Acute hepatitis due to brucellosis: 13 years of experience

Brucellosis is a zoonotic infection that can affect almost any organ system. The liver is one of the most affected organs. Liver involvement is usually manifested by mild aminotransferase elevations. Liver function is usually normal, and clinical hepatitis is rare. In this study, 13 years of follow-up and treatment experience of our clinic was presented by evaluating acute hepatitis cases due to brucellosis hospitalized. Materials and Methods: Patients with brucellosis hepatitis who were hospitalized in the Infectious Diseases and Clinical Microbiology service of Yüzüncü Yıl University Medical Faculty Hospital between January 2008 and June 2020, and who were older than 18 years were included in this study. 103 adult patients, 61 female and 42 male, were evaluated retrospectively in the study. In the presence of clinical suspicion, the diagnosis of brucellosis was made according to the criteria for brucellosis standard tube agglutination (STA) titer ≥ 1/160 and / or Brucella spp. growth in blood and tissue cultures and / or positive brucellosis polymerase chain reaction (PCR) test. The presence of hepatitis was established by the presence of aminotransferases 5 times the upper limit of normal (ULN) and / or the total bilirubin level ≥ 2 mg / dl and / or by showing the local hepatic lesion. Hepatic involvement type was determined according to laboratory and radiological findings. In laboratory examination, we made clinical hepatitis diagnosis based on alanine aminotransferase (ALT) and/or aspartate aminotransferase (AST) level higher than 5 times of ULN. We made cholestasis (cholestatic hepatitis) diagnosis based on alkaline phosphatase (ALP) level higher than 3 times of ULN and/or gamma glutamyl transferase (GGT) level higher than 1.5 times of ULN and/or total bilirubin level higher than 2 mg/dl. Radiological distinction was determined according to ultrasonography (USG) findings: presence of granulomatous lesions in the liver for the diagnosis of granulomatous hepatitis and absence of granulomatous lesions for diffuse hepatitis diagnosis. Results: According to biochemical findings, 35.9% of the cases had clinical hepatitis, 17.5% of the cases had cholestatic hepatitis and 46.6% of the cases had these two conditions were together. In radiological evaluation, USG was performed in 88.3% of all cases, and granulomatous hepatitis was found in 5.5% of them. Abdominal USG was performed in 91 (88.3%) of the cases, and there was no finding in USG in 24 (26.4%) of the cases. Hepatosplenomegaly (HSM) was detected in 46 (50.5%) cases, hepatomegaly (HM) in 15 (16.5%) cases and splenomegaly (SM) in 5 (5.5%) cases. 83.5% of the cases had acute, 14.6% subacute and 1.9% chronic brucellosis. The most common complaints of the cases were fever (85.4%), sweating (84.5%), weakness (84.5%), anorexia (79.6%) and muscle-joint pain (72.8%). In hemogram examinations, 10 (9.7%) patients had leukocytosis, 47 (45.6%) patients had leukopenia, 57 (55.3% patients) had anemia, 55 (53.4%) patients had thrombocytopenia and 35 (34.0%) patients had pancytopenia. The most commonly used treatment regimen was a triple combination of an aminoglycoside (AG) with doxycycline (DOX) and rifampin (RIF). Conclusion: Our study showed that clinical response with treatment and improvement in the laboratory is high even in the presence of hepatitis. In our study, no parameter affecting the duration of hospitalization was found, but the improvement in ALT, AST and total bilirubin values was observed to be longer in blood culture positivity, in the presence of secondary organ involvement and in the presence of ALT/AST>1. The treatment regimens we provided did not have an effect on this duration. Although there are retrospective studies in the literature reporting that choosing regimens with AG in treatment provides faster improvement, prospective studies are needed in larger patient groups.