Age and duration of disease as factors affecting clinical findings and sacroiliitis in brucellosis

Determining Diagnostic Sensitivity: A Comparison of Rose Bengal Test, Coombs Gel Test, ELISA and Bacterial Culture in Brucellosis Diagnosis-Analyzing Clinical Effectiveness in Light of Inflammatory Markers

BACKGROUND

Brucellosis is a zoonotic infectious disease. It is estimated that the number of cases reported today is much less than the actual number. We still have difficulty in diagnosing the disease and its organ involvement. In this sense, new approaches that can be useful in clinical practice are required, and we aimed to evaluate this situation in our study.

METHODS

171 of 213 patients followed in our center between January 2021 and April 2024 were included in the study. A total of 150 patients were included in the study as a control group. Rose Bengal test (RBT), Coombs gel test (CGT), enzyme-linked immunosorbent assay (ELISA), and automated blood culture were used for diagnosing brucellosis. Complete blood count, sedimentation, C-reactive protein, and biochemical parameters were obtained. Inflammation markers such as neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, systemic immune-inflammation index, and systemic inflammation response index were calculated.

RESULTS

The most successful results in the diagnosis were ELISA (89.4%), RBT (88.3%), CGT (83%), and blood culture (34.8%). For diagnosing sacroiliitis and spondylodiscitis, instead of resorting to expensive methods like magnetic resonance, a combination of ELISA positivity with elevated acute phase reactants and inflammatory markers could be significantly instructive.

CONCLUSIONS

Optimizing diagnostic algorithms and exploring novel diagnostic approaches, such as inflammatory markers, hold promise for improving diagnosis and management.

Research progress on complications of Brucellosis

Brucellosis is a common zoonotic disease that is widely spread worldwide and poses a major threat to human health. Clinically, it often presents with non-specific symptoms such as fever, excessive sweating, malaise, myalgia, arthralgia, loss of appetite, weight loss, and enlarged liver, spleen and lymph nodes. The disease has a long and recurrent course, often accumulating in multiple systems and organs. Of these, osteoarticular involvement is the most common complication, with a prevalence of approximately 2-77%, usually manifesting as spondylitis, sacroiliac arthritis and peripheral arthritis. Hepatosplenomegaly is seen in about 50% of patients with brucellosis, and gastrointestinal disturbances such as abdominal pain, nausea, and vomiting are common. Although respiratory involvement is less common, pneumonia, pleurisy, pleural effusion, and pulmonary nodules have been reported. Besides, approximately 2-20% of cases involve infections of the male genitourinary system, mainly manifesting as unilateral epididymal-orchitis and orchitis. The most serious complication facing brucellosis is cardiovascular involvement, and although the overall mortality rate of brucellosis is about 1% and the incidence of brucellosis endocarditis is less than 2%, more than 80% of deaths are associated with endocarditis. Furthermore, brucellosis is complicated by hematologic disease, with anemia occurring in approximately 20-53% of children during the acute phase. In addition, the neurological incidence of brucellosis is about 0.5-25%, mainly manifested as meningitis. In this study, we review the multisystem complications of brucellosis with the aim of improving early diagnosis, timely treatment and prevention of long-term complications.

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INTRODUCTION

Brucellosis, the most common zoonosis globally, is considered a major public health problem.

OBJECTIVE

A retrospective study was carried out over 21 years (1998-2018) to determine the epidemiological features of human brucellosis in the province of El-Oued (south-eastern Algeria).

RESULTS

1,832 confirmed cases of human brucellosis were reported during the study period, with an average incidence rate of around 12.26 cases per 100,000 inhabitants. The annual distribution of the incidence was characterized by an increasing trend and a strong fluctuation ; its values ranged between 2.27 and 24.96 per 100,000 inhabitants. The monthly distribution showed that the highest incidence rates were recorded from mid-February to July, with a peak of 2.74 cases per 100,000 inhabitants in April.Human brucellosis has affected all municipalities. The highest incidence rate was observed in border municipalities such as Ben Guecha and Oum Tiour (89.76 and 66.14 per inhabitants, respectively).The incidence in the male population was higher than that of the female at 14.63 versus 9.83 per 100,000 inhabitants, respectively, noting that it increases with age. Individuals over 65 years are the most at risk, with an incidence rate of 22.32 per 100,000 inhabitants.

