Medically treated intraspinal "Brucella" granuloma

Venous thrombosis, peripheral aneurysm formation, and fever in a feral pig hunter with Brucellosis

Brucellosis is a systemic bacterial zoonotic disease with potential endovascular complications including endocarditis, although multifocal vasculopathy is rare. Moreover, swine-associated human infections are less common since brucellosis was eradicated in commercial swine in U.S. states and territories. However, feral swine continue to serve as a reservoir for Brucella suis. We describe the case of a feral swine hunter who presented with fever and respiratory symptoms and was diagnosed with pulmonary embolus. Blood cultures revealed growth of Brucella, later confirmed as Brucella suis. Despite initial appropriate antimicrobial therapy, he maintained fever with worsening knee pain, and magnetic resonance imaging and two-dimensional echocardiography subsequently confirmed the presence of a thrombosed popliteal artery aneurysm and mitral valve vegetation, respectively. To our knowledge, this is the first report of contemporaneous venous and arterial thromboembolism attributable to B. suis infection.

Epidemiology of Brucellosis in Saudi Arabia

Objectives:

To provide a comprehensive summary of brucellosis incidence, prevalence, risk associated factors, and impact on the Saudi population.

Methods:

A systematic review was conducted using the PubMed database. The articles included in the review were written in English and investigated the epidemiology, etiology, distribution, impact, or burden of brucellosis in the Saudi population. Articles to be included were finalized after a mutual consensus of 2 researchers.

Results:

Seventeen (n=17) studies were included which were conducted in diverse geographical areas of Saudi Arabia. Of them, 3 studies reported the prevalence of brucellosis among pregnant women and pregnancy outcomes; 3 studies focused on risk associated factors and symptoms and signs of brucellosis among children; 2 studies highlighted the prevalence of brucellosis among workers; 9 studies reported the prevalence/incidence and risk associated factors of brucellosis. Brucellosis incidence and prevalence vary widely among regions. Contact with infected animals and consumption of raw milk and milk products were identified as the main risk associated factors of brucellosis. Abortion and intrauterine fetal deaths rates were significantly higher among pregnant women with brucellosis compared with pregnant women without brucellosis.

Conclusion:

Brucellosis poses a considerable impact on human and has a higher prevalence in developing countries as compared to developed countries. Our results revealed that brucellosis is a risk factor for adverse reproductive outcomes. PROSPERO No: CRD4201912430

Brucella Case That Led to Atlantoaxial Spinal Instability in Childhood

BACKGROUND

Atlantoaxial subluxation caused by Brucella infection is rarely seen in children.

CASE DESCRIPTION

C1-C2 dislocation, erosion in the odontoid bone, and compression to the brainstem were detected on cervical computed tomography and magnetic resonance imaging in a 6-year-old patient who suffered neck pain, deviation to the right in the neck, fever, and pain in his extremities. He was hospitalized in the Clinic of Pediatric Infectious Diseases. Positive Brucella agglutination tests were obtained, so C1-C2 stabilization and fusion were performed. Antibrucellosis antibiotic treatment was administered for 6 months. It was suggested that the dislocation was related to odontoid erosion and laxity of the atlantoaxial ligamentous structures during Brucella infection.

CONCLUSIONS

Atlantoaxial dislocation and instability develops secondarily to paravertebral abscesses, only rarely. Like brucellosis of childhood, granulomatous infectious diseases rarely cause atlantoaxial subluxation or dislocation. Torticollis and neck pains should be taken seriously for the purpose of early diagnosis of patients at risk in endemic regions. Stabilization and fusion should be performed when instability is detected, and these patients should be assessed with both pediatric infectious diseases and neurosurgery clinics. Our case is the first one in the literature in which atlantoaxial instability developed due to Brucella infection and stabilization was performed.

