Case Brucella causes bloodstream infection in children

Foreword

Foreword

A 4-year-old female patient was admitted to the hospital due to fever of unknown cause, with a maximum body temperature of 40°C
.

After three days of anti- infection treatment, there was no obvious improvement

Infection case history

A 4-year-old female patient was admitted to the hospital on May 19th.
The main cause was fever after catching a cold 7 days ago.
The body temperature was as high as 40℃, accompanied by intermittent red macules and papules on the skin all over the body.
), the superficial lymph nodes are not palpable, the cardiopulmonary and abdominal examinations are not abnormal, there is no joint swelling and pain, and the nervous system has no positive pathological signs
.

Laboratory examination: C-reactive protein was slightly higher than 12.
4mg/L, blood routine, atypical lymphocytes, ion series, and renal function were not abnormal
.

ALT 102U/L, AST 136U/L, CK 91U/L, CK-MB 34.

Chest radiograph suggests bronchitis
.

Using ceftriaxone sodium combined with azithromycin for anti-infective treatment for three days, the child still had fever.

Laboratory blood culture critical value report on May 22: Gram-negative bacilli, consider Brucella
.

It was later identified as Brucella Maltese with a biological code of 1000001300001001

On May 23, the rash subsided and the body temperature was normal
.

She was discharged from the hospital on May 27 and continued to take oral compound sulfamethoxazole tablets 0.

Clinical case analysis

Bronchitis is a common respiratory disease in infants and young children.
The common causes are various bacterial, viral, and mycoplasma infections or mixed infections
.

Immune dysfunction, specific physical, nutritional disorders etc.

Immunize children

Children with fever for 7 days, combined with skin rash, consider not excluding immune diseases such as Kawasaki disease; physical examination has no obvious positive signs, routine blood white blood cell value is normal, combined with age does not exclude infection with atypical pathogens such as Mycoplasma pneumoniae or Chlamydia, give empirical combined azithromycin Anti-infective treatment
.

Serum liver enzymes and myocardial enzymes higher than normal are considered to be related to the cause of fever, but the cause of fever is unknown at first, and hepatoprotective and symptomatic treatment should be given
.

After three days of anti-infection treatment, the child's condition still did not improve

After communication, he immediately took blood and sent for a clotting test, and further asked the child's epidemiological history.
The pathogen was quickly locked on Brucella, and the antibiotics were replaced in time, and the child's condition was under control
.

Test case analysis

Test case analysis

The rapid and accurate report of blood culture critical value is crucial to the choice of clinical anti-infective treatment plan
.

Is it bacteria or fungus? Is Gram stain positive or negative? Is it a coccus or a bacillus? Furthermore, whether it is Staphylococcus or Streptococcus, or some uncommon pathogens, a quick and accurate prompt from the laboratory department plays a vital role in the treatment and prognosis of the patient's disease

In this case, the blood culture aerobic bottle reports positive for 2.
66 days, and the growth curve is relatively slow (Figure 1), so it is considered as a slow-growing aerobic bacteria
.
The morphology of the bacteria under the microscope is characterized by small bacilli and cocci.
Because the patient in this case is a 4-year-old child, the Haemophilus influenzae is first considered, but from the arrangement of the bacteria (fine sand-like), Brucella is highly suspected (Figure 2), however, this is very different from the brucellosis population
.

Whether the critical value is to report Gram-negative bacilli or to further prompt clinical consideration of Brucella, communication with the clinic is particularly important at this time
.
Does the patient have a history of contact with cattle and sheep? What is the result of the cloth setting test? What antibacterial drugs are used and how effective are they? Through communication, our critical value report is more accurate
.

Precise

Figure 1 The growth curve of the bacteria after blood culture reports positive

Figure 1 The growth curve of the bacteria after blood culture reports positive

 

Figure 2 The microscopic morphology of the bacteria directly smeared after blood culture reports positive (x1000)

Figure 2 Expanded knowledge of the microscopic morphology (x1000) of the bacteria directly smeared after blood culture reports positive

Brucella human zoonotic disease pathogens, through human skin, respiratory tract, digestive tract into the body caused by infection, the incubation period of 5-21 days, but can be up to several months
.
It is mainly characterized by long-term fever, hyperhidrosis, joint pain, and general fatigue and pain
.
It was mostly seen in pastoral areas in the past, and it has been distributed in large and medium-sized cities in recent years ^[1]
.