CONCLUSION

Along with strengthening preventive measures in the population, eliminating brucellosis in animals is the most effective method to protect humans against infection.

The influence of illness duration before diagnosis on clinical characteristics and outcome in human brucellosis

Our study assesses the influence of illness duration before establishing the diagnosis of brucellosis and initiating therapy on patients' main clinical characteristics and outcome in an endemic area. The medical files of 297 patients with brucellosis were retrospectively analysed. They were divided into four groups according to illness duration before initiating therapy: <10 days; 11-30 days; 31-90 days; and >90 days. There were significant differences in the occurrences of fever (P = 0.019), focal forms (P = 0.026), spondylitis (P = 0.034) and therapeutic failures (P = 0.006) between the groups. Duration of >30 days before treatment initiation is responsible for more serious clinical presentation and outcome, whereas illness duration of >90 days further worsens the clinical progression in human brucellosis.

A Case Report of Pediatric Brucellosis in an Algerian Immigrant

An 8-year old girl presented to our facility with a 10-day history of fever, fatigue, abdominal pain and refusal to walk. She recently travelled from her native Algeria where she first developed symptoms. On evaluation, she was ill-appearing, febrile and tachycardic with hepatosplenomegaly and lymphadenopathy noted on examination. A strong musty odor was also noted from the child. Laboratory evaluation revealed pancytopenia, hyponatremia, and an elevated AST, ALT, and LDH. Malaria testing was negative, as was a PPD. On further questioning, the family reported multiple sick contacts in Algeria with similar symptoms. After discussion with Oncology and Infectious Diseases, she underwent a bone marrow biopsy that was significant for multiple non-caseating ring granulomas. She was started on combination therapy of doxycycline and for presumed brucellosis infection with improvement in her symptoms and resolution of fever. Bone marrow culture returned several days later positive for Brucella melitensis.

Characteristics of liver function in brucellosis patients with liver injury: A retrospective evaluation of 254 cases

AIM

To summarize the characteristics of liver function in brucellosis patients with liver injury.

METHODS

The clinical and laboratory data of 254 brucellosis patients with liver injury treated at the First Hospital of Jilin University were retrospectively evaluated.

RESULTS

The age of the 254 patients ranged from 2 to 80 years. All of the patients were diagnosed according to the 2012 brucellosis guidelines. Among the 254 patients, the majority had an increase in alanine transaminase (ALT) and aspartate transaminase (AST) levels < 3 times, an increase in γ-glutamyl transferase > 3 times, slightly elevated alkaline phosphatase, and normal total bilirubin. The disease duration was shorter in the abnormal liver function group than in the normal liver function group, but the highest temperature was higher in the abnormal liver function group. All patients were treated according to the World Health Organization recommendations. The time to fever relief in the two groups had no significant difference, but white blood cells, C-reactive protein, and erythrocyte sedimentation rate were higher in patients with normal liver function than in those without. Of 31 patients with abnormal liver function who were followed, no treatment failure occurred, but five had relapse. In the 44 patients with normal liver function who were randomly followed, three had treatment failure and six had recurrence. There was no significant difference between the two groups in the recurrence rate (P = 0.764). Total bilirubin was higher in patients with viral hepatitis than in those without.

CONCLUSION

Brucella infection can cause varying degrees of liver dysfunction, and ALT or AST increase is usually not more than 3 times. Occasionally, patients may develop severe liver injury, but systemic inflammatory is slight. After a short period of treatment, liver function returns to normal in most cases. Liver injury is more severe in those also having viral hepatitis.

