A 35-year-old man presents to the Emergency Department, having just returned from helping with spring lambing on a farm in Spain. He presents with fever, joint pains and a dry cough that began some 24–48 hours earlier. Examination reveals he has a temperature of 38.2°C, blood pressure (BP) is 122/82 mmHg and his pulse is 85 bpm and regular. There is occasional wheeze on auscultation of his chest, and mild tenderness on abdominal palpation. Investigations:
Investigations Results Normal Values
Haemoglobin (Hb) 131 g/l 135 - 175 g/l
White cell count (WCC) 6.5 × 10 /l 4 - 11 x 10 /l
Platelet (PLT) 203 × 10 /l 150 - 400 x 10 /l
Sodium (Na ) 142 mmol/l 135 - 145 mmol/l
Potassium (K ) 4.5 mmol/l 3.5 - 5.0 mmol/l
Creatinine (Cr) 102 µmol/l 50 - 120 µmol/l
Alanine aminotransferase (ALT) 189 IU/l 5 - 30 IU/l
Alkaline phosphatase 102 IU/l 30 - 130 IU/l
Bilirubin 10 µmol/l 2 - 17 µmol/l
Brucella IgM antibody is positive. Which one of the following options is the most appropriate intervention?
- Ceftriaxone
- Doxycycline and rifampicin
- Doxycycline and streptomycin
- Doxycycline and trimethoprim-sulfamethoxazole
- Gentamicin, doxycycline and rifampicin
0 voters
Explanation
This patient has evidence of uncomplicated brucellosis, with no strong evidence of sacroiliitis and only a minor elevation in his transaminases. As such, oral out-patient therapy is appropriate. Although doxycycline can be used as a monotherapy, combination treatment with rifampicin is thought to be associated with a lower risk of relapse, and a six-week oral course is usually given.
Intravenous (IV) therapy with ceftriaxone is not normally considered in the treatment of brucellosis unless there is evidence of neurological involvement, when it is added to doxycycline and rifampicin.
Doxycycline and streptomycin is less convenient than a dual oral regimen; for this reason, it is usually reserved for patients with more severe symptoms or where there is resistance to rifampicin.
This is an oral regimen usually considered for patients with exposure to live attenuated cattle virus Brucella RB51. This can be shed by cows in milk, and infects humans when pasteurisation of the milk does not take place. This particular virus is resistant to rifampicin.
This triple regimen is considered in patients when there is evidence of Brucella endocarditis, and we have no evidence to support endocarditis being present here.
Doxycycline and rifampicin