Abstract
Brucellosis is a zoonotic infection that can present with a wide range of systemic manifestations. Hepatic involvement is usually mild; however, in rare cases, it can result in focal lesions such as brucellar microabscesses or brucellomas. These may closely mimic hepatic malignancies or other infectious etiologies on imaging, particularly in patients with underlying chronic liver disease, posing a significant diagnostic challenge. We report the case of a 55-year-old Saudi male with a history of type 2 diabetes mellitus, hypertension, and cirrhosis secondary to metabolic dysfunction-associated steatotic liver disease (MASLD), who presented with hematemesis and intermittent fever. Laboratory findings revealed elevated aminotransferases, raised inflammatory markers, and positive serology for Brucella melitensis. Imaging demonstrated multiple small ring-enhancing hepatic lesions, initially raising concern for malignancy or disseminated infection. PET-CT showed no hypermetabolic activity, making malignancy less likely. A liver biopsy confirmed advanced fibrosis consistent with cirrhosis, without evidence of malignancy or organized abscess formation. Given the clinical and radiologic context, a multidisciplinary team initiated antimicrobial therapy with gentamicin for two weeks, in combination with doxycycline and trimethoprim-sulfamethoxazole for three months. Follow-up imaging showed significant resolution of the hepatic lesions. This case highlights the diagnostic complexity of hepatic brucellosis in cirrhotic patients, where radiological findings may mimic hepatocellular carcinoma or metastases. Despite advancements in imaging, definitive diagnosis often requires histologic confirmation and clinical correlation. The case underscores the importance of considering brucellosis in the differential diagnosis of hepatic lesions, especially in endemic regions or in patients with exposure risk factors. Early diagnosis and appropriate antimicrobial therapy can lead to complete resolution and avoid unnecessary interventions for presumed malignancy.