Demystifying Pyrexia of U...

Demystifying Pyrexia of Unknown Origin: A Case of Splenic Brucellosis:- 48‑year‑old man was brought to the outpatient department with high‑grade fever with chills, generalized malaise, and significant weight loss (>10 kg in 45 days). The patient is a farmer by occupation from Jammu and routinely consumes unpasteurized or raw milk. The patient’s medical records and history from relatives revealed fever with night sweats and generalized malaise and significant weight loss from 18 months, for which he was evaluated as fever of unknown origin. On clinical examination, at admission, he was afebrile, with normal vital signs. He had no pallor, icterus, cyanosis, clubbing, pedal edema, or lymphadenopathy. Systemic examination of the abdomen showed splenomegaly 10 cm below the costal margin. No abdominal lumps. Other systems examination was normal. Investigations revealed hemoglobin of 11.4 g/dl with a total leukocyte count of 10,000/cumm and platelet count of 1.25 lakhs. His blood sugar, renal function tests, lipid profile, serum electrolytes, and liver function tests are within normal limits. Screening for viral markers was negative. Peripheral blood smears reveal normocytic normochromic red blood cells with mild poikilocytosis, no hairy cells, and no malaria parasites. Immunochromatographic test for malaria parasite, typhidot test for salmonella, dengue serology, and rapid test for Leishmania were negative. Sputum for acid‑fast bacillus, staining, MTB GeneXpert, culture, and sensitivity were negative. Mantoux test was negative. Blood, urine, stool for culture, and sensitivity revealed no growth. Urine routine and microscopy were normal. Tumor markers were negative. Bone marrow aspiration and biopsy suggestive of hypocellular marrow aspirate showed trilineage hematopoiesis and no significant hemophagocytosis. Bone marrow flow for chronic lymphoproliferative disorder and GeneXpert was negative. Ultrasonography (USG) was suggestive of massive splenomegaly 20 cm. Contrast‑enhanced computed tomography abdomen revealed massive splenomegaly 20.1 cm in long span with multiple, well‑defined round‑to‑oval variable‑sized hypodense lesions (Average attenuation ~50–55 HU) scattered in the spleen, largest 12‑mm largest diameter. Brucella serology was IgM positive. Positron emission tomography (PET) WB scan showed, few fluorodeoxyglucose avid and nonavid iso hypodense lesions noted in the spleen, largest ~11 mm SUV max 5.0 along superior border shown in Figure 1. USG‑guided fine‑needle aspiration cytology (FNAC) of splenic SOL showed features of necrotizing granulomatosis inflammation/organizing abscess. Diagnosis of systemic brucellosis with splenic SOLs was made. To summarize, we had successfully diagnosed a case of systemic brucellosis who had presented with pyrexia of unknown origin (PUO) with splenic SOLs on the basis of clinical, radiological, histopathological, and serological tests. The patient was successfully treated with oral doxycycline (200 mg/day) and rifampin (600 mg/day) for 6 weeks. The patient improved symptomatically with the absence of fever. The patient was discharged. The patient is in follow‑up. Take‑home message, to manage this case, it not only required sound clinical judgment but also required sophisticated imaging like PET‑computed tomography (CT) and risky procedures like splenic FNAC. This case further enforces the importance of splenic FNAC practices at times to clinch the diagnosis.