A Brucellosis Case Presenting With Mass
Formation Suggestive for Tumor in Soft Tissue
Hasan Karsen, MD, Hayrettin Akdeniz, MD, Hasan Irmak, MD, Turan Buzgan, MD,
M. Kasım Karahocagil, MD, Zeliha Kocak, MD, and Mahmut Su ¨nnetc ¸iog ˘lu, MD
Abstract: We report here a 70-year-old female patient who was
diagnosed with brucellosis and presented with mass formation re-
sembling a tumor. The mass was protuberant, 10 cm from the skin
surface with a diameter of 15 cm, located at the inferior-lateral
region of the left scapula. Brucella melitensis was yielded from
culture of mass fluid. The patient responded to ceftriaxone, rifampin
and doxycycline therapy and recovered without any sequela at the
end of surgery and 3 months of medical treatment.
Key Words: Brucellosis, soft tissue masses
oping countries, especially among the population living
in rural areas and dealing with stock breeding.1During the
course of the disease, hematopoietic, endocrine, neuropsychi-
atric, cardiovascular, gastrointestinal, genitourinary, ocular,
skin, respiratory and musculoskeletal systems may be in-
volved.2In this article, a case of brucellosis presenting with
soft tissue involvement is reported.
rucellosis remains an important health problem in devel-
A 70-year-old female patient dealing with stock
breeding was admitted to the department of internal med-
icine with complaints of fever, night sweats, loss of ap-
petite, backache, and arthralgia in her knees beginning 3
months prior. The patient was diagnosed with brucellosis
and given streptomycin for 21 days together with
rifampin and doxycycline treatment. The complaints of
the patient persisted, and she developed an increasing
protuberance at the inferior region of her left scapula
which appeared 2 weeks before. The Rose Bengal test
was positive, and the patient was hospitalized in our
clinic with a preliminary diagnosis of brucellosis. Her
medical history included diabetes mellitus (DM) and
hypertension (HT) for 6 years, but she had not been
taking the required treatment regularly or obeying the
required diet. History of fresh cheese consumption made
from raw milk and history of abortus in their animals
On physical examination, she was quite exhausted
and pale. Arterial blood pressure was 150/ 100 mm Hg,
pulse rate 88/min, and temperature 36.8°C. There was a
painful firm mass with clear margins, protuberant 10 cm
from the skin surface with a diameter of 10 cm, at the
inferior lateral area of her left scapula (Fig. 1). Her lab-
oratory findings were as follows: leukocytes 4300/mm3;
hemoglobin 11 gr/dL; platelets 194,000/mm3; erythro-
cyte sedimentation rate (ESR) 65 mm/h; C-reactive pro-
tein (CRP) 79 mg/dL; fasting blood sugar 405 mg/dL.
(continued next page)
From Yuzuncu Yil University, Faculty of Medicine, Department of In-
fectious Diseases and Clinical Microbiology, Van, Turkey; Ankara
Research and Training Hospital, Department of Infectious Diseases
and Clinical Microbiology, Ankara, Turkey; and Primary Health Care,
Reprint requests to Dr. Hasan Irmak, SB Ankara Egitim ve Arastirma
Hastanesi, Infeksiyon Hastaliklari ve Klinik Mikrobiyoloji Klinig ˘i,
Ulucanlar, Ankara, Turkey. Email: firstname.lastname@example.org
Accepted April 27, 2007.
Copyright © 2007 by The Southern Medical Association
• In this article, a case of brucellosis presenting with soft
tissue involvement and mass formation is reported.
• To determine whether the mass was a soft tissue tu-
mor or had developed secondary to brucellosis, the
mass fluid was aspirated on the second day of hospi-
talization, and brucella SAT was positive at 1:5120
dilution from this mass fluid.
• B melitensis was yielded from the mass fluid on the
9th day. The mass was totally excised and the fluid
tissue inside the mass was removed. Triple antibiotic
treatment was given.