Subclinical sacroiliitis in brucellosis. Clinical presentation and MRI findings

PURPOSE

The aim of this work was to detect subclinical sacroiliac joint involvement in patients with brucellosis and study their clinical and laboratory features.

PATIENTS AND METHODS

The study included 100 brucellosis patients being followed-up in the Gastroenterology and Hepatology Unit, Theodor Bilharz Research Institute and Cairo University outpatient clinics. A thorough history, physical examination, routine laboratory tests, and abdominal ultrasound were obtained for all patients. Extended rheumatological examination was performed including clinical testing for sacroiliitis and enthesitis. None of the patients reported a history of back pain or any symptoms suggestive of sacroiliitis during the course of the infection. Plain x-ray and MRI scan of the sacroiliac joints were performed for all patients.

RESULTS

Asymptomatic sacroiliitis was present in 24 % of the brucellosis patients; none of the patients had tenderness over their spine with preserved lumbar spine mobility. Sacroiliitis was mainly unilateral being bilateral in 20.83 %. There was an obvious relationship with animal contact and occupation of the patients. Osteoarticular involvement was common (67 %) including arthralgias, arthritis, myalgias, spondylitis, enthesitis and bursitis, being clearly higher in those with sacroiliitis. The MRI scan showed blurring of the margins in 66.67 %, widening in 25 %, narrowing in 54.17 %, erosions in 20.83 %, and sclerosis in 12.5 %.

CONCLUSION

Osteoarticular manifestations of brucellosis are prevalent and subclinical sacroiliitis is evident, a finding that may classify these patients as having brucellar spondyloarthropathy (BSA). Referring brucellosis patients for rheumatological assessment has the advantage of early assessment of asymptomatic cases with sacroiliitis which is commonly overlooked.

Frequency of sacroiliitis among patients with low back pain

Introduction

Sacroiliitis is one of the important symptoms in patients attending infectious diseases and rheumatology clinics. Some patients with sacroiliitis are asymptomatic, and some have unspecific symptoms. The aim of this study was to determine the frequency of sacroiliitis causes among patients attending Shahid Sadoughi’s infectious disease and rheumatology clinics.

Methods

In this study, we evaluated patients attending Shahid Sadoughi rheumatology and infectious diseases clinic in 2014. Patients who had positive findings in favor of sacroiliitis were evaluated by history, physical exam, laboratory tests, and imaging. The patients were divided into infectious, inflammatory non-infectious, and degenerative causes. The data were analyzed by IBM SPSS version 20 using the independent samples t-test, ANOVA, the chi-squared test, and the Fisher’s exact test.

Results

We studied 136 patients. Among them 64 (47.1%) were male, and 72 (52.9%) were female. The mean age of the participants was 34.28 ± 10.36 years. Among the patients, 12 (8.8%) had infectious causes, 120 (88.2%) had inflammatory non-infectious causes, and four (2.9%) had degenerative causes.

Conclusion

Based on our results, inflammatory non-infectious causes are at the top of the list of sacroiliitis causes, but we should always consider infectious causes, including brucellosis.

Clinical characteristics of human brucellosis in patients with various monoarticular involvements

