An 11-year-old male with rolandic epilepsy treated with valproic acid.
No history of rurality or contact with animals.
Upon admission, the patient had a two and a half-month history of fever up to 40oC, arthralgias of both knees and shoulders, holocrane headache and general malaise.
Physical examination revealed palpable liver 5 cm below the costal margin, sweating, lymphadenopathy of the lateral cervical chains, and systolic murmur of 2-3/6 at the aortic focus.
Of the tests performed on an outpatient basis, it is worth mentioning: 6 hemocultives (-)s, PCR of 83 mg/l, seropositivity for Epstein&#146;s virus and hepatomegaly, retroperitoneal TAC
She was hospitalized in the Infectious Diseases Unit with the following diagnoses: febrile syndrome of prolonged evolution: infectious endocarditis?, mesenchymopathy (juvenile rheumatoid arthritis)?, mononucleosis?
Episodes feverish, with thermal episodes accompanied by myalgias, distal tapes and profuse sweating.
Later, arthralgia of the right hip and maculopapular lesions in the trunk and lower extremities were added, of which the biopsy showed eosinophilic interstitial and perivascular dermatitis.
Hepatomegaly was reduced to 3 cm, and enlarged spleen was 1 to 2 cm below the costal margin.
One month after admission, the patient presented an extensive gingivostoma, which made feeding difficult, and an eczematous lesion of 4 cm per 4 cm in the left arm, which resolved spontaneously within 10 days.
The admission blood count showed a normal leukocyte count with a slight left shift, mild normocytic anemia, normochromic, and platelet count in normal values.
Coinciding with the picture of gingivostoma and hospitalisation with 1000 neutropenia, there was an absolute neutrophil count of 357 (RAN/mm3), remaining with a lower neutrophil count (RAN/mm3) during the entire period
ESR and CRP were within normal ranges.
Two conventional Doppler echocardiography and one transesophageal echocardiography were performed, ruling out the diagnosis of infective endocarditis.
The patient was evaluated by rheumatology and a diagnosis of probable panarteritis nodosa was proposed.
The immunological study showed no significant alterations and included: immunoglobulins IgA, IgG, IgM, IgE, C3 subpopulations of immunoglobulins G, % natural killer, phagocytosis, hemocytic activity, CD4 subpopulations.
Antinuclear antibodies and lupus cells were negative.
The serological study (IgM for cytomegalovirus, IgG for Bartonella haenselae, IgM for cytoplasmic virus and IgM for parvovirus B19, IgM for Mycoplasma pneumoniae was negative for IgM.
Hepatitis B surface antigen, HIV ELISA, VDRL, eye fundus and brain CT were normal.
Coinciding with the gingivostoma, neutropenia, and anti-streptomycin (ASO) of 400 IU/ml, Streptococcus a hemolytic was isolated in three hemocultives.
The strain was sent for study to the ISP and subsequently identified as Streptococcus mitis.
Valproic acid was suspended, starting treatment with penicillin G and then vancomycin due to persistence of hemocultives (+) to this same bacterium, which was associated with a poor clinical outcome.
The patient had a fever, malaise and right side pain, without inflammatory signs or functional impotence.
Bone scintigraphy showed hyperuptake of the radiopharmaceutical in the metaphyseal and distal submetaphyseal regions of the right tibia; therefore, given the evidence of bone involvement associated with rifampicin, treatment was changed.
Reassessing the clinical picture, with a period of 3 and a half months, up to that moment, which were not explained exclusively by the stellate infection, a normal honeycombing was requested.
In the light of new epidemiological background that required repeated ingestion of cheese of clandestine origin (from a rural area of Maria Pinto town) and the visit to a farm where the child would not have aborted, the milk would have been repeated in Lon.
The Wright-Huddleson reaction gave a titer of 1/640.
The hemocultives were positive at 72 hours of isolation, small irregular Gram-negative cocci and sent to the ISP, a reference center for identification.
The patient was treated with rifampicin and gentamicin for 6 weeks, associated with the former for the first 14 days.
The patient slowly fell from neutropenia, the fever disappeared, the pain disappeared in the right side and the general condition was compromised.
Myelogram was repeated one month after treatment, with normal results.
The Wright-Huddleson reaction showed a decrease in titles from the start of specific therapy to 1/160; 1/10 and 1/10, at one month, 3, 8 and 12 months, respectively.
ELISA was positive for IgG and negative for IgM at 10 months and one year of follow-up.
Bone scintigraphy performed one month after treatment was normal.
Finally, the child was discharged after one year of asymptomatic follow-up and in good general condition.
The Wright-Huddleson reaction of the family group was negative.
The epidemiological research undertaken by the Department of Epidemiology of the Metropolitan West S.S. Metropolitano Occi found that the educational establishment where the patient had taken milk exacerbated the non pasteurized product.
An inspective visit by the Environmental Service found that this area did not have the certification that it believed free of brucellosis, which was communicated to the SAG.
Since at the time of this visit the child already had the symptoms of the disease, it is believed that in this case, the most probable source of bovine brucellosis was the ingestion of a street vendor from a rural area.