Digestion ^[1]

Key points of identification of Brucella

Key points of identification of Brucella

(1) Strictly aerobic bacteria, so the blood culture aerobic bottle grows, anaerobic bottle does not grow, the growth is slow, and the blood culture takes a long time to report positive;

(2) Gram staining is weak, negative, Coccus pumilus, fine sand-like under the microscope;

(3) Kozlowski staining method (referred to as Korotkoff staining method), one of the classic staining methods to identify Brucella, used to quickly identify Brucella ^[2] ;

^[2]

(4) Fast urease test (+), can directly put the culture solution of Baoyang into the urea tube

(5) The GN card of French Mérieux Vitek2Compact instrument can be used for the identification of bacteria
.

(6) Because there are very few cases of Brucella being resistant to antibiotics and treatment failure, the laboratory does not routinely conduct drug susceptibility tests ^[3] ;

Antibiotic ^[3]

(7) The bacteria is a highly pathogenic pathogenic microorganism, and attention must be paid to biological safety protection during the whole process of detection
.

Summary

The age of onset of brucellosis is mainly young and middle-aged, but this case is a 4-year-old child.
Childhood brucellosis is relatively rare in non-epidemic areas and non-farm living conditions.
After questioning the epidemiological history, the parents of the child have had recent visits.
Experience of visiting a sheep farm and buying food
.
When the child was admitted to the hospital, no obvious foci of infection were seen except for high fever, so blood culture was routinely submitted for examination
.
After the blood culture is reported in time, the clinical diagnosis is confirmed, the patient can be effectively treated, and the continued use of ineffective antibacterial drugs is avoided
.

diagnosis

From the diagnosis and treatment process of this case, we can see the importance of cooperation and communication between clinical and medical technology departments, which are mutually dependent and indispensable
.

Expert Reviews

Brucellosis is a zoonotic disease caused by Brucella infection.
It is relatively common in pastoral areas.
It is relatively rare in non-epidemic areas and non-farm living conditions, especially in children.
In addition, children’s expression ability is limited, and more often after the onset Reported by parents, medical history, clinical manifestations, such as fatigue, hyperhidrosis, muscle and joint pain and other symptoms and signs cannot be accurately expressed, which brings great difficulties to clinical diagnosis and is easy to misdiagnose and mistreatment
.

Just like this case, there were no other clinical manifestations except fever and recurrent rash upon admission, which made the previous treatment ineffective
.
After the blood culture results are clear, the diagnosis is corrected in time and the effective antibiotic treatment plan is replaced, which achieves a good treatment effect and alleviates the suffering of the patient
.

Therefore, clinicians should understand the relevant knowledge of commonly used test items, including the clinical significance of each test, precautions for specimen retention, etc.
, and send qualified specimens to the laboratory
.
Laboratory physicians should also learn more about the characteristics of clinical test results for various diseases, provide accurate test results for the clinic, and at the same time guide clinicians to rationally analyze the results and further need to improve the test items
.
Only through mutual cooperation can we effectively improve the level of diagnosis and treatment, relieve patients from pain, provide high-quality diagnosis and treatment services, and build a harmonious doctor-patient relationship
.

Diagnosis and treatment

Reviewer: Jia Yanhong (Chief Physician, Fenyang Hospital, Shanxi Province)

Reviewer: Jia Yanhong (Chief Physician, Fenyang Hospital, Shanxi Province)

references

references

[1] Ni Yuxing, Shang Hong.
Clinical Microbiology and Testing [M].
4th edition, Beijing: People's Medical Publishing House, 2007.
182-186.

[1] Ni Yuxing, Shang Hong.
Clinical Microbiology and Testing [M].
4th edition, Beijing: People's Medical Publishing House, 2007.
182-186.

[2] Chen Dongke, Chen Li, etc.
Discussion on the rapid identification of Brucella by Korotkoff staining method[J].
Journal of Clinical Laboratory Science.
2015, 11(33), 805-806.

[2] Chen Dongke, Chen Li, etc.
Discussion on the rapid identification of Brucella by Korotkoff staining method[J].
Journal of Clinical Laboratory Science.
2015, 11(33), 805-806.

[3] Wang Hui, Ren Jiankang, Wang Minggui.
Clinical Microbiology Examination [M].
First edition, Beijing: People's Medical Publishing House, 2015.
430.

[3]Wang Hui, Ren Jiankang, Wang Minggui.
Clinical Microbiology Test[M].
First edition, Beijing: People's Medical Publishing House, 2015.
430.
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