica, I shall now discuss brucellosis and possible
bacterial infection in the form of subacute extrapul- coexisting diseases as the explanation for the clinical
monary tuberculosis with possible pulmonary, renal, picture in this case.
or osseous involvement.9 In this case, active tuber- The clinical findings are compatible with the pres-
culosis could have been either a reactivation of latent ence of B. melitensis infection for several reasons. First,
disease or a new infection acquired in the Middle the protean, frequently elusive, nonspecific manifes-

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 The Ne w E n g l a nd Jo u r n a l o f Me d ic i ne

tations of this disease, including a nonspecific febrile seminated intravascular coagulation.30-32 Most patients
syndrome without localizing signs and symptoms, with brucella endocarditis have underlying valvular
have long been recognized.15-19 Neither a normal heart disease.30-33
white-cell count nor the absence of neutrophilia rules Transesophageal echocardiography has a very high
out the diagnosis.16 Second, the absence of a history sensitivity for the diagnosis of infective endocarditis.34
of ingestion of unpasteurized dairy products in this In this case, the transesophageal echocardiographic
case does not rule out brucellosis, since the patient study showed only thickening of the mitral and aortic
might have been exposed to the organism in another leaflets, a common incidental finding in elderly pa-
manner.1 Third, even though other pathogenic bru- tients but not a major risk factor for infective endo-
cella species, such as B. abortus, B. suis, and B. canis, carditis.35 The fever and anemia in combination with
can cause a clinical picture identical to that caused sclerotic leaflets may account for the patient’s systol-
by B. melitensis, these other species have never been ic murmur.36
misidentified as M. phenylpyruvica, as in this case, nor In the rare cases in which brucella species cause in-
are they prevalent in the Middle East.1,15-19 fective aortitis, it is always associated with backache
and an expanding abdominal aortic aneurysm — find-
Identification of the Organism ings that were not present in this case.37 Moreover,
Misidentification of B. melitensis is not uncommon I found no reports of aortitis caused by brucellosis
in clinical microbiology laboratories in both Europe in patients with atherosclerotic plaques alone.
and the United States that routinely use a rapid, au-
tomated commercial method (API [Analytical Pro- Explanation of Organ Abnormalities
file Index] 20 NE system, BioMerieux) to identify Could a multisystem disease due to brucella account
gram-negative bacilli not belonging to the Entero- for this patient’s renal, pulmonary, and osseous ab-
bacteriaceae family.22 Brucella species may grow quick- normalities? Renal abnormalities in cases of brucella
ly with the use of newer blood-culture systems.23,24 infection are rare,18,19 and the absence of any associ-
The description of the gram-negative bacterium as a ated symptoms, the negative urine cultures, and the
bacillus (in the first positive blood culture) and as a nonspecific appearance of the renal cysts in the present
rod (in the second positive blood culture), the absence case make the possibility of renal involvement by bru-
of b-lactamase production, and the susceptibility pro- cella very unlikely. In rare cases, brucellosis has caused
file of the organism are all consistent with infection pneumonia after occupational inhalation of the or-
by a brucella species, which can have a coccoid or ganism.38 Although the yield of sputum cultures for
rod-like appearance.22,25,26 brucella species is very low,19,38 attempts to culture
the organism as well as tubercle bacilli would be advis-
Explanation of the Relapse of Disease able in this case, even though the patient has no pul-
If this patient had brucellosis, why did his disease monary symptoms. The possibility of early spondylitis
relapse? The most likely explanation is inappropriate due to brucella merits consideration in this patient
monotherapy with a quinolone (ciprofloxacin) and a because it is very common in brucellosis.15-19,39 Final-
cephalosporin (cefuroxime).26,27 Drug-resistant bru- ly, the absence of sacroiliac- or sternoclavicular-joint
cellosis is very unlikely, since resistant brucella strains involvement makes the diagnosis of brucella arthritis
are rarely found in patients who remain infected after unlikely.
they have received antibiotic therapy.26 Two prospec-
tive studies in Spain28,29 identified several independent Possibility of Concomitant Tuberculosis
risk factors for a relapse of brucellosis: suboptimal Extrapulmonary tuberculosis can simulate brucel-
antibiotic therapy, male sex, and various clinical mark- losis, especially when the spine is involved.13 A diag-
ers indicative of severe infection (positive blood cul- nosis of brucellosis does not exclude the possibility
tures during the initial infection, illness for less than of associated tuberculosis, and a partial response to
10 days before the start of treatment, thrombocyto- treatment for brucellosis with drugs that have activity
penia, and a high initial temperature). This patient had against mycobacteria, such as rifampin, streptomycin,
almost all these risk factors. and quinolones, may make it difficult to establish a
This patient’s relapsing bacteremia may be due to diagnosis of concomitant tuberculosis. Plain radio-
a persistent visceral nidus of infection, valvular veg- graphs and CT or magnetic resonance imaging studies
etation, or an infected atheromatous plaque. An oc- occasionally help differentiate between osseous tuber-
cult splenic or prostatic abscess was ruled out, how- culosis and brucellosis.15 Paraspinal abscesses and ver-
ever, by the imaging studies. Brucella endocarditis, a tebral collapse are more common in the former dis-
rare but potentially lethal complication of brucello- order, whereas a combination of reactive sclerosis and
sis,30-32 has a predilection for the aortic valve. It is usu- lytic changes are more likely in the latter.15,19 If the
ally manifested as a destructive process causing ab- spinal findings in this case suggest the presence of
scesses in the myocardium and aortic root, rapidly spondylitis or diskitis, a fine-needle aspiration biopsy
evolving heart failure, major thromboemboli, and dis- of the lesion may be helpful. I would also rule out