• The patient was followed up for one year and no
complaint occurred again.
Southern Medical Journal • Volume 100, Number 11, November 2007
(Case Report continued from previous page)
Other laboratory findings were within normal limits.
Brucella standard agglutination test (SAT) (with Bru-
cella abortus 99S antigen from SL Barcelona Spain
Chromotest, Linear Chemical) of blood was positive at
1:640 titer. Treatment with rifampin 600 mg/d and doxy-
cycline 200 mg/d, orally and ceftriaxone 4 gr/d IV was
administered. Naproxen was added as an anti-inflamma-
tory drug. To determine whether the mass was a soft
tissue tumor or had developed secondary to brucellosis,
the mass fluid was aspirated on the second day of her
hospitalization, and brucella SAT was positive at 1:5120
titer from this mass fluid. Gram stain was negative. His-
topathological examination of the fluid revealed no ma-
lignant cells. Blood and mass fluid cultures were per-
formed using BACTEC culture bottles. Ultrasound of
the mass revealed a hypoechoic mass with thick walls,
including multiple septations, with lobulated borders of
15 cm localized at the inferior lateral area of the left
scapula. The mass was totally excised and the fluid tis-
sue inside the mass was removed. The material was sent
to the pathology laboratory. The mass size was reduced
on a large scale (Fig. 2). The patient’s complaints dis-
appeared at the end of 2 weeks’ treatment, and biopsy
result returned as mature fat and connective tissue. No
growth occurred on blood culture. B melitensis was
yielded from the mass fluid on the 9th day.
At the end of one month therapy, brucella SAT was
1:320 titer. The patient recovered and the mass entirely
disappeared. Ceftriaxone was stopped at the end of one
month and the patient was discharged with rifampin and
doxycycline treatment. In the control follow-up per-
formed one month later, increase in CRP and blood sugar
was detected, thus treatment duration of brucellosis was
lengthened. Brucellosis treatment was stopped after 3
months, as all laboratory parameters were normal and all
patient complaints were dissolved. The patient was fol-
lowed up for one year and no complaint occurred again.
Brucellosis is a zoonotic disease which can be seen all
over the world.3Transmission to human generally occurs by
gastrointestinal route, then the bacteria enters and replicates
within the regional lymph nodes. Hematogenous dissemina-
tion is then followed by localization of bacteria within organs
rich in elements of the reticuloendothelial system.4While
complications related to the musculoskeletal and gastrointes-
tinal system are frequently seen, complications related to the
skin and soft tissues are rarely encountered.5
To our knowledge, a brucellosis case manifested by a
tumor-like formation in the soft tissue is very rare. Gasser et
al6reported one case with breast abscess suspected as breast
tumor. Skin lesions due to brucellosis include erythema no-
dosum, cutaneous vasculitis, skin ulcer, maculopapular rash,
contact dermatitis, purpura, petechia and abscess.7–9Soft tis-
sue and skin manifestations of brucellosis are generally ac-
companied by general symptoms of brucellosis.7Also in our
case, there were general brucellosis symptoms continuing for
3 months before the development of superficial mass forma-
tion. Soft tissue and skin complications of brucellosis occur
with a few mechanisms. These are direct inoculation, hyper-
sensitivity phenomenon, immune complex deposits and he-
In our case, it was concluded from the history and phys-
ical examination results that the soft tissue involvement may
be hematological route. Because the clinical symptoms of
brucellosis resemble other infectious and noninfectious dis-
eases, it is required to take into consideration many diseases
in the differential diagnosis.9The fact that the patient was 70
years old, and the duration of her complaints such as fever,
backache, and loss of appetite made us consider that a tumor
or tumor metastasis could exist in the patient. Evaluation of
the brucella SAT test positive at 1:5120 titer performed from
the mass fluid taken by fine needle aspiration and observation
of no malignant cells from the fluid made the diagnosis of
tumor improbable. The Gram stain of the mass was negative.