Brucella - Virulence Factors, Pathogenesis and Treatment

Brucellae are Gram-negative, small rods infecting mammals and capable of causing disease called brucellosis. The infection results in abortion and sterility in domestic animals (sheeps, pigs, rams etc). Especially dangerous for humans are: Brucella melitensis, Brucella suis, Brucella abortus, and Brucella canis that trigger unspecific symptoms (flu-like manifestation). Brucella rods are introduced via host cells, by inhalation, skin abrasions, ingestion or mucosal membranes. The most important feature of Brucella is the ability to survive and multiply within both phagocytic and non-phagocytic cells. Brucella does not produce classical virulence factors: exotoxin, cytolisins, exoenzymes, plasmids, fimbria, and drug resistant forms. Major virulence factors are: lipopolysaccharide (LPS), T4SS secretion system and BvrR/BvrS system, which allow interaction with host cell surface, formation of an early, late BCV (Brucella Containing Vacuole) and interaction with endoplasmic reticulum (ER) when the bacteria multiply. The treatment of brucellosis is based on two-drug therapy, the most common combinations of antibiotics are: doxycycline with rifampicin or fluoroquinolones with rifampicin. Currently, also other methods are used to disrupt Brucella intracellular replication (tauroursodeoxycholic acid or ginseng saponin fraction A).

Seroreactivity and Risk Factors Associated with Human Brucellosis among Cattle Slaughterhouse Workers in South Korea

The prevalence rate of human brucellosis in high-risk populations, as well as their risk factors, have not been well understood in South Korea. In this cross-sectional study, we investigated the seroreactivity and risk factors associated with human brucellosis among South Korean cattle slaughterhouse workers. We enrolled 922 subjects working in 71 slaughterhouses across the country in 2012. A structured questionnaire was used to obtain data from the subjects, following which blood samples were collected and tested using the microagglutination test; serum titers ≥ 1:20 were considered reactive. Independent risk factors were identified using multivariate logistic regression analysis with backward elimination. Overall, 62 of 922 participants (6.7%) exhibited seroreactivity for brucellosis, and 0.4% had a seroprevalence at a dilution of 1:160. Multivariate analysis revealed that the risk factors for human brucellosis seroreactivity included large-scale slaughtering (≥100 cattle per day; odds ratio (OR), 5.41; 95% confidence interval (CI), 2.95–9.91) and medium-scale slaughtering (50–99 cattle per day; OR, 2.53; 95% CI, 1.16–5.51). Moreover, the risk of brucellosis infection was significantly lower among slaughterhouse workers who always wear protective glasses (OR, 0.27; 95% CI, 0.11–0.69) than in those who sometimes or rarely wore such glasses. Regular and consistent use of personal protective equipment, especially protective glasses, should be encouraged among cattle slaughterhouse workers to reduce brucellosis infection.

ISOLATION AND CHARACTERIZATION OF A NOVEL MARINE BRUCELLA FROM A SOUTHERN SEA OTTER (ENHYDRA LUTRIS NEREIS), CALIFORNIA, USA

We characterize Brucella infection in a wild southern sea otter ( Enhydra lutris nereis) with osteolytic lesions similar to those reported in other marine mammals and humans. This otter stranded twice along the central California coast, US over a 1-yr period and was handled extensively at two wildlife rehabilitation facilities, undergoing multiple surgeries and months of postsurgical care. Ultimately the otter was euthanized due to severe, progressive neurologic disease. Necropsy and postmortem radiographs revealed chronic, severe osteoarthritis spanning the proximal interphalangeal joint of the left hind fifth digit. Numerous coccobacilli within the joint were strongly positive on Brucella immunohistochemical labelling, and Brucella sp. was isolated in pure culture from this lesion. Sparse Brucella-immunopositive bacteria were also observed in the cytoplasm of a pulmonary vascular monocyte, and multifocal granulomas were observed in the spinal cord and liver on histopathology. Findings from biochemical characterization, 16S ribosomal DNA, and bp26 gene sequencing of the bacterial isolate were identical to those from marine-origin brucellae isolated from cetaceans and phocids. Although omp2a gene sequencing revealed 100% homology with marine Brucella spp. infecting pinnipeds, whales, and humans, omp2b gene sequences were identical only to pinniped-origin isolates. Multilocus sequence typing classified the sea otter isolate as ST26, a sequence type previously associated only with cetaceans. Our data suggest that the sea otter Brucella strain represents a novel marine lineage that is distinct from both Brucella pinnipedialis and Brucella ceti. Prior reports document the zoonotic potential of the marine brucellae. Isolation of Brucella sp. from a stranded sea otter highlights the importance of wearing personal protective equipment when handling sea otters and other marine mammals as part of wildlife conservation and rehabilitation efforts.

