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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 10  |  Issue : 3  |  Page : 99-101

Unexplained fever and arthritis in a teenager with Type 1 diabetes


Department of Medicine, Rashid Hospital, Dubai, United Arab Emirates

Date of Web Publication4-Jun-2018

Correspondence Address:
Dr. Touseef Azhar Kazmi
Department of Medicine, Rashid Hospital, Oud Mehta, Dubai
United Arab Emirates
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmbs.ijmbs_30_18

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  Abstract 


Brucellosis is a relatively prevalent zoonotic infection in the Mediterranean region and the Arabian Peninsula. Due to the multi-system involvement and nonspecific nature of the complaints, making a diagnosis can sometimes be particularly challenging. We present the case of a Libyan-American adolescent with type 1 diabetes mellitus (T1DM) residing in the United Arab Emirates who presented with fever, flu-like symptoms, and arthritis. When his initial septic workup did not reveal a focus of infection, and he continued to be febrile with the development of multiple painful and swollen joints, a diagnosis of autoimmune arthritis was entertained given his background history of autoimmune T1DM. However, on further probing, we ascertained a history of raw camel cheese ingestion. This redirected us to look for and subsequently confirm the diagnosis of brucellosis. Appropriate antibiotic treatment led to rapid recovery of the patient.

Keywords: Autoimmune, brucellosis, fever, polyarthritis


How to cite this article:
Kazmi TA, Abbas SB, Hafidh KA. Unexplained fever and arthritis in a teenager with Type 1 diabetes. Ibnosina J Med Biomed Sci 2018;10:99-101

How to cite this URL:
Kazmi TA, Abbas SB, Hafidh KA. Unexplained fever and arthritis in a teenager with Type 1 diabetes. Ibnosina J Med Biomed Sci [serial online] 2018 [cited 2021 Oct 22];10:99-101. Available from: http://www.ijmbs.org/text.asp?2018/10/3/99/233760




  Introduction Top


 Brucellosis More Details is one of the differential diagnoses of fever of unknown origin and is one of the most widespread zoonosis worldwide. Exact data regarding the practice of drinking raw milk in our population is unknown; although, several cases of brucellosis have been reported from the United Arab Emirates.[1]

Osteoarticular involvement is common in brucellosis. However, it is not the first thing that usually comes to mind in a patient from an urban background presenting with fever and arthritis.


  Case Report Top


A 14-year-old boy presented with a 6 day history of fever, sore throat, coryza, and productive cough. This was associated with generalized joint pains, muscle aches, redness, and swelling of some large and small joints. He also described an erythematous rash in the initial course of his illness which had settled spontaneously. There was nausea with loss of appetite but no documented weight loss. Fever was intermittent, high grade, and temporarily relieved by paracetamol. There was no history of recent travel or sick contacts. He had no exposure to tobacco, ethanol, or history of sexual contact. No contact with animals was reported. His current medications consisted of a combination of short- and intermediate-acting insulin 3 times per day.

On examination, he was a pleasant boy who appeared lethargic. He was febrile with a temperature of 38.4°C and tachycardia with a blood pressure of 129/75 mmHg. He had a mild fading erythematous macular rash on his face and abdomen, and the throat was congested. Examination of the cardiovascular and respiratory system was unremarkable. On abdominal examination, he had mild generalized abdominal tenderness but no organomegaly. There were mild swelling and redness of the metacarpophalangeal and proximal interphalangeal joints of the right middle finger, left big toe, and left knee. The right shoulder also was tender, but no swelling or erythema was noted.

Given the history and initial laboratory workup [Table 1], he was managed as a case of upper respiratory tract infection possibly atypical pneumonia with reactive arthritis. He was empirically commenced on intravenous (IV) ceftriaxone and azithromycin. The persistence of fever and rising white blood cells count prompted a change in antibiotic to IV tazobactam/piperacillin. However, he showed no response and continued to have high-grade fever with new sites of peripheral joint involvement over the following few days. Thus, additional investigations were requested.
Table 1: Initial investigations

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Outcome and follow-up

Due to the significant inflammatory polyarthritis and history of autoimmune type 1 diabetes mellitus, we consulted the rheumatology services. While awaiting investigations [Table 2], the rheumatologist recommended initiation of steroids entertaining a diagnosis of Still's disease or juvenile rheumatoid arthritis. We reviewed the history with the patient, and this time when asked about contact with animals or ingestion of raw milk, he remembered consuming camel milk cheese at a friend's farm a few weeks before his presentation. Serological tests for  Brucella More Details were requested which was reported as significantly positive [Table 3]; although, Brucella could not be isolated from the blood culture. Steroids were discontinued, and he was commenced on a combination of IV gentamicin with oral doxycyline and Rifampicin. After 1 week of treatment, there was a significant improvement in his symptoms as well as inflammatory markers. The antibiotics were continued for 8 weeks, and he remained asymptomatic after that. Repeat serological testing was negative [Table 3].
Table 2: Autoimmune workup

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Table 3: Brucella serology and follow up investigations

