Mark Crislip, MD

Disclosures

September 28, 2010

The Diagnosis

This patient has the classic signs and symptoms for Brucella and blood cultures grew B melitensis. She has a prolonged febrile illness that is nonfocal, has lassitude, and Faget's sign (a pulse-temperature disassociation). For every degree of temperature elevation, the pulse should go up about 10 beats per minute. Although this patient's temperature was 104°F, her pulse rate was only 75 beats per minute. Other common causes for Faget's sign are typhoid fever, tularemia, yellow fever, and Legionella. Relative cytopenias and hepatitis are also common in brucellosis.

In this case the pathology of the gallbladder revealed mild inflammation but not acute cholecystitis, a rare manifestation of Brucella.[1]

Brucella has multiple sources, depending on the species: B abortus (cattle), B melitensis, B ovis (sheep, and goats), B suis (pigs), and rarely B canis (dogs).[2] In the United States, the most common source for exposure is travel to Mexico.

In this case, the problem was the source. Almost no Brucella is found in the United States, and most cases occur in the south. She denied any dietary exposures as did her family. However, a month later in follow-up her mother finally recalled that her brother, when visiting from Mexico, brought goat cheese for the family to eat.[3]

Sometimes it is the patient who travels to the disease, and sometimes it's the disease that comes to the patient. The United States receives food from all over the world and with it, on occasion, the associated bacteria.

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