The aim of the study was to determine the main demographic, epidemiological, clinical characteristics, and outcome in patients with various types of brucellar monoarticular involvement. Retrospectively, we analyzed medical histories of 331 patients with brucellar monoarticular involvement who were treated at the infectious diseases departments in Prilep, Shtip, and Veles, Republic of Macedonia, during the period 1990-2012. Their data were compared accordingly to the affected joint (sacroiliac, hip, knee, ankle, wrist, and shoulder).Patients with shoulder arthritis were significantly the oldest (mean ± standard deviation [SD] 46.0 ± 14.5 years) whereas sacroiliitis and hip arthritis were present predominantly in younger patients (mean ± SD 28.7 ± 14.1 and 28.3 ± 18.3 years, respectively) (p = 0.014). Shoulder arthritis duration was significantly the longest (mean ± SD 24.5 ± 12.4 days), and wrist arthritis duration was significantly the shortest (mean ± SD 4.1 ± 2.5 days) (p < 0.001), before establishing the diagnosis of brucellosis. With appropriate treatment, the need for restitution of the joint impairment was significantly longer when sacroiliitis and hip arthritis were present (mean ± SD 32.8 ± 23.0 and 24.6 ± 12.5 days, respectively) (p < 0.001). The relapses were noted in 14.5, 14, 16.5, 5.5, 6, and 5.5 % of the patients with sacroiliitis, hip-, shoulder-, knee-, ankle-. and wrist arthritis, respectively. In endemic areas, brucellosis should be included in the differential diagnostic consideration in patients with monoarticular involvement. Knee-, ankle-, and wrist arthritis seem to be more benign and with appropriate treatment result in short duration and satisfactory outcome. On the other hand, the involvement of sacroiliac, hip-, and shoulder joint deserves more serious approach due to longer arthritis duration and higher frequency of relapses.

Enterobacter cloacae Sacroiliitis with Acute Respiratory Distress Syndrome in an Adolescent

Enterobacter cloacae has emerged as an important nosocomial pathogen, but is rarely a cause of sacroiliitis. Herein, we present the first reported case of Enterobacter cloacae sacroiliitis associated with sepsis and acute respiratory distress syndrome (ARDS). A previously healthy 14-year-old boy presented with low-grade fever and pain in the left side of the hip that was aggravated by walking. Pelvic computed tomography (CT) showed normal findings, and the patient received supportive care for transient synovitis with no antibiotics. However, there was no clinical improvement. On the third day of hospitalization, magnetic resonance imaging of the hip revealed findings compatible with sacroiliitis, for which vancomycin and ceftriaxone were administered. The patient suddenly developed high fever with dyspnea. Chest radiography and CT findings and a PaO2/FiO2 ratio <200 mmHg were suggestive of ARDS; the patient subsequently received ventilatory support and low-dose methylprednisolone infusions. Within one week, defervescence occurred, and the patient was able to breathe on his own. Following the timely recognition of, and therapeutic challenge to, ARDS, and after 6 weeks of parenteral antimicrobial therapy, the patient was discharged in good health with no complications.

Risk factors associated with the presentation of brucellosis in the spine

OBJECTIVE: The aim of this study is to describe the risk factors associated with the presentation of brucellosis on the spine, and determine the strength of association between these factors. METHODS: The medical records of patients with brucellosis on the spine were analyzed and a spreadsheet was created to compile the following data: age, sex, place of origin and residence, risk factors (exposure at work, consumption of unpasteurized products and comorbidities), clinical presentation (lumbar pain, anorexia, headache, myalgia, fatigue, paresthesia, dysesthesia, muscle weakness, weight loss, fever), affected spine level, presence of abscesses, disease duration (acute, subacute, chronic), laboratory studies (erythrocyte sedimentation rate, C-reactive protein, serology, blood culture, Rose Bengal test, histopathological reports), imaging studies (x-rays, MRI, bone gammagraphy), established treatment (medical and/or surgical), therapeutic failure and sequelae. RESULTS: A total of 17 patients, 10 women (58.8%) and seven men (41.2%), were reviewed from January 2007 to January 2011. The group had a mean age of 57.8 years with a standard deviation of +13.91 and age range between 16-74 years. CONCLUSIONS: There is no significant difference between the groups compared with respect to age and sex, however, improvement of the neurological deficit was observed in eight patients who underwent surgical procedure.

