HIV–brucellosis coinfection in a pastoral region of China: clinical features, diagnosis, and management in a seven-patient case series

Background Brucellosis is an under-recognized opportunistic and endemic infection in people living with human immunodeficiency virus (PLWH), particularly in pastoral settings with frequent livestock exposure. Evidence from China remains limited, and practical guidance on diagnosing and co-managing brucellosis with antiretroviral therapy (ART) is scarce. Methods We conducted a single-center, retrospective case series of seven consecutive PLWH with confirmed brucellosis managed at a tertiary infectious diseases referral hospital in northwest China between July 2021 and May 2025. Diagnosis was based on blood culture and/or standard tube agglutination test (SAT) according to accepted diagnostic thresholds. Data on demographics, exposure history, clinical manifestations, diagnostic findings, treatment, co-infections, and follow-up outcomes were abstracted from medical records. Results All seven patients were male, with a median age of 46 years (IQR 36–75), and all had documented livestock-related exposure. Constitutional symptoms were common, while focal manifestations were prominent. Two patients had lumbar spondylitis/spondylodiscitis, including one who required surgical intervention, and two had epididymo-orchitis and/or hydroceles. Brucellosis was confirmed by blood culture in four patients, while six had positive SAT results; one patient was culture-positive but persistently SAT-negative. Advanced immunosuppression was frequent, and co-infections included tuberculosis (TB; 2/7), chronic hepatitis C virus (HCV) infection (1/7), syphilis (1/7), Pneumocystis jirovecii pneumonia (PJP; 1/7), and cryptococcal pneumonia (1/7). All patients received individualized doxycycline–rifamycin–based regimens, with additional agents and/or surgery used in complicated cases. ART was coordinated using interaction-aware strategies during rifamycin exposure. Clinical improvement was achieved in all patients, generally within 8–12 weeks. During the follow-up period of 6 to 54 months, no recurrence was observed in the microbiological records of the 7 patients. By approximately 6 months of follow-up, six of seven patients had maintained or achieved human immunodeficiency virus (HIV) virologic suppression, while the remaining patient had persistent low-level viremia. Conclusions In PLWH from pastoral settings, brucellosis should be actively considered in the differential diagnosis of fever, low-back pain, scrotal symptoms, or other focal inflammatory presentations, especially when livestock exposure is present. Diagnosis requires a multimodal approach combining culture, serology, and targeted imaging. Favorable outcomes are achievable through individualized antibiotic therapy, timely management of focal complications, and protocolized coordination of ART with rifamycin-containing regimens.