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 CASE RECORDS OF TH E MAS SACH USET TS GENERA L H OS PITA L

active pulmonary and renal tuberculosis by obtain- of serum, detects antibodies to the common brucella
ing sputum and urine samples, respectively, for acid- pathogens, B. abortus, B. suis, and B. melitensis, but
fast bacilli smears and cultures. not to B. canis. The titer of IgM and IgG antibodies
In summary, the most likely diagnosis in this case is in this case was high (1:640). Typically, elevated im-
subacute, partially treated brucellosis caused by B. me- munoglobulin titers become detectable one to two
litensis. Confirmatory studies could include a serolog- weeks after infection and may persist for weeks or
ic test for brucella species and identification of the months after effective therapy has been administered.
gram-negative bacillus in the patient’s blood as B. me- Moraxella organisms and brucella have similar ap-
litensis. pearances on Gram’s staining, but the former have
the spherical shape of cocci, whereas the latter have
CLINICAL DIAGNOSIS the elongated shape of coccobacilli. The two organ-
Subacute brucellosis. isms have similar biochemical profiles, including de-
tectable catalase, oxidase, and urease activity. Brucella
DR. DIMITRIOS P. KONTOYIANNIS’S may also resemble other gram-negative coccobacilli
DIAGNOSIS such as haemophilus species.
Brucellosis due to Brucella melitensis. DR. TIMOTHY E. GUINEY: After the diagnosis
had been established, the patient was treated with
PATHOLOGICAL DISCUSSION doxycycline and rifampin, and the fever disappeared
DR. JAMES VERSALOVIC: Blood was obtained for rapidly. When seen four months after discharge, the
culture, and serologic studies were performed. The patient felt well. On questioning him, we learned that
blood specimen was inoculated into our routine during his travels in Lebanon, he had handled raw
blood-culture system (the BACTEC 9240 system), sheep and goat meat and had regularly consumed
and both aerobic and anaerobic bottles were used. unprocessed cheese.
B. melitensis was cultured from the aerobic bottle six
days after inoculation, signaling the presence of a ANATOMICAL DIAGNOSIS
fastidious organism. Gram’s staining showed the small, Brucellosis masquerading as moraxella infection.
gram-negative coccobacilli that are characteristic of
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 The Ne w E n g l a nd Jo u r n a l o f Me d ic i ne

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