Brucellosis and uveitis

Ocular Involvement in Patients with Brucellosis: A Single-Center Prospective Study

PURPOSE

The aim of this study was to evaluate the prevalence, type and treatment outcomes of ocular involvement in patients with brucellosis.

METHODS

This prospective, single-center study enrolled patients admitted to the infectious disease outpatient clinic with diagnosed brucellosis between July 15, 2022 and July 15, 2023. Diagnosis was based on clinical symptoms and a standard Brucella tube agglutination test (≥1/160) or a positive blood culture. Ophthalmologic examinations were performed at baseline and in the first month of treatment. Third and sixth month follow-up examinations were also performed for patients with ocular findings.

RESULTS

Ocular involvement occurred in 60 (24.8%) of 242 patients. Conjunctivitis was the most common ocular involvement and was observed in 39 patients (16.1%). Uveitis was the second most common ocular involvement in 14 patients (5.8%). Scleritis was the least common ocular involvement and was observed in only one patient. Patients with ocular involvement were older (p = 0.027) and had higher rates of weight loss and spondylodiscitis (p = 0.044 and 0.001, respectively). Among laboratory parameters, erythrocyte sedimentation rate and lactate dehydrogenase levels were significantly higher in patients with ocular involvement (p = 0.001 and 0.036, respectively). There were no significant differences in other demographic, clinical, and laboratory characteristics between patients with and without ocular involvement. In 56 (93.3%) patients, the ocular findings improved during the follow-up examination.

CONCLUSION

Brucellosis, a systemic infection, can manifest with ocular involvement. Early detection and treatment through ophthalmological examination are crucial in managing brucellosis.

An Unusual Manifestation of Brucella-Associated Uveitis in a Young Male Patient

This is a unique case of retinoschisis as an ocular manifestation of brucellosis. A 38-year-old male presented with recurrent episodes of bilateral eye redness, predominately in his left eye. His visual acuity was not affected, and he did not report any other symptoms. On slit lamp examination, binocular Koeppe nodules of the iris and cells in the left anterior chamber were observed. Fundoscopy followed by meticulous multimodal imaging confirmed left inferior retinoschisis. The patient was diagnosed with panuveitis, and a series of laboratory examinations revealed positive anti-IgM Brucella antibodies. Ocular brucellosis can cause variable, atypical, and serious presentations, hence, early diagnosis is paramount to avoid complications.

Ocular Involvement of Brucellosis: A Pooled Analysis Study

AIM

Brucellosis may affect the eye to varying degrees. The aim of this study was to investigate the ocular involvement of brucellosis and highlight key points.

MATERIAL AND METHODS

Published literature in English language on the ocular involvement of brucellosis within last 30 years was evaluated. The PubMed international database was screened using certain keywords.

RESULTS

The study included 27 publications evaluating a total of 159 cases. The most common types of ocular involvement were uveitis (52.2%) and conjunctivitis (17.6%). Most cases had concomitant systemic brucellosis (27.7%), and the most commonly used diagnostic method was a serological test (92.4%). Of all the patients, 37.1% recovered with sequelae.

CONCLUSION

Brucellosis may cause a wide range of ophthalmic manifestations, and an overlooked or late diagnosis may also lead to the development of sequelae or loss of vision. A routine ophthalmologic examination should be performed in all patients with systemic brucellosis.

Ocular Lesions in Brucella Infection: A Review of the Literature

Ocular lesions due to Brucella infection are uncommon and easily overlooked in clinical management, but must be differentiated from non-infectious eye diseases and treated promptly to protect the patient's vision. We reviewed the relevant literature and identified 47 patients with ocular complications of Brucella infection. Among them, 28 showed ocular neuropathy, 15 presented with uveitis, and four patients displayed other ocular symptoms. Ocular symptoms accompanying Brucella infection require prompt diagnosis and treatment. The main methods of diagnosis are intraocular fluid tests and blood tests. Early diagnosis and treatment with suitable antibiotics are central to protecting the patient's vision. Notably, in terms of mechanism of injury, Brucella infection is chronic and cannot be eliminated by phagocytes, and can cause damage to the eye by inducing autoimmune reactions, antigen-antibody complex production, release of endogenous and exogenous toxins, and bacterial production of septic thrombi in the tissues. In this review, we summarize the ocular symptoms, diagnosis, treatment and prognosis of Brucella infection, and discuss the mechanisms of Brucella in ocular lesions, providing a reference for the diagnosis and treatment of Brucella ocular lesions.

