A 63 year-old man was admitted to Erciyes University Hospital with complaints of weakness, backache, abdominal pain and abdominal swelling. He had a history of diabetes mellitus for 13 years. On physical examination, temperature was 38˚C. He had ascites and an enlarged spleen.
Laboratory analyses were as follows: haemoglobin 11.4 g / dl, white blood cell count 4100 / mm3 and platelet count 150000 / mm3. Abnormal biochemical findings were gamma-glutamyl transpeptidase: (GGT) 552 U / L, alkaline phosphatase: 504 U / L, total proteins: 5.2 g / dl, albumin: 2.4 g / dl, LDH: 892 U / L. The prothrombin time was 12 seconds. Ascitic fluid findings were as follows: leukocytes 800 / mm3 (with 70% lymphocytes), total proteins 2.8 g / dl, albumin 1.2 g / dl. Serum ascide albumin gradient (SAAG) was 1.2 g / dl. The HBs Ag and antibodies for HBs Ag (anti-HBs), HCV (anti-HCV), smooth muscle antigen (SMA), nuclear antigen (ANA), liver-kidney microsomal antigen (LKM-1) and mitochondrial antigen (AMA) were all found to be negative. Congestive gastropathy was observed during upper GI endoscopic examination and a abdominal ultrasonography revealed splenomegaly and ascites, with the portal vein diameter being 14 mm. Due to persistent fever and backache, serum Brucella agglutination test was performed. Brucella serology showed a positive slide test, micro-agglutination titer 1/ 1280. The slide test was also positive in peritoneal fluid as was the micro-agglutination test. On the fourth day of admission, gram-negative coccobacilli were noted in blood culture bottles and on day six, they were identified as Brucella melitensis, which was also isolated from ascitic fluid culture. Liver biopsy findings revealed cirrhosis (Figure 1) and a nongranulomatous hepatitis which was thought might be due to Brucella infection (Figures 2-3). Endoscopic retrograde cholangiopancreatography (ERCP) was performed due to increased GGT and alkaline phosphatase levels and a radioopaque shadow compatible with a common bile duct stone was seen.
A diagnosis of cryptogenic cirrhosis was established according to histologic, viral and serologic findings. Doxycycline (100 mg. bid) and rifampin (300m. gdaily), in addition to diuretics were administered for spontaneous ascites infection due to Brucella. A week later, the patient’s condition had improved and the became afebrile. After two months of therapy, the ascites has almost disappeared.
Figure 1: Irregular fibrosis with rare mononuclear inflammatory cells surrounding a macronodule (H&E, x100)
Figure 2: Enlarged portal tract and piecemeal necrosis (H&E, x100)
Figure 2: Inflammatory cells marching into parenchyma through the destroyed limiting plate (H&E, x200)