A case of brucellosis and crimean-congo hemorrhagic fever coinfection in an endemic area; [Endemik Bir Bölgede Bruselloz ve Kirim Kongo Kanamali Ateşi Koenfeksiyonu Olgusu]

Brucellosis, a zoonotic disease which is especially seen in developing countries is still an important public health problem worldwide. Crimean-Congo hemorrhagic fever (CCHF) is another zoonotic disease that transmits to humans by infected tick bites as well as exposure to blood or tissue from infected animals. Both of the diseases are common among persons who live in rural areas and deal with animal husbandry. Since brucellosis usually presents with non-specific clinical symptoms and may easily be confused with many other diseases, the diagnosis of those infections could be delayed or misdiagnosed. In this report, a case of coinfection of brucellosis and CCHF has been presented to emphasize the possibility of association of these infections. A 70-year-old female patient with a history of dealing with animal husbandry in a rural area admitted to our hospital with the complaints of fever, malaise, generalized body and joint pains, and headache. Her complaints had progressed within the past two days. She also reported nausea, vomiting, abdominal pain and bloody diarrhea. She denied any history of tick bites. Her physical examination was significant for the presence of 38.8°C fever, increased bowel sounds and splenomegaly. Laboratory analysis revealed leukopenia, thrombocytopenia and high levels of liver enzymes. The patient was admitted to our service with the prediagnosis of CCHF. Serum sample was sent to the Department of Microbiology Reference Laboratory at Public Health Agency of Turkey for CCHF testing. During patient's hospitalization in service, more detailed history was confronted and it was learned that she had fatigue, loss of appetite, sweating, joint pain, and intermittent fever complaints were continuing within a month and received various antibiotic treatments. The tests for brucellosis were conducted and positive results for Brucella Rose Bengal test, tube agglutination (1/160 titers) and immune capture test with Coombs (1/320 titers) were determined. The tests performed in the reference laboratory revealed CCHF virus-specific IgM positivity by immunofluorescence assay and viral RNA positivity by real-time polymerase chain reaction. Two blood cultures remained sterile during hospitalization, this situation was considered to be the cause of antibiotic usage in the last month. Doxycycline and rifampicin therapy were initiated for brucellosis, and close monitoring with supportive therapy for CCHF. On the second day of admission, the patient was transfused with 5 units random platelets and 2 units fresh frozen plasma due to dramatic decline of platelet count (37.000/mm3). Early clinical response to brucellosis therapy was confirmed with resolution of fever and improved blood counts and the treatment was completed in eight weeks on an outpatient basis. No other problems were encountered during follow-ups after completion of treatment. According to accessible literature search, coinfection of brucellosis and CCHF has not been reported previously. In conclusion, as our country is endemic for both brucellosis and CCHF, it is important to consider both infections in the differential diagnosis. Physicians should keep in mind that, likewise in our case, coinfection of brucellosis and CCHF can be detected.