FUO in a healthcare worker

A 45 year old woman presented with fever since 10 days. She did not report cough, diarrhea, arthralgias or urinary symptoms. History was notable for hospital admission 1 month prior for similar symptoms treated with antibiotics. She worked as a microbiology technician in a hospital, and had travelled to rural Maharashtra 2 weeks prior to onset of symptoms. Physical examination was normal. Investigations revealed elevated liver enzymes (ALT 125, AST 110) with normal bilirubin, alkaline phosphatase, serum creatinine, hemogram, urine analysis and chest radiograph. She was started on IV ceftriaxone in the hospital after blood cultures were collected. Severe laryngeal pain developed during the hospital stay and fever spikes were persistent. A CT chest with contrast was normal, and indirect larynogoscopy was unremarkable.

Gram negative bacilli were isolated from blood cultures on day 3 of hospital admission. These were subsequently identified as Brucella melitensis on Vitek-2 automated identification. The patient was started on rifampicin and doxycycline regimen for 3 months with IV gentamicin for 1 week; symptoms resolved rapidly. The patient did not recall any unpasteurized milk consumption or direct contact with cattle, sheep or goats. Lab records did not identify any previous Brucella isolation. However the patient recalled handling a culture plate from an outside facility which was subsequently identified as Brucella approximately 4 weeks prior to onset of symptoms.

Brucella is the most common cause of laboratory associated bacterial infection. Antibiotic prophylaxis is often indicated for exposure events but regimens may be poorly tolerated. The CDC offers guidelines on management of exposure events