An 11-year-old girl presented to Qingdao Women and Children's Hospital affiliated to Qingdao University (Qingdao, China) with recurrent fever, headache, and abdominal pain for more than 2 months. Blood tests revealed a leucocyte count of 3·08 × 109/L with 0·3% eosinophils, a haemoglobin concentration of 122 g/L, and a platelet count of 204 × 109/L. C-reactive protein was 6·8 mg/L and the erythrocyte sedimentation rate was 20 mm/h. Examinations for Epstein-Barr virus, Mycobacterium tuberculosis, antinuclear antibodies, and thyroid function were negative or normal. Abdominal ultrasound revealed hepatosplenomegaly. Subsequently, the child received a bone marrow aspiration to rule out haematological disorders. Bone marrow smears showed haemophagocytic cells (figure A) and macrophages containing fine, pink, sand-like particles (typhoidal cells; figure B). The presence of these cells indicated the possibility of typhoid fever. However, on the 5th day of admission, the patient's blood culture returned positive for Gram-negative coccobacilli, which were confirmed as Brucella melitensis rather than Salmonella typhi. The standard tube agglutination test for Brucella spp antigens yielded a ratio of 1:400. A more detailed patient history was taken and showed that the patient had drunk unpasteurised goat milk 2 months before presentation. The girl was transferred to an infectious disease hospital and was administered oral rifampicin (15 mg/kg/day) and co-trimoxazole (10 mg/kg/day) for 12 days. Her clinical condition improved gradually and the patient was discharged after 12 days of treatment in hospital with normal body temperature and a healthy size of liver and spleen. The patient continued to take rifampicin (15 mg/kg/day) and co-trimoxazole (10 mg/kg/day) for 6 weeks after discharge, and was asymptomatic at 6-month follow-up.

FigureThe bone marrow aspirate of an 11-year-old girl with recurrent fever

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(A) A haemophagocytic cell engulfing two white blood cells. (B) A distinct type of macrophage containing a variable number of fine, pink, sand-like particles. Both images show magnification × 1000.