Brucella infection of the thoracic vertebral arch presenting with an epidural abscess: a case report

Introduction

Although Brucella spondylitis and Brucella discitis have been frequently reported, Brucella infection of the vertebral arch is rare and has not been previously described. We present the first case of Brucella infection of the thoracic vertebral arch with epidural abscess formation and discuss the clinical key points.

Case presentation

A 57-year-old man of Han nationality with a history of contact with an isolated sheep stomach 2 months previously was admitted with an undulant fever, night sweats, back pain, and weakness. Thoracic magnetic resonance imaging showed laminar destruction of T9 and an epidural abscess at the T9 to 10 level with significant cord compression. Diagnosis of Brucella infection of his vertebral arch was confirmed by a positive blood culture with growth of Brucella melitensis. Total laminectomy, abscess cleansing, and percutaneous pedicular screw fixation was performed initially, followed by antibiotic treatment with a combination of doxycycline and rifampin for 4 months. Recovery was confirmed by clinical, magnetic resonance imaging, and blood culture findings.

Conclusions

This is an unusual case of Brucella infection of the vertebral arch with epidural abscess formation. Effective antibiotic therapy of a sufficient duration and timely performance of surgical treatment are the key points in management of such cases.

Human brucellosis: sero-prevalence and associated risk factors in agro-pastoral communities of Kiboga District, Central Uganda

BACKGROUND

Brucellosis remains a neglected zoonotic disease among agro-pastoral communities where unprocessed milk and milk products are consumed. A cross-sectional study was carried out in Kiboga district to determine the seroprevalence and risk factors associated with human brucellosis in communities where livestock rearing in a common practice.

METHODS

A total of 235 participants were involved in the study. Blood samples from the participants were collected and screened for Brucella using Serum Agglutination Test and Rose Bengal Plate Test. A questionnaire was used to collect data on socio-demographic characteristics and human brucellosis related risk factors.

RESULTS

Human Brucella seroprevalence was at 17.0 % (n = 235). The prevalence was highest among males (20.5 %, n = 78) and the elderly - above 60 years (22.2 %, n = 18). Residence in rural areas (OR 3.16, 95 % CI: 1.16-8.56), consuming locally processed milk products (OR 2.54, 95 % CI: 1.12-5.78) and being single (OR 2.44, 95 % CI: 1.05-5.68), were associated with increased risk of brucellosis.

DISCUSSION

Human brucellosis seroprevalence was high at 17 %, this was parallel with animal brucellosis prevalence that has been reported to range from 10.2 % to 25.7 % in cattle in the region. The participants were from communities known to habitually consume raw milk and milk products, know to process milk products using bare hands which are major risk factors for brucellosis in humans. This also explains why consumption of unpasteurized milk products was associated with the occurrence of brucellosis in study area. This strengthened the argument that humans get infected through consumption of contaminated animal products as reported in other earlier studies. Males and elderly being more affected because of traditional roles of these groups they play in livestock care and management. The single were also to be more associated to brucellosis, due to the fact that this group consume milk and milk products more as it is readily available in the informal markets as highly nutritious fast foods in this community as also observed in USA.

CONCLUSIONS

Brucellosis is highly prevalent in Kiboga district, and therefore, an important public health problem. The transmission risk was aggravated by consumption of unpasteurized milk products, residing in rural settings and being single. There is a need to initiate screening, treat infected humans early, and educate the public about risk factors and appropriate preventive measures of brucellosis.

