5-year-old girl (weight 15 kg) was admitted to the Kunming Children’s Hospital (Kunming, China) in May 2020 due to epistaxis for 2 days. The patient did not have fever, weight loss, nausea, sweating, and vomiting.
Physical examination showed the patient was pale, general petechiae, and purpura extremities. But no splenomegaly, hepatomegaly, or lymphadenopathy.
The results of blood tests before transfusion were shown in the Table 1 which indicated that the child suffered from moderate anemia (hemoglobin: 74 g/L) and severe thrombocytopenia (platelet count: 3×109/L). White blood cell (WBC) was 5.38×109/L. Activated thromboplastin time tests (APTT) were 31.9 s (normal, 28-44.5), prothrombin time (PT) was 13.3 s (normal, 11-14.5), international normalized ratio (INR) was 1.07 (normal, 0.8–1.5), ferritin was 212 µg/L (normal, 7-142), d-dimer (> 20 µg/nl) and fibrinogen degradation products (27.19 µg/nl) were increased, fibrinogen (1.54 g/L) was decreased. Complement C3 and C4 were normal. Immunoglobulin IgG was slight increased 17.4 g/L (normal range 5.9–14.3 g/L). Antinuclear antibodies and anti-dsDNA were negative. Coombs tests were negative. Abdominal ultrasonography was normal. No significant abnormalities in liver or kidney function were reported. She was given platelet infusion for epistaxis. Meantime, the patient also was given immunoglobulin (IVIg) intravenous (1g/kg/day) for 2 days and high dose methylprednisolone treatment (20 mg/kg/d for 3 days). Platelet counts which did not show any improvement,were 10×109/L and 7×109/L, at the beginning and end of the treatment, respectively.
On the third day of admission, the patient was suffered severe epistaxis and anemia. The patient was received platelet and red blood cell (RBC) infusion again. Bone marrow aspiration was performed after platelet infusion. Bone marrow aspiration revealed trilineage hematopoiesis, megakaryocytes hypercellularity. The entire bone marrow smear showed 623 megakaryocytes. Analysis of 100 megakaryocytes, the results showed granulosa megakaryocytes 82% and lamellar megakaryocytes 18%. Examination of bone marrow aspiration findings showed no malignancy. The patient was continually received methylprednisolone treatment (10 mg/kg/d for 3 days). However, the platelet count did not increase even after frequent platelet transfusions and receiving this regimen.
On the sixth day of admission, platelet count was dropped 1×109/L. Because the patient had continual severe epistaxis, the patient received platelet infusion again. Meantime, the patient was given oral treatment with 25 mg/d eltrombopag and prednisone (2 mg/kg/d orally).
On the seventh day of admission, the patient was given RBC infusion again due to severe anemia. After 3 days of eltrombopag and 3 days of prednisone intervention, the platelet count was increased to 9×109/L. The treatment continued.
On the tenth day of admission, the patient’s blood culture demonstrated the growth of Brucella melitensis. Further history was obtained, and it was discovered the girl had contacted the goat and consumed unpasteurized goat milk. In consideration of the patient history, laboratory test results, positive Brucella serology, and Brucella melitensis on the blood culture, the patient was finally diagnosed with brucellosis complicated with severe thrombocytopenia. The patient was started on empiric treatment with oral rifampin (30 mg/kg/d orally) and trimethoprim sulfamethoxazole (30 mg/kg/d orally, twice a day) for 5 days.
On the fifteenth day of admission, the patient's symptoms have improved. Her thrombocyte and blood values reached normal levels. the patient was discharged from the hospital and was advised to avoid unpasteurized diary. The changes of platelet count, Hb, and the treatment during admission were shown in Fig. 1.