Hematologic Manifestations of Brucellosis in Children: 5 Years Experience of an Anatolian Center Elvan Caglar Citak, MD,* Funda Erkasar Citak, MD,w Bilge Tanyeri, MD,z and Dilek Arman, MDy Background: Brucellosis continues to be an important cause of fever in underdeveloped countries and in the rural areas of developed world. It is a multisystemic disease, associated with a wide variety of symptoms. A wide variety of symptoms, including hematologic abnormalities, such as anemia, thrombocytopenia, pancytopenia, dissemine intravascular coagulation, and leucopenia could be seen. The aim of the study is to review the hematologic findings of brucellosis in childhood. Procedure: In this short study, the records of 146 children with brucellosis were evaluated for hematologic manifestation retro- spectively. Among them, 9 patients had pancytopenia and 5 had brucella-induced immune thrombocytopenia and were identified in a 5-year period between June 2004 and July 2009. Results: Eight of the 9 patients with pancytopenia had Brucella melitensis isolated from blood cultures and/or bone marrow cultures, and all 9 patients had Brucella agglutination titers of at least 1:320. All patients with immune thrombocytopenia blood cultures were positive for Brucella. Except 1 patient the pancyto- penia in these patients regressed completely and their peripheral blood counts returned to normal after treatment of Brucella infection. One patient was not responding to the brucella treatment and underwent allogeneic hematopoietic stem cell transplantation. All patients with brucella-induced immune thrombocytic purpura were symptomatic and had severe thrombocytopenia, they were placed on intravenous g globulin for 2 days. Between day 3 and day 5 platelet counts increased in these patients. Conclusion: Brucellosis should be considered as a possible diagnosis among patients with pancytopenia and immune thrombocytopenic purpura in endemic regions. Key Words: brucella, pancytopenia, immune thrombocytopenic purpura, treatment, children (J Pediatr Hematol Oncol 2010;32:137–140) B rucellosis is a zoonotic infection existing worldwide, with predominance in central Asia and some developing countries. The disease is also present, in varying trends, in European countries and the USA. 1 The infection owing to B. melitensis is a common disease in Turkey 2 and humans are commonly infected through ingestion of raw milk, cheese, or through direct contact with infected animals, products of conception, or animal excreta. It is a multisystem disease with a broad spectrum of clinical manifestations. And it mimics many other diseases. Brucellosis produces a variety of nonspecific hematologic abnormalities. 3–13 Hematologic complications of mild ane- mia and leucopenia have been frequently associated with acute brucellosis, but pancytopenia and thrombocytopenia are less frequently seen. 3–13 As mentioned above, thrombo- cytopenia during the clinical course of brucellosis is not common, with an incidence varying from 1% to 8% in adults. 3,13 Thrombocytopenia is usually moderate and attributed to bone marrow suppression or hypersplenism. 9,13 In this report, we discuss the management of children with brucellosis who presented with hematologic manifes- tations as the first sign of their illness. PATIENTS AND METHODS Gaziantep Children Hospital is the referral center in the southeast Anatolia of Turkey. Records of children aged less than or equal to 16 years and admitted to the hospital between June 2004 and July 2009 were analyzed retro- spectively, and patients with the diagnosis of brucellosis were enrolled. Patients who were known to have any acute or chronic systemic disease other than brucellosis were excluded. In addition to history and physical examination, all children had a complete blood count and Brucella serology and cultures. Over this time period, 146 patients who had been referred to our hospital were diagnosed as brucellosis. The diagnosis of brucellosis was made on the basis of a clinical picture compatible with the disease, together with Brucella agglutination titers of at least 1:160 or isolation of Brucella organism from the blood, bone marrow, or both. Only the initial hematologic findings, before starting the specific treatment, were included in this study. Leukocyte and differential counts and hemoglobin levels were considered abnormal according to the estab- lished reference values in infancy and childhood. 8 Throm- bocytopenia was defined as a platelet count of less than 150  10 9 /L. Pancytopenia was considered as abnormal low counts of white cells, hemoglobin, and platelets in the same patient. Bone marrow aspirations were carried out in all patients for the differential diagnosis of pancytopenia. For treatment of brucellosis, the preferred antibiotic regimen consisted of a combination of doxycycline and rifampicin or cotrimoxazole, rifampicin, and gentamycin for 6 to 8 weeks. Follow-up was carried out according to individual response. Copyright r 2010 by Lippincott Williams & Wilkins Received for publication September 11, 2009; accepted December 5, 2009. From the Departments of *Pediatric Oncology; zNeonatology, Gaziantep Children Hospital, Gaziantep; wLOSANTE-Hospital for Children With Leukemia; and yFaculty of Medicine, Depart- ment of Infectious Disease, Gazi University, Ankara, Turkey. Reprints: Elvan Caglar Citak, MD, Associate Professor of Pediatric Oncology, Huseyin Onat Street No: 15/13, Asagiayrnaci, Ankara, Turkey (e-mail: caglarcitak@yahoo.com). CLINICAL AND LABORATORY OBSERVATIONS J Pediatr Hematol Oncol  Volume 32, Number 2, March 2010 www.jpho-online.com | 137