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\begin{document}

\title{A Rare Case Report of Deep Vein Thrombocytosis associated with
Brucellosis in Iran}



\author[1]{Majid Ghafouri}%
\author[1]{Mojtaba Danafar}%
\author[1]{Azar Shokri}%
\affil[1]{North Khorasan University of Medical Sciences}%


\vspace{-1em}



  
  \date{May 27, 2024}


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\selectlanguage{english}
\begin{abstract}
Brucellosis is among the most prevalent zoonotic diseases that can
involve almost any organ. Here we present a case of deep vein thrombosis
due to human brucellosis. We described a 62 old male farmer with a
history of brucellosis and deep vein thrombosis on his right leg%
\end{abstract}%



\sloppy


A Rare Case Report of Deep Vein Thrombocytosis associated with
Brucellosis in Iran

Majid Ghafouri\textsuperscript{1,3}, \emph{Mojtaba
Danafar}\textsuperscript{2}, Azar Shokri *\textsuperscript{1}

\textsuperscript{1} Vector-borne Diseases Research Center, North
Khorasan University of Medical Sciences, Bojnurd, Iran

Email: M.Ghafouri@nkums.ac.ir

\textsuperscript{2} Student Research Committee, North Khorasan
University of Medical Sciences, Bojnurd, Iran

Email: mojtaba.danafar@gmail.com

*Correspond author:

Email: azar\_sh1969@yahoo.com

\textbf{Key clinical message}

Deep vein thrombosis should be considered in any patient with a history
of brucellosis. It is an important point in brucellosis endemic regions.

\textbf{Abstract}

Brucellosis is among the most prevalent zoonotic diseases that can
involve almost any organ. Here we present a case of deep vein thrombosis
due to human brucellosis. We described a 62 old male farmer with a
history of brucellosis and deep vein thrombosis on his right leg.

\textbf{Key words} : Deep vein thrombosis, Brucellosis, Iran

\textbf{INTRODUCTION}

Brucellosis is a cosmopolitan zoonotic disease that mainly affects
persons with close contact with domestic animals and their products
{[}1{]}. The infection is caused by Gram negative intracellular,
non-motile, nonsporulating, nontoxigenic, non-fermenting, facultative
cocco-bacilli bacteria of genus \emph{Brocella} with over than ten
species. The disease is endemic in many countries including Iran and the
incidence of the disease is estimated to be 500,000 cases annually all
around the world {[}2{]}. Brucellosis is a multi-systemic disease with a
broad spectrum of clinical manifestations and, can be potentially lethal
due to complications {[}3{]}. Despite of common osteoarticular
complication in endemic regions, the vascular complication is almost
rare {[}4{]}. Hereby we describe a case of deep vein thrombosis (DVT) in
Bojnurd, North east of Iran.

\textbf{CASE REPORT}

A 62 old male farmer, with a history of brucellosis in last two months
referred to our hospital. His main complaint was pain and swelling of
right calf muscle. His symptoms started with irregular fever, dyspnea
and malaise two months earlier. He was treated for brucellosis with
Rifampin, Cotrimoxazole and Doxycycline, and after one week break in
medication, his shin started swelling. He had no history of brucelloisi
in his family. Also, he claimed to opium addiction. Laboratory tests
were asked for further evaluation. In physical examination, his legs
were asymmetric and the left shin obviously was larger than right one.
The rest of the physical examinations were normal. The patient underwent
to Doppler ultrasonography (Image 1).

