Abstract
Brucellosis is a zoonosis in which hepatic involvement is common but usually mild. Acute liver failure and acute-on-chronic liver failure (ACLF) are rarely attributed to brucellosis, and even more rarely to people living with HIV (PLWH). We describe a 50-year-old man from Ghana with newly diagnosed advanced HIV infection and HBV reactivation (anti-HBc IgG positive, anti-HBc IgM negative) who developed ACLF shortly after starting antiretroviral therapy (ART). After an initial viro-immunological response to a bictegravir-based regimen, he experienced a paradoxical deterioration of liver function and was evaluated for liver transplantation. During this phase, he developed painful swelling of the left neck; imaging revealed osteo-articular and muscular lesions. Serology (Wright 1:320) was positive, blood cultures were negative and Brucella PCR was not available; therefore, disseminated brucellosis was considered probable based on serology, compatible clinical syndrome and complete response to anti-Brucella therapy. Targeted treatment with intravenous gentamicin plus oral doxycycline, with maintenance of ART, led to improvement of liver function, resolution of lesions and avoidance of transplantation. Based on timing, viro-immunological response and exclusion of alternative causes, we interpret this ACLF as likely precipitated by disseminated brucellosis in the setting of an unmasking immune reconstitution inflammatory syndrome (IRIS). Brucellosis should be considered as a potentially reversible cause of ACLF in PLWH from endemic areas, particularly soon after ART initiation.
Keywords
Brucellosis, Acute-on-chronic liver failure, HIV infection, HBV co-infection, Immune reconstitution inflammatory syndrome, Case report