SCIENTIFIC LETTER TO THE EDITOR Severe Persistent Thrombocytopenia as a Sole Manifestation of Brucellosis Rukiye Sac & Nese Yarali & Betul Tavil & M. Fatih Azik & Abdurrahman Kara & Bahattin Tunc Received: 20 September 2011 / Accepted: 4 April 2012 / Published online: 28 April 2012 # Dr. K C Chaudhuri Foundation 2012 Sir, Thrombocytopenia as a sole initial manifestation of brucello- sis is very rare and may mimic idiopathic thrombocytopenic purpura (ITP). Recently a 9-y-old girl was admitted to our department with the complaints of hematuria and bleeding from her mouth for 2 d. She did not have fever, weight loss, or sweating and no history of consuming unpasteurized dairy products, contact with sheep and/or cow. On physical examination she had generalized purpuric lesions on her extremities. The liver was palpable 2 cm below the costal margin. Hemoglobin level was 10.8 g/dL, white blood cell count was 6.5×10 9 /L, and platelet count was 10×10 9 /L. Peripheral blood smear showed 24 % neutrophils, 16 % monocytes, 46 % lymphocytes, 14 % atypical lymphomonocytes with absent thrombocytes. Bone marrow aspiration examination revealed cellular bone mar- row, increased megakaryocytes and no hemophagocytosis. Coombs tests were both negative. Macroscopic hematuria was noted. Urine culture was negative. Abdominal ultraso- nography was normal. Antinuclear antibodies and anti dsDNA were negative. Complement C3 and C4, and immu- noglobulin levels were in the normal range. Hepatitis B, C, Human immune deficiency virus, Epstein Barr virus and Cytomegalovirus IgM and Parvovirus PCR were negative. Vitamin B12 and folic acid levels were within normal ranges. Platelet count did not increase with 0.8 g/kg/d intrave- nous immunoglobulin (IVIG) for two days and massive hematuria continued. Persistent severe thrombocytopenia persisted despite commencing high dose methylprednisolone treatment (30 mg/kg/d for 3 d, then 20 mg/kg/d orally for 4 d). Platelet counts were 6×10 9 /L and 9×10 9 /L, at the beginning and end of the high dose methylprednisolone treatment, re- spectively. Meanwhile she had fever; Brucella melitensis was isolated from blood culture and standard tube agglutination test for Brucella was 1/640. Rifampicin and trimetoprim/sul- famethoxazole treatment was initiated and at the third day of treatment, platelet count increased to 94×10 9 /L. She was dis- charged with a thrombocyte count of 156×10 9 /L on the 24th day of treatment. The frequency of thrombocytopenia among children with brucellosis has been reported to vary between 2.6 and 6 % [1–5]. The mechanism of brucellosis associated thrombocyto- penia is unclear and may be multifactorial, including immune destruction of platelets, reactive hemophagocytosis, bone mar- row depletion and/or hypersplenism. Immune destruction of platelets due to antiplatelet antibodies has been noted in some patients with brucellosis [5]. Although antimicrobial therapy is the main treatment of infection related thrombocytopenia, IVIG or steroid treatment may also correct the immune-mediated thrombocytopenia. We conclude that hematological consequences of brucello- sis should be kept in mind in the differential diagnosis of isolated thrombocytopenia. Patients with ITP, particularly re- sistant to steroid and IVIG treatment should be investigated for brucellosis, especially in endemic areas. Prompt recogni- tion of this complication and aggressive therapy are essential to avoid life-threatening bleeding. References 1. Akbayram S, Dogan M, Akgun C, Peker E, Parlak M, Oner AF. An analysis of children with Brucellosis associated with isolated throm- bocytopenia. Clin Appl Thromb Hemost. 2011;17:E36–8. R. Sac : N. Yarali (*) : B. Tavil : M. F. Azik : A. Kara : B. Tunc Department of Pediatric Hematology, Ankara Children’s Hematology and Oncology Hospital, İrfan baştuğ caddesi Kurtdereli sokak No:10 06110, Ankara, Turkey e-mail: neseyarali@yahoo.com Indian J Pediatr (January 2013) 80(1):85–86 DOI 10.1007/s12098-012-0754-4