\textbf{DIFFERENTIAL DIAGNOSIS, INVESTIGATIONS AND TREATMENTS}

Complete blood count and biochemical parameters were within normal
range. 5.1\selectlanguage{ngerman}×10\textsuperscript{12} / L, hemoglobin 14.3 g/L, white blood
cells 12.5×109/L (65\% neutrophils). Erythrocyte sedimentation rate
(ESR) was 20 mm/h. C reactive protein (CRP) was positive (+2). All
laboratory parameters including protein C\&S, Anti Phospholipid
antibodies (IgM, IgG), Anti Cardiolipin antibodies (IgM, IgG), Anti
lupus Anti-Coagulant IgG, Factor V Leiden and Prothrombin G20210A
(Factor II) were within normal range. The tubal standard agglutination
test (Wright test) and 2ME reduction test were positive (in a titer of
1/1280 and 1/640, respectively). A Doppler ultrasound study revealed
right popliteal vein thrombosis (Figures 1, 2). There was no effusion in
sonographic evaluation of right hip joint. Subcutaneous soft tissue
edema in right lower extremity was reported. The patient was diagnosed
with thrombophlebitis due to brucellosis. He was advised to have bed
rest and right leg elevation. The patient was treated with Rifampicin
300 mg twice a day, Cotrimoxazole 800 mg twice day, Azithromycin 200 mg
once a day and two days later Rivaroxaban 15 mg twice a day for the
first three weeks and 20 mg once a day. Also, Enoxaparin 60-unit S.C
twice a day was prescribed. Some days later, his leg pain and swelling
decreased and he walked without any help. Nine days after the onset of
this treatment, thrombophlebitis was cured. Warfarin was discontinued
after six months. Follow up of the patient showed no abnormality after
approximately one year later.

\textbf{DISCUSSION}

Brucellosis is among the most prevalent zoonotic diseases all around the
world including. Iran is an endemic region for disease and the annual
incidence rate of human and animal infection is still considerable
{[}2{]}. Deep vein thrombosis is a rare complication of brucellosis and
its pathogenesis has not been described well {[}5,6{]}. The probable
mechanisms are including the occurrence of granulomatous endophlebitis,
inflammation and injury of perivascular tissue, a transient
hypercoagulable state, or the immune reaction in the vessel wall to the
brucella antigen {[}7{]}. Nine reports are available from 1973 to 2012
which are describing deep vein thrombosis associated with brucellosis in
endemic regions {[}8,9{]}. Protein S deficiency with DVT was observed
during infection with \emph{Salmonella typhimurium}, and HIV infection
{[}10,11{]}. In our patient anti Phospholipid antibodies, anti
Cardiolipin antibodies, anti-lupus anti-Coagulant IgG, Factor V Leiden
and Prothrombin G20210A (Factor II) were normal. Also, local infection
adjacent to his right leg deep veins was not observed during his
illness. Therefore, it is possible that endothelial damage induced
directly by \emph{Brucella}, or indirectly by toxins or cytokines, was
responsible for the patient's DVT.\textbf{CONCLUSIONS:} Due to the
non-specific manifestations of acute brucellosis, it is suggested that
the infection should be considered in patients suffering from DVT,
particularly in those coming from Brucellosis-endemic
areas.\textbf{ACKNOWLEDGMENTS:} The authors thank Clinical Research
Development Unit, Imam Hasan Hospital, North Khorasan University of
Medical Sciences, Bojnurd, Iran. CONFLICT OF INTEREST: None
declared.\textbf{AUTHOR'S CONTRIBUTIONS}: All authors, M Gh, M D and A
Sh are equally contributed to the design, analysis, and presentation of
this study M Ghis specialist in infectious disease and involved in study
design. M D: involved in study design and writing. A Sh: Involved in
study design, writing, submission and
revision\textbf{DECLARATION}-Ethics approval and consent to participate:
applicable -Consent for publication: Written informed consent was
obtained from the patient for publication of this case report and any
accompanying images. A copy of the written consent is available for
review by the Editor of this journal. -Availability of data and
material: All the data are available without restriction. -Funding: No
funding.

References

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\selectlanguage{polish}İ\selectlanguage{english}mre. Simultaneous acute deep vein thrombosis and acute brucellosis. A
case report. Kardiochirurgia i Torakochirurgia Polska 2016; 13 (2)

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8. Koubaa M, Frigui M, Cherif Y, et al. Deep vein thrombosis associated
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9. Odeh M, Pick N, Oliven A. Deep venous thrombosis associated with
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10. Ceyhan M, Kanra G, Benderlioglu B, et al: Transient protein S
deficiency with deep venous thrombosis during Salmonella typhimurium
infection. Arch Dis Child 68:138-139, 1993.

11. Becer DM, Saunders TJ, Wispelwey B, et al: Case report: Venous
thromboembolism in AIDS. Am J Med Sci 303:395-397, 1992

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