Fulminant

Brucellosis commonly manifests with fever, arthralgia, and hepatosplenomegaly, whereas severe cholestatic hepatitis is exceedingly rare. We report a 54-year-old goat farmer who presented with a 4-day history of right upper quadrant tenderness, progressive jaundice, and generalized pruritus after consuming unpasteurized milk from his own herd, with which he also had daily close contact. Examination showed scleral icterus and mild lethargy without peritoneal signs. Laboratory investigation revealed profound, predominantly conjugated hyperbilirubinemia (total 25.1 mg/dL, direct 23 mg/dL) with a cholestatic enzyme pattern (alkaline phosphatase 565 U/L, gamma-glutamyl transferase 225 U/L; R factor 0.4) and only mild transaminase elevation, together with acute kidney injury, thrombocytopenia with an elevated mean platelet volume and no platelet aggregates, hypofibrinogenemia, a markedly elevated D-dimer, and scant schistocytes. Thrombotic microangiopathy was initially considered, but a positive direct antiglobulin test, overt coagulopathy, and absent reticulocytosis favored sepsis-associated disseminated intravascular coagulation, confirmed by an International Society on Thrombosis and Haemostasis score of 6. Marked hyperferritinemia prompted consideration of hemophagocytic lymphohistiocytosis, which was not substantiated. Cross-sectional abdominal imaging excluded mechanical obstruction and showed hepatosplenomegaly with subcentimeter splenic nodules and no hepatic focal lesions.