When the ultrasound examination revealed a mass with thick
Fig. 1 Mass before surgery. The mass is shown in our patient
at the inferior lateral section of her left scapula.
Karsen et al • Brucellosis Case Presenting With Mass Formation Suggestive for Tumor in Soft Tissue
© 2007 Southern Medical Association
walls including multiple septations, the patient was consulted Download full-text
with general surgeons, and an excision and biopsy were made.
Because the histopathologic examination of the mass was
evaluated as mature fat and connective tissue, along with
positive brucella SAT titer from the mass fluid and growth of
B melitensis from the fluid, we decided that the mass devel-
oped secondary to brucellosis.
Because the complaints of our patient had increased in
spite of administration of triple anti-brucella antibiotic treat-
ment before she was admitted to our clinic, we chose an
alternative combination of antibiotics. Streptomycin was re-
placed by ceftriaxone because of the advanced age of the
patient, and rifampin and doxycycline were maintained in the
triple combination. Since Al-Idrissi et al12have reported in
their study that the use of 4 gr daily is quite efficient, we also
gave the ceftriaxone dose as 4 gr daily. We think that in spite
of the treatment used for DM, advanced age and the irregular
fasting blood sugar led to weakening of her immune system.
This may have predisposed her to soft tissue invasion and
mass formation secondary to brucellosis.
Taking into consideration that brucellosis may result in
miscellaneous complications, it must be considered in the
differential diagnosis of soft tissue masses, and the diagnosis
should be achieved by serologic tests and/or culture results.
1. Irmak H, Buzgan T, Karahocagil MK, et al. The effect of levamisole
combined with the classical treatment in chronic brucellosis. Tohoku J
Exp Med 2003;201:221–228.
2. Coka F, Yilmaz-Bozkurt G, Azap A, et al. Meningoencephalitis, pan-
cytopenia, pulmonary insufficiency and splenic abscess in a patient with
brucellosis. Saudi Med J 2006;27:539–541.
3. Young EJ. Brucella species: Principles and Practice of Infectious Dis-
ease. In: Mandell GL, Bennett JE, Dolin R, eds. Churchill Livingstone,
2000, pp 2386–2391.
4. Baldwin C. Pathogenesis of Brucellosis: Intracellular Bacterial Infec-
tions. In: Pechere EJ, ed. Cambridge Med Pub,1996, pp 87–92.
5. Madkour MM. Skin manifestations. Brucellosis. In: Madkour MM, ed.
Butterworths, 1989, pp 180–184.
6. Gasser I, Almirante B, Fernandez-Perez F, et al. Bilateral mammary
abscess and uveitis caused by Brucella melitensis: report of a case.
7. Ariza J, Servitje O, Pallares R, et al. Characteristic cutaneous lesions in
patients with brucellosis. Arch Dermatol 1989;125:380–383.
8. Al-Orainey IO, Siddiqui MA, Wright SG, et al. Skin lesions in brucel-
losis: report of two cases. Ann Saudi Med 1988;8:219–220.
9. Dakdouk GK, Araj GF, Awar GN. Buttock abscess brucellosis. Scand
J Infect Dis 2002;34:934–936.
10. Cokca F, Azap A, Meco O. Bilateral mammary abscess due to Brucella
melitensis. Scand J Infect Dis 1999;31:318–319.
11. Trunnell TN, Waisman M, Trunnell TL. Contact dermatitis caused by
brucella. Cutis 1985;35:379–381.
12. Al-Idrissi HY, Uwaydah AK, Danso KT, et al. Ceftriaxone in the treat-
ment of acute and subacute human brucellosis. J Intern Med Res
Please see Shashank Purwar’s editorial on page
1074 of this issue.
Fig. 2 After surgery and treatment, the mass completely dis-
Southern Medical Journal • Volume 100, Number 11, November 2007