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Journal of Pediatric Gastroenterology & Nutrition:
Clinical Quiz

Clinical Quiz

Fitzgerald, Joseph F. NASPGHAN Clinical Quiz Editor; Troncone, Riccardo ESPGHAN Clinical Quiz Editor; Lacaille, Florence; Contributor

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Gastroenterology and Nutrition Unit, Necker-Enfants Malades Hospital, Paris, France

Correspondence to Florence Lacaille, Gastroenterology and Nutrition Unit, Necker-Enfants Malades Hospital, 149 rue de Sevres, 75015 Paris, France (e-mail: Florence.lacaille@nck.ap-hop-paris.fr).

The patient was an 11-year-old female of Portugese origin, born and living in France. She was seen the first time in June for fever (39°C) for the past three weeks, variable during the daytime and during the week, following an angina 3 weeks before (amoxicillin). She sometimes had shivers, mild myalgias, or arthralgias. Physical examination was normal. Blood count was: 4430/mm3 white cells, neutrophils 51%, lymphocytes 45%, ESR was 22 mm/h, CRP 6 mg/l. The fever persisted, variable, during the next month. The patient complained of vague abdominal pain and arthralgias, but was otherwise in good general status. Blood count was unchanged, CRP was normal, urine culture negative, Paul-Bunnel-Davidson negative, AST 206 IU/L, ALT 243 IU/L. The mother complained of nearly the same symptoms as her daughter but more prominent joint pain. Because of hypertransaminasemia, she underwent liver biopsy (figure). During the summer, blood tests showed persistent cytolysis (AST 50-200 IU/L, ALT 60-250 IU/L) without cholestasis. She was first seen in our unit in October. Clinical examination was normal, except for a weight loss of 1 kg since June.

FIG. Histiocytic gra...
FIG. Histiocytic gra...
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What is the Diagnosis?

1) Auto-immune hepatitis

2) Systemic lupus erythematosus

3) Brucellosis

4) Cat-scratch disease

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Answer:

Brucellosis The diagnosis was made in the patient's mother on liver biopsy. It showed small histiocytic granulomas in the lobule, suggestive together with the clinical features of brucellosis. It was then confirmed by specific serology. The infection probably came from eating cheese in Portugal, where it is endemic, and where the family vacationed in February. The diagnosis was delayed in the patient because the first serology in July was negative. It was not controlled until October, when it was strongly positive. The patient was treated with doxycycline and rifampicin for 6 weeks. All symptoms disappeared quickly and liver tests normalized in 2 weeks. Always listen to the mothers...

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Acknowledgment:

We thank Dr. Maggy Crossin from the unit of Pathology in Bichat Hospital (Paris) for her collaboration with the biopsy picture of the patient's mother.

© 2002 Lippincott Williams & Wilkins, Inc.

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