Hypopyon: Is-it Infective or Noninfective?

Hypopyon usually corresponds to the sedimentation of white blood cells, and it signifies severe intraocular inflammation. This key clinical sign may occur in association with a wide variety of infectious, inflammatory, and neoplastic conditions that may be sight- and, occasionally, life-threatening. A careful history and thorough clinical examination are the cornerstones for orienting the differential diagnosis, identifying the causative agent, and initiating prompt and appropriate treatment. This review outlines the clinical characteristics and management of hypopyon in relation with the underlying causative infectious or noninfectious ocular or systemic diseases.

Choroidal thickness and retinal nerve fiber layer analysis in acute systemic brucellosis

Introduction

This study aims to detect changes in choroidal thickness and retinal nerve fiber layer (RNFL) thickness in acute stage brucellosis.

Methods

Fnewly diagnosed patients with acute brucellosis and 19 healthy individuals as control group were included in the study. Choroidal thickness and RNFL thickness were measured using the Spectral Domain Cirrus OCT Model 400 (Carl Zeiss Meditec, Jena, Germany) for each participant in the patient and control group.

Results

In the brucella group, in the right eyes, the mean nasal choroidal thickness was 272.77 ± 50.26 μm ( p = 0.689), the mean subfoveal choroidal thickness was 321.14 ± 33.08 μm ( p = 0.590), the mean temporal choroidal thickness was 278.86 ± 48.84 μm ( p = 0.478), and the mean RNFL thickness was 90.43 ± 8.93 μm ( p = 0.567). In the left eyes, the mean nasal choroidal thickness was 282.29 ± 48.93 μm ( p = 0.715), the mean subfoveal choroidal thickness was 316.79 ± 39.57 μm ( p = 0.540), the mean temporal choroidal thickness was 284.93 ± 50.57 μm ( p = 0.392), and the mean RNFL thickness was 92.64 ± 8.95 μm ( p = 0.813).

Conclusion

No difference was found between the control and the brucella groups regarding to all choroidal regions and RNFL thickness.

Endogenous Brucella endophthalmitis: A case report

Brucellosis may be associated with a wide range of ophthalmic manifestations including endophthalmitis, which is a sight-threatening condition that needs to be rapidly recognized and treated to avoid permanent visual loss. A 26-year-old female with a 6-month history of vision loss in the left eye was treated with high dose systemic corticosteroids and azathioprine with an initial misdiagnosis elsewhere. A dense vitreous haze with opacities at the posterior hyaloid and a wide area of retinochoroiditis led to the diagnosis of endogenous endophthalmitis at presentation to us. The vitreous sample and blood cultures demonstrated growth of Brucella melitensis. She received 6 months of systemic antibiotherapy, which resulted in resolution of inflammation; however, visual acuity remained poor due to irreversible damage. Infectious etiology, including brucellosis in endemic countries, has to be considered in the differential diagnosis before administering immunomodulatory therapy in patients with panuveitis of unknown origin.

Infectious optic neuropathies: a clinical update

Different forms of optic neuropathy causing visual impairment of varying severity have been reported in association with a wide variety of infectious agents. Proper clinical diagnosis of any of these infectious conditions is based on epidemiological data, history, systemic symptoms and signs, and the pattern of ocular findings. Diagnosis is confirmed by serologic testing and polymerase chain reaction in selected cases. Treatment of infectious optic neuropathies involves the use of specific anti-infectious drugs and corticosteroids to suppress the associated inflammatory reaction. The visual prognosis is generally good, but persistent severe vision loss with optic atrophy can occur. This review presents optic neuropathies caused by specific viral, bacterial, parasitic, and fungal diseases.