Liver involvement in patients with brucellosis: results of the Marmara study

Brucellosis is a zoonotic disease that primarily affects the reticuloendothelial system. But, the extent of liver damage in due course of the disease is unclear. This study included 325 brucellosis patients with significant hepatobiliary involvement identified with microbiological analyses from 30 centers between 2000 and 2013. The patients with ≥5 times of the upper limit of normal for aminotransferases, total bilirubin level ≥2 mg/dl or local liver lesions were enrolled. Clinical hepatitis was detected in 284 patients (87.3 %) and cholestasis was detected in 215 (66.1 %) patients. Fatigue (91 %), fever (86 %), sweating (83 %), arthralgia (79 %), and lack of appetite (79 %) were the major symptoms. Laboratory tests showed anemia in 169 (52 %), thrombocytopenia in 117 (36 %), leukopenia in 81 (25 %), pancytopenia in 42 (13 %), and leukocytosis in 20 (6 %) patients. The most commonly used antibiotic combinations were doxycycline plus an aminoglycoside (n = 73), doxycycline plus rifampicin (n = 71), doxycycline plus rifampicin and an aminoglycoside (n = 27). The duration of ALT normalization differed significantly in three treatment groups (p < 0.001). The use of doxycycline and an aminoglycoside in clinical hepatitis showed better results compared to doxycycline and rifampicin or rifampicin, aminoglycoside, doxycycline regimens (p < 0.05). However, the length of hospital stay did not differ significantly between these three combinations (p > 0.05). During the follow-up, treatment failure occurred in four patients (1 %) and relapse was seen in three patients (0.9 %). Mortality was not observed. Hepatobiliary involvement in brucellosis has a benign course with suitable antibiotics and the use of doxycycline and an aminoglycoside regimen seems a better strategy in select patients.

Clinical manifestations of human brucellosis: a systematic review and meta-analysis

Background

The objectives of this systematic review, commissioned by WHO, were to assess the frequency and severity of clinical manifestations of human brucellosis, in view of specifying a disability weight for a DALY calculation.

Methods/Principal Findings

Thirty three databases were searched, with 2,385 articles published between January 1990–June 2010 identified as relating to human brucellosis. Fifty-seven studies were of sufficient quality for data extraction. Pooled proportions of cases with specific clinical manifestations were stratified by age category and sex and analysed using generalized linear mixed models. Data relating to duration of illness and risk factors were also extracted. Severe complications of brucellosis infection were not rare, with 1 case of endocarditis and 4 neurological cases per 100 patients. One in 10 men suffered from epididymo-orchitis. Debilitating conditions such as arthralgia, myalgia and back pain affected around half of the patients (65%, 47% and 45%, respectively). Given that 78% patients had fever, brucellosis poses a diagnostic challenge in malaria-endemic areas. Significant delays in appropriate diagnosis and treatment were the result of health service inadequacies and socioeconomic factors. Based on disability weights from the 2004 Global Burden of Disease Study, a disability weight of 0.150 is proposed as the first informed estimate for chronic, localised brucellosis and 0.190 for acute brucellosis.

Conclusions

This systematic review adds to the understanding of the global burden of brucellosis, one of the most common zoonoses worldwide. The severe, debilitating, and chronic impact of brucellosis is highlighted. Well designed epidemiological studies from regions lacking in data would allow a more complete understanding of the clinical manifestations of disease and exposure risks, and provide further evidence for policy-makers. As this is the first informed estimate of a disability weight for brucellosis, there is a need for further debate amongst brucellosis experts and a consensus to be reached.

Brucellosis is a bacterial disease transmitted to humans by consumption of infected, unpasteurised animal milk or through direct contact with infected animals, particularly aborted foetuses. The livestock production losses resulting from these abortions have a major economic impact on individuals and communities. Infected people often suffer from a chronic, debilitating illness. This systematic review on the symptoms of human brucellosis is the first ever conducted. Using strict exclusion criteria, 57 scientific articles published between January 1990–June 2010 which included high quality data were identified. Severe complications of brucellosis infection were not rare, with 1 case of endocarditis and 4 neurological cases per 100 patients. One in 10 men suffered from testicular infection, which can case sterility. Debilitating conditions such as joint, muscle, and back pain affected around half of the patients. Given that most patients had fever, brucellosis poses a diagnostic challenge in malaria-endemic areas where fever is often assumed to be malaria. More high quality data is needed for a more complete understanding of the clinical manifestations of disease and exposure risks, and to provide further evidence for policy-makers.