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  Discussion Top


Brucellosis, commonly known as, “undulent fever” is caused by Gram-negative, intracellular bacterium belonging to the genus Brucella which has many subtypes.[2] The species known to cause disease in humans are Brucella melitensis, Brucella suis, Brucella Abortus, and Brucella canis. Both B. melitensis and B. abortus can be found in camels.[3] Human brucellosis is usually associated with occupational or domestic exposure to infected animals or their products. Brucellosis may be acquired by ingestion, inhalation, or percutaneous exposure. Human-to-human transmission is extremely rare. The fact that our patient was diabetic did not make him at increased risk of this disease as there is no evidence that its prevalence is higher in diabetic patients.[2] A detailed history clearly helps in suspecting the diagnosis; although in a small percentage of cases, no risk factors can be identified.[4]

Osteoarticular involvement is quite common in brucellosis and is the most common symptom along with fever.[4],[5] Peripheral arthritis is probably the most common form of skeletal involvement in children.[6] Sacroiliitis and spondylitis are the other common forms of arthritis observed.[7]

In a study of 195 cases from Turkey, musculoskeletal involvement was found in 69% of cases [7] and in a more recent Turkish analysis of 1028 cases osteoarticular involvement occurred in 25.3% of cases.[4] In another systematic review from Iran, the prevalence of peripheral joint involvement with brucellosis ranged from 13.6% to 50%.[6] Joints can be directly involved in infection causing septic arthritis, but reactive arthritis is also known to occur. Involvement of the small joints of hands and feet is rare.

Although the definitive diagnosis of brucellosis requires isolation of the bacterium from blood or tissue sample, this is not invariably possible. The percentage of cases with positive cultures ranges from 15% to 70%.[5] Serological tests involving serum agglutination are commonly used for diagnosing cases. Real-time polymerase chain reaction is most likely the diagnostic tool of the future, offering the possibility of results in 30 min; although, it is not currently widely available.[5]

Treatment of brucellosis requires a prolonged course of combination antibiotics.[8],[9] The latest recommendation from the Centers for Disease Control in 2012 is a combination of rifampicin and doxycycline for a minimum of 6–8 weeks.[10] The course of antibiotics can be extended to up to 3 months for focal and more complex cases. Brucellosis has a high incidence of relapse and patients ideally require long-term follow-up.

We chose to report this case due to the initial diagnostic uncertainty with a strong suspicion of a rheumatological process. Brucellosis was not suspected until the history was reviewed, clearly indicating the importance of good history taking. Brucellosis should always be considered in the differential diagnosis of fever and polyarthritis, especially in endemic areas.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Authors' contributions

All authors contributed to the care of the patient, drafting of the case report, revision, and approval of its final version.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Compliance with ethical principles

No prior ethical approval is usually required for single case reports. However, the patient provided consent for publication as stated above.



 
  References Top

1.
Jamil G, Jamil M, Al Nuaimi NS, Taha M. Splenic abcess owing to brucellosis. BMJ Case Rep 2013;2013. pii: bcr2013009004.  Back to cited text no. 1
    
2.
Corbel MJ, Beeching NJ, Brucellosis. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, editors. Harrison's Principles of Internal Medicine. 18th ed., Cha. 157. New York: McGraw-Hill; 2012.  Back to cited text no. 2
    
3.
Gwida M, El-Gohary A, Melzer F, Khan I, Rösler U, Neubauer H, et al. Brucellosis in camels. Res Vet Sci 2012;92:351-5.  Back to cited text no. 3
    
4.
Buzgan T, Karahocagil MK, Irmak H, Baran AI, Karsen H, Evirgen O, et al. Clinical manifestations and complications in 1028 cases of brucellosis: A retrospective evaluation and review of the literature. Int J Infect Dis 2010;14:e469-78.  Back to cited text no. 4
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5.
Pappas G, Akritidis N, Bosilkovski M, Tsianos E. Brucellosis. N Engl J Med 2005;352:2325-36.  Back to cited text no. 5
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6.
Sanaei Dashti A, Karimi A. Skeletal involvement of Brucella melitensis in children: A Systematic review. Iran J Med Sci 2013;38:286-92.  Back to cited text no. 6
[PUBMED]    
7.
Geyik MF, Gür A, Nas K, Cevik R, Saraç J, Dikici B, et al. Musculoskeletal involvement of brucellosis in different age groups: A study of 195 cases. Swiss Med Wkly 2002;132:98-105.  Back to cited text no. 7
    
8.
Joint FAO/WHO expert committee on brucellosis. World Health Organ Tech Rep Ser 1986;740:1-32.  Back to cited text no. 8
    
9.
Ariza J, Bosilkovski M, Cascio A, Colmenero JD, Corbel MJ, Falagas ME, et al. Perspectives for the treatment of brucellosis in the 21st century: The ioannina recommendations. PLoS Med 2007;4:e317.  Back to cited text no. 9
[PUBMED]    
10.
Centres for Disease Control and Prevention. Brucellosis; 2012. Available from: http://www.cdc.gov/brucellosis/treatment/index.html. [Last accessed on 2018 May 13].  Back to cited text no. 10
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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