Ocular involvement of brucellosis

A 29-year-old male diagnosed with brucellosis a week earlier was referred to the ophthalmology clinic with visual complaints. On examination, visual acuity was 20/25, he had conjunctival injection on slit lamp examination. There was also bilateral optic disk swelling plus retinal hyperemia (optic disc hyperemia and vascular tortuosity) and intraretinal hemorrhage on funduscopy. The patient was admitted and treated with cotrimoxazole, rifampin, doxycycline and prednisolone for 2 months. Ocular manifestations subsided gradually within 6 months after treatment. Brucellosis can affect the eye and lead to serious ocular complications. Early diagnosis and prompt treatment should be considered in endemic areas.

The visual impairment and inscrutable disease of Samuel Johnson

Samuel Johnson, the acclaimed author of the Dictionary of the English Language, survived childhood scrofula with impaired sight and hearing. The cause of his scrofula has been attributed to bovine tuberculosis, but mycobacterial infection does not satisfactorily account for the peculiar features of Johnson's eye disorder or his hearing loss. The subject of numerous biographies, Johnson may have the most scrutinized medical history of all time. Medical detectives, hampered by the vagueness of 18(th)-century diagnosis, suspect that phlyctenular eye disease related to tuberculosis was the reason for his visual impairment. Pediatric brucellosis can also explain childhood scrofula associated with visual and auditory disabilities, but it may be difficult to reconcile any single diagnosis given the uncertainties surrounding Johnson's medical and ocular histories.

Brucella meningitis and papilledema in a child

PURPOSE

To report a rare case of Brucella meningitis with papilledema in a child and to discuss the findings of neurobrucellosis in children.

METHODS

A 6-year-old girl was admitted with headache, fever, and vomiting for 1 week. Her family reported intake of raw unpasteurized goat's milk in the past. Meningeal signs were strongly positive. Bilateral moderate optic disc edema with flame-shaped hemorrhages was observed.

RESULTS

The diagnosis of Brucella infection was established by positive blood culture for Brucella species, serum agglutination titer of antibodies to Brucella >1:160, and positive CSF culture. After treatment consisting of trimethoprim-sulfamethoxazole, rifampin, and doxycycline, the patient's condition gradually improved. One month later, the papilledema disappeared. One year after presentation, the patient remains free of symptoms.

CONCLUSIONS

Brucella meningitis must be ruled out in symptomatic patients reporting ingestion of raw unpasteurized goat's milk. Papilledema is a frequent clinical feature, but irreversible visual impairment is extremely rare.

Bilateral severe visual loss in brucellosis

PURPOSE

To report a case of brucellosis with bilateral permanent loss of vision.

METHODS

Case report.

RESULTS

Bilateral loss of vision developed within two weeks in a young adult with positive Brucella antibodies. There was optic disc swelling with optic neuropathy and serous retinal detachment in both eyes. The patient had chronic active brucellosis confirmed by serum antibody titers (1/640).

CONCLUSION

This case shows that optic neuropathy may result in severe visual loss in patients with brucellosis.

Unusual clinical presentations of brucellosis

The purpose of this paper is to draw attention to atypical presentations of brucellosis. A prospective study identified 240 consecutive patients with brucellosis admitted to our department between December 1999 and July 2002. From these cases we present 11 patients with unusual clinical presentations. Neurobrucellosis, peritonitis, pericarditis, pancytopenia, and uveitis were diagnosed in 2 patients each and 1 presented with epididymo-orchitis.

Clinical resolution of Brucella canis-induced ocular inflammation in a dog

A 2-year-old spayed female mixed-breed dog was referred with an 8-month history of recurrent bilateral anterior uveitis and hyphema secondary to infection with Brucella canis. Treatment with doxycycline PO and atropine and prednisone acetate topically prior to referral had failed to resolve the ocular inflammation. Successful control of ocular inflammation was achieved after initiation of treatment with gentamicin SC and ciprofloxacin and doxycycline PO. The finite indirect fluorescent antibody (IFA) titer was reduced by half, and results of an agar gel immunodiffusion (AGID) test became negative after rifampin was added to the treatment protocol. Treatment with gentamicin was eventually discontinued because of evidence of renal toxicosis and cutaneous reactions to repeated injections. Thirty-five months after initial examination of the dog, results of the AGID test were still negative, the finite IFA titer was stable, and ocular inflammation had resolved, suggesting that the ocular infection may have been eliminated. To our knowledge, this represents the first report of the successful treatment of ocular inflammation caused by B canis infection in a dog.