Human brucellosis in Macedonia - 10 years of clinical experience in endemic region

AIM

To present our 10-year clinical experience with brucellosis patients at the University Clinic for Infectious Diseases and Febrile Conditions in Skopje, Republic of Macedonia.

METHODS

A total of 550 patients with brucellosis treated between 1998 and 2007 were retrospectively assessed for their demographic, epidemiological, and clinical characteristics and outcomes.

RESULTS

Of the 550 patients, 395 (72%) were male. The median age was 34.5 years (range, 1-82). Direct contact with infected animals was recorded in 333 (61%) patients and positive family history in 310 (56%). The most frequently seen symptoms were arthralgia (438, 80%), fever (419, 76%), and sweating (394, 72%). The most common signs were fever and hepatomegaly, which were verified in 357 (65%) and 273 (50%) patients, respectively. Focal brucellosis was found in 362 patients (66%) and osteoarticular in 299 (54%). Therapeutic failures were registered in 37 (6.7%) patients. Of the 453 (82%) patients who completed a follow-up period of at least 6 months, relapses occurred in 60 (13%).

CONCLUSION

Due to non-specific clinical manifestation and laboratory parameters, brucellosis should be considered one of the differential diagnoses of any patient suffering from obscure involvement of various organs in a brucellosis-endemic region. High percentage of relapses and therapeutic failures in spite of the use of currently recommended therapeutic regimens indicates the seriousness of this zoonosis and the need to control it.

Clinical manifestations and complications in 1028 cases of brucellosis: a retrospective evaluation and review of the literature

INTRODUCTION

Brucellosis is the most prevalent bacterial zoonosis worldwide. In this study, we aimed to compare our 1028 brucellosis cases with other big series in the literature in view of epidemiological, clinical, and laboratory findings and therapeutic features.

METHODS

A total of 1028 brucellosis cases admitted to the Department of Infectious Diseases and Clinical Microbiology over a 10-year period were included in the study. A retrospective analysis was undertaken and patient files were reviewed for history, clinical and laboratory findings, and therapeutic features, as well as complications.

RESULTS

Of the 1028 patients, 539 (52.4%) were female and 489 (47.6%) were male. The mean age of patients was 33.7+/-16.34 years and 69.6% of cases were aged 13-44 years. Four hundred and thirty-five cases (42.3%) had a history of raising livestock and 55.2% of the cases were found to have no occupational risk for brucellosis. Six hundred and fifty-four of the cases (63.6%) had a history of raw milk and dairy products consumption. The most frequently seen symptoms were arthralgia (73.7%) and fever (72.2%), while the most common clinical findings were fever (28.8%) and hepatomegaly (20.6%). The most frequent laboratory finding was a high C-reactive protein level (58.4%). The standard tube agglutination (STA) test+Coombs STA test was positive in 1016 cases (98.8%). Focal involvement was present in 371 (36.1%) cases. The most frequent involvement was osteoarticular involvement with 260 cases (25.3%). The overall relapse rate for patients with brucellosis was 4.7%. The highest relapse rate, 8.5%, was observed in the group of patients with osteoarticular involvement. Regimens including doxycycline and streptomycin with or without rifampin appeared more effective than other regimens in osteoarticular involvement.

CONCLUSIONS

In humans, brucellosis may lead to serious morbidity, and it continues to be a major health problem in Turkey. There is no recommended treatment protocol for complicated brucellosis. Large multicenter studies are needed to determine the most appropriate treatment choices and durations in complicated brucellosis.