Cervical spinal brucellosis with epidural abscess causing neurologic deficit with negative serologic tests

BACKGROUND

Here we present a case of cervical spinal epidural abscess causing neurologic deficits despite negative serologic tests.

CASE DESCRIPTION

Unlike a previously reported case, blood cultures and serologic tests were negative for this 50-year-old male with cervical brucellar spondylodiscitis and neurologic deficits. The diagnosis was made based on magnetic resonance imaging (MRI) findings and tissue culture. We drained the epidural abscess, performed anterior cervical discectomy fusion with an iliac strut bone graft, and administered antimicrobial therapy (gentamicin and doxycycline). At the 1-year follow-up visit, a C-spine lateral plain radiograph revealed solid fusion achieved by autogenous strut bone grafting at C4-C5 and C5-C6, and a T2-weighted image showed that epidural abscess and granulation tissue causing spinal cord compression were absent. In addition, the patient had recovered from all of the neurologic deficits with the exception of voiding difficulty.

CONCLUSION

It is important for clinicians to consider brucellar cervical spondylodiscitis when an epidural abscess is identified in a patient with a history of potential exposure. We recommend both blood and tissue cultures for diagnosis when serologic tests are negative.

Cervical intramedullary granuloma of Brucella: a case report and review of the literature

The aim of this study was to present a unique case of intramedullary brucellar granuloma (IBG) and to discuss the diagnosis and management. To our knowledge, only one case of thoracic IBG has been reported previously, and our case is the first in cervical spine. A 35-year-old female patient was admitted with headache, pain and weakness in her four extremities. She had no gastrointestinal symptoms and fever. She had been diagnosed with Brucella meningitis 3 months ago and a triple therapy of doxycyclin, rifampicin and trimetoprim/sulfametoxazol (TMP/SMZ) had been started. Medical history revealed that she had ingested raw cheese and taken her medication improperly. Loss of strength was detected in her four extremities, which led us to assume the formation of a mass lesion at cervical level. Therefore, we performed a magnetic resonance imaging scan and found enhancement of an intramedullary mass lesion at cervical 1-2 level. Diagnosis of neurobrucellosis was confirmed by titer of >1/160 Brucella antibodies both in blood and cerebrospinal fluid. Based on these findings, brucellar granuloma of cervical spine was diagnosed and a combination therapy of doxycyclin, TMP/SMZ and rifampicin was administered for additional 6 months. At the ninth month of treatment, the patient recovered both radiologically and clinically. Our case is unique, in terms of cervical IBG formation. The excellent response to antimicrobial therapy in our patient suggests that, a trial of medical treatment for 6 months may be effective in such cases.

Spinal brucellosis: Turkish experience based on 452 cases published during the last century

BACKGROUND

Spinal brucellosis continues to be the leading cause of morbidity from infectious disease in the infested regions of the world, particularly in the rural areas including Turkey. The purpose of this review was to present the Turkish experience by analyzing the literature on the management of spinal brucellosis during the last century.

MATERIALS AND METHOD

To establish new guidelines for the diagnosis and treatment of this disabling health problem, publications reported from Turkey in national (n = 27) and international (n = 37) journals during the last century and databases containing medical literature were analysed.

RESULTS

It was observed that the number of articles produced by Turkish authors regarding spinal brucellosis has tremendously increased throughout the study period. Although the total number of reported cases with spinal brucellosis from a total of 34 secondary or tertiary referral centers in Turkey was 452, only cases having detailed information were evaluated for further analysis according to inclusion/exclusion criteria. Despite the inherent limitations, this type of study clearly indicates that the incidence of brucellosis has not decreased in Turkey over recent years. The clinical and radiological findings of brucellosis involving the spine were mostly atypical and it was difficult to diagnose this infectious disease owing to its nonspecific and variable clinical picture. Therefore, it may easily lead to a misdiagnosis of lumbar disc herniation or other spinal infections and a high index of suspicion is required to diagnose this condition in endemic parts of the world. In addition to serological tests, CT and/or MRI techniques were found to be sensitive for diagnosis and follow-up because they provide early diagnosis of lesions involving the spine and more accurate localization of intraspinal and paraspinal infestation by means of multiplanar images. Histologically, noncaseating granulomatous tissue and chronic inflammation were characteristic features of cases of brucellosis with spinal involvement.