Hearing status in brucellosis

BACKGROUND

Although brucellosis can lead to multisystem complications, involvement of the ear in brucellosis is rarely reported in the literature. The purpose of this study was to assess the hearing status of patients with brucellosis.

STUDY DESIGN

Thirty-two patients with brucellosis were included in the study. Pure tone and speech audiometry and tympanometry were performed in the patients.

RESULTS

The mean pure tone averages of the patients were within normal limits and were similar in both ears (P > 0.05). The pure tone averages of the patients with or without anti-Brucella treatment were not significantly different (P > 0.05) and were within the normal limits. When the hearing levels of these patients were compared at the frequencies of 250, 500, 1000, 2000, 4000, and 8000 Hz, there was no significant difference as well (P > 0.05).

CONCLUSIONS

Peripheral brucellosis does not appear to be associated with hearing loss.

Systemic disorders associated with episcleritis and scleritis

Inflammation of the episclera and sclera still represents a diagnostic challenge. Many of these presentations are idiopathic and are managed empirically with the use of anti-inflammatory therapy, usually with a satisfactory response. However, some cases will have a more aggressive nature or will show resistance to conventional therapy, and those potentially are connected to an infectious or underlying disease. In such cases, there is an increased risk of visual loss and severe systemic complications requiring intensive investigations and aggressive therapy. The diseases more commonly associated with these conditions, especially with scleritis, are the connective tissue disorders and systemic vasculitis, but systemic infections and malignancies also must be excluded. Management depends on the specific diagnosis, and every year a new list of potential associations or atypical presentations is reported. For a successful outcome, it is important that these presentations are recognized.

Recurrent episcleritis associated with brucellosis

PURPOSE

To document the clinical course and the treatment of episcleritis associated with brucellosis.

METHODS

Three consecutive cases of patients with recurrent episcleritis associated with brucellosis were evaluated through clinical and laboratory data including serology (tube agglutination), blood culture, and synovial fluid culture.

RESULTS

All the patients had ingested contaminated milk and/or fresh cheese. The diagnosis of brucellosis was confirmed by high antibody titer, positive blood culture, negative synovial fluid culture and unresponsive condition to the previous nonspecific therapy for episcleritis and reactive arthritis. The patients responded well to the therapy with doxycycline and rifampicin.

CONCLUSION

We proposed that recurrent episcleritis had a co-occurence with reactive arthritis in the course of the brucellosis, and that it responded well to the antibrucellar antibiotics rather than to steroids. This also implies that brucellosis as a rule is an underlying triggering infection associated with reactive arthritis.

Canine systemic bacterial infections

Although systemic bacterial diseases are an uncommon cause of uveitis in dogs, they should be included in the differential diagnoses for uveitis. A work-up for uveitis should include tests for B. canis and B. burgdorferi. If an aqueous centesis is performed, Leptospira titers or PCR can be performed on the aqueous humor and the serum. Better documentation of the role of Leptospira and B. burgdorferi in uveitis in the dog is needed. Any suspected cases should be worked-up thoroughly. If the dog does prove to be positive for the organism, the case should be submitted to a peer-reviewed journal.

Symptoms and signs in pulmonary medicine: old observations and new interpretations

Andre Gide wrote, "Everything has been said before, but since nobody listens we have to keep going back and beginning all over again." To a certain extent, that statement applies to the importance of accurate and systematic history taking and physical examination in clinical practice. Although we are trained in habits of comprehension and accuracy in history taking and examination of patients, periodic reminders are required to develop a diagnostic framework based on observation (inspection), palpation, percussion, and auscultation. This monograph reemphasizes the method to be pursued in the treatment of a patient with pulmonary symptoms. It consists of three parts: (1) questioning the patient about his or her medical history; (2) performing the physical examination of the respiratory system; and (3) examining the extrapulmonary signs and symptoms. Once a strong clinical framework has been constructed, its further development and refinement depend on the clinician's experience, power of observation, and systematic reading of the medical literature. Good physicians must continue to learn throughout their careers; this is the most essential element of a physician's development. Be patient, however; as Cowper said, "Knowledge, to become wisdom, needs experience."