Abstract
HLH - Hemophagocytic lymphohistiocytosis, WBC - White blood cell, RBC - Red blood cell, ALT - Alanine aminotransferase, AST - Aspartate aminotransferase, ALP - Alkaline phosphatase, LDH - Lactate dehydrogenase, PCR - Polymerase Chain Reaction, CBC - Complete blood count, TNF-a - Tumor necrosis factor-a INDEX TERMS: Characteristic signs of HLH include fever, hepatosplenomegaly, and cytopenia in at least two cell lines.1,2 Other laboratory findings seen in HLH include elevated triglycerides, ferritin, transaminases, bilirubin, and decreased fibrinogen.2 Activated macrophages secrete ferritin and plasminogen activator, accounting for the patient's increased ferritin and abnormal coagulation results [Table 2, 3].1 Increased inflammatory cytokines are responsible for observed cytopenias, elevated triglycerides, and decreased fibrinogen.2 A bone marrow biopsy was ordered for confirmation, which displayed markedly increased macrophages, decreased myeloid to erythroid ratio, and hemophagocytosis of nucleated erythroid precursors. The physician noted that treatment with three antimicrobials for neurobrucellosis was preferable due to lesser chance of relapse. Because of the severity of the patient's presentation, quadruple therapy with doxycycline, gentamicin, rifampin, and ceftriaxone was utilized. According to a recent study comparing severity of disease states between Brucella abortus and Brucella melitensis infection, there was no difference in clinical presentation.3,6 The classic method for isolation of Brucella spp. is with the use of Castaneda bottles, but the gold standard for identification of brucellosis is a bone marrow culture, where greater concentrations of the organism can be obtained.3 The intracellular nature of this organism makes isolation on routine media extremely difficult.