Brucella infection in total knee arthroplasty. Case report and revision of the literature

Bilateral Prosthetic Knee Joint Infection Caused by Brucella melitensis: A Rare Case Report from Iran

Introduction: Brucella prosthetic joint infection is a rare condition. We report a case of bilateral prosthetic knee joint infection caused by Brucella melitensis, which was cured by prolonged antibiotic therapy without implant removal. Case Presentation: A 62-year-old woman was admitted to the Labbafinejad Hospital (Tehran, Iran), complaining of pain and swelling in her knee joints from two months ago. She was also suffering from intermittent fever and night sweats. She underwent bilateral total knee arthroplasty five years ago because of a severe degenerative joint disease. Agglutination tests (wright and 2-mercaptoethanol (2-ME)) were positive. Her knee joint fluid and blood cultures yielded B. melitensis. The polymerase chain reaction result from her knee joint fluid was positive for Brucella spp. The patient was cured after combination therapy with doxycycline, rifampin, and gentamicin. The prosthesis was retained due to the lack of loosening in radiography. Ten months after the treatment, the patient had no symptoms and could walk with no pain. Conclusions: Clinicians should consider brucellosis in the differential diagnosis of prosthetic joint infection in the endemic regions. They should also be aware that if patients have no sign of implant loosening, they can achieve favorable outcomes only by using antibiotics and with no need for implant removal.

Brucella infection following total joint arthroplasty: A systematic review of the literature

INTRODUCTION

The aim of this systematic review was to analyze the results of published treatment options in Brucella infection following total joint arthroplasty (TJA).

METHODS

We performed a systematic review of the literature regarding outcomes of Brucella infection after TJA (hip and knee). We searched multiple databases for articles in the area published from 1950 to 2016.

RESULTS

A total of 18 patients (12 male and 6 female; mean age 59 years) from 14 published studies were identified. The minimum follow-up time was 6 months (range, 6-120 months). Seven patients were treated with debridement or antibrucella treatment only. Eleven patients (61%) underwent removal of the prosthesis and were treated with one or two-stage exchange arthroplasty. The mean duration of antibiotic therapy was 5.8 months. There was no relapse of infection.

CONCLUSIONS

In the absence of loosening of the components of the prosthesis, an attempt to treat Brucella infection medically might be a reasonable choice. One or two-stage exchange arthroplasty could provide successful results without relapse of infection when combined with appropriate antibiotherapy.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Brucella melitensis prosthetic joint infection

Periprosthetic joint infection (PJI) due to Brucella spp. is rare. We report a case in a 75-year-old man and review 29 additional cases identified in a literature search. The diagnosis of Brucella PJI is challenging, in particular in non-endemic countries. Serological tests prior to joint aspiration or surgical intervention are reasonable. Involvement of infection control and timely information to laboratory personnel is mandatory upon diagnosis. There is no uniform treatment concept, neither with respect to surgical intervention nor for the duration of antimicrobials. Most cases have a successful outcome, irrespective of surgical modality, and with an antimicrobial combination regimen for 12 or more weeks.

Brucella melitensis prosthetic joint infection in a traveller returning to the UK from Thailand: Case report and review of the literature

BACKGROUND

Brucella spp. prosthetic joint infections are infrequently reported in the literature, particularly in returning travellers, and optimal treatment is unknown.

METHOD

We describe a prosthetic joint infection (PJI) caused by Brucella melitensis in a traveller returning to the UK from Thailand, which we believe to be the first detailed report of brucellosis in a traveller returning from this area. The 23 patients with Brucella-related PJI reported in the literature are summarised, together with our case.

RESULTS

The diagnosis of Brucella-related PJI is difficult to make; only 30% of blood cultures and 75% of joint aspiration cultures were positive in the reported cases. Culture of intraoperative samples provides the best diagnostic yield. In the absence of radiological evidence of joint loosening, combination antimicrobial therapy alone may be appropriate treatment in the first instance; this was successful in 6/7 [86%] of patients, though small numbers of patients and the likelihood of reporting bias warrant caution in drawing any firm conclusions about optimal treatment. Aerosolisation of synovial fluid during joint aspiration procedures and nosocomial infection has been described.

CONCLUSIONS

Brucella-related PJI should be considered in the differential of travellers returning from endemic areas with PJI, including Thailand. Personal protective equipment including fit tested filtering face piece-3 (FFP3) mask or equivalent is recommended for personnel carrying out joint aspiration when brucellosis is suspected. Travellers can reduce the risk of brucellosis by avoiding unpasteurised dairy products and animal contact (particularly on farms and abattoirs) in endemic areas and should be counselled regarding these risks as part of their pre-travel assessment.

A case of brucellar monoarthritis and review of the literature

Brucellosis is a systemic infectious disease, which constitutes a public health problem in Turkey. Brucellosis has a broad spectrum of clinical manifestations. Osteoarthicular manifestations are often seen in brucellosis but most of the brucellar monoarthritis cases are reactive rather than being septic. We report a case of brucellar (septic) monoarthritis of the knee in a 74-year-old cattleman and review of the literature.