Discussion:
The diagnosis of brucellosis with a wide range of nonspecific clinical
presentations may last for months, as it occurred in our case, in which
the specific therapy was started for him after several months of being
symptomatic. The extended disease and inappropriate treatment may lead
to even more severe consequences and some of the body system
impairment.5 On the other hand, responding slowly to
the specific treatment is one of the characteristics of brucellosis, and
this feature led to pulmonary manifestations in our case while he had
been treated with effective medications for a week.
In addition to the common clinical findings in brucellosis, including
fever, headache, malaise and weakness, myalgia, arthralgia, backache,
and anorexia, some organs of the body may be affected like
gastrointestinal, respiratory, cardiovascular, hematopoietic, and
nervous systems.6
Andriopoulos et al. in 2007 investigated the presentation, diagnosis,
and treatment of 144 cases of acute brucellosis. According to the data,
no one exerted respiratory impairment features; however, osteoarticular,
hematologic, or gastrointestinal complications were confirmed in many
cases.7
The incidence of respiratory complications of brucellosis has been
reported lower than 1 to 5%. The exact pathophysiology of this
complication is not defined well. The most reported symptoms are fever,
cough, dyspnea, sputum production, hemoptysis, and lymphadenopathy; and
the most radiographic findings are interstitial pattern, lobar
pneumonia, and pleural effusion.8
Studies showed that timely diagnosis and appropriate treatment result in
a good prognosis. Hakan Erdem et al. in the largest series of pulmonary
brucellosis in 2014 showed that the most symptoms of the patients were
fatigue (87.2%), cough (85.7%), sweating (79.6%), lack of appetite
(74.4%), and arthralgia (68.4%); while, our patient referred with
chest pain, arthralgia, and low-grade fever. In that research, the most
forms of pulmonary involvement were pneumonia, pleural effusion,
bronchitis, nodular lung lesions, pulmonary embolism, ARDS, and
surprisingly no pleurisy.9
To the best of our knowledge, there are three published case reports of
brucella pleurisy, which all were completely recovered after treatment
with rifampin plus doxycycline for a total of 8 to 12 weeks. There were
also no radiological findings or relapses on their
follow-up.10-13 The same was happened to our case,
except for the selected regimen according to the patient’s intolerance,
which was consisted of ofloxacin instead of doxycycline.
Brucellosis and tuberculosis (TB) often are endemic in some regions
simultaneously. Since they are completely different in treatment
strategies, it is important to differentiate the respiratory involvement
of brucellosis from TB infection.14 Of course, the
presence of arthralgia along with the history of unpasteurized dairy
products consumption can be considered to the detriment of TB diagnosis.
Since Iran is an endemic region for TB, TB infection was ruled out for
our patient with a negative MTB-PCR test. It should be noted that the
pleural fluid adenosine deaminase (ADA) levels elevate in TB, and
measuring ADA alone could not help to confirm
brucellosis.10