CONCLUSIONS

Based on this critical review of literature from Turkey, it is concluded that early diagnosis and correct management are important to prevent the harmful effects of brucellosis and its complications, and that the treatment of choice is antibiotic therapy alone in most cases of brucellosis involving the spine.

Spinal epidural abscess due to Brucella

BACKGROUND

Brucellar spinal epidural abscess (SEA) is a rarely encountered clinical entity during the course of the systemic Brucella infection.

METHODS

We reported 9 patients diagnosed with Brucellar SEA with a mean follow-up of 20 months. Spinal epidural abscess was detected by magnetic resonance imaging in all cases. Brucella diagnosis was established by specific blood tests. Patients were administered antibiotics for a duration of 6 to 12 weeks.

RESULTS

Spinal epidural abscess was localized in lumbar region in 6 patients, dorsal in 2 patients, and cervical in 1 patient. Abscess mimicked disk herniation clinically in 3 patients. Although neurologic examination was normal in 6 patients, we detected motor deficit in 3 patients. Symptoms regressed in all patients but 1 after the institution of antibiotic regimens, and all recovered fully without any sequel. Surgical drainage of abscess was performed in 1 patient.

CONCLUSIONS

Proper antibiotic regimens in required doses and duration should be the primary treatment in Brucellar SEA. The criteria for terminating antibiotic therapy are clinical recovery and dissolution of abscess images radiologically. Lastly, should any neurologic deterioration be detected during the course of medical treatment, surgical decompression is to be considered.

Neurobrucellosis as an exceptional cause of transient ischemic attacks

We report a series of four cases presented with transient ischemic attacks (TIA) or ischemic stroke as the predominant manifestation of neurobrucellosis (NB). Three of the patients were 20-28 years of age, and one patient was 53 years old. They all used to consume unpasteurized milk or its products. Two patients had systemic brucellosis in the past and received antibiotic treatment. Other causes of TIA including cardiac embolism, hypercoagulability, vascular malformations, systemic vasculitis, and infective endocarditis were excluded. NB was diagnosed with serological tests or cultures for Brucella in the cerebrospinal fluid. None of the patients had any further TIA after the initiation of specific treatment. NB should always be sought in young patients with TIA or ischemic stroke, especially if they have no risk factors for stroke and live in an endemic area for brucellosis, even if they do not have other systemic signs of brucellosis.

Brucellar spinal epidural abscesses. Analysis of eleven cases

Brucellar spinal epidural abscesses (BSEA) are rare and very few series of them have been reported. In order to evaluate the clinical characteristics, management and outcome of this entity, the clinical records and current status of a series of 11 patients have been retrospectively reviewed. A series of 11 patients treated for BSEA in our Service during a period of 12 years (1989-2000) have been retrospectively studied. Spinal epidural abscesses (SEA) were diagnosed by MRI, CT or at surgery. Brucellar aetiology of SEA was considered when seroagglutination tests were positive at a titre of 1/160 or higher, and/or Brucella spp. were isolated in the blood or sample cultures. Ten of the 11 cases were treated with rifampicin plus doxycycline and in the remaining patient streptomycin was added because of a poor initial response. Six patients underwent surgical decompression and debridement of the SEA. Outcome was excellent in nine cases and good in two. There was no mortality and only one patient recovered incompletely from preadmission neurological deficits. Although BSEA is considered to be an unusual complication of spondylitis, our findings show that in some cases it can follow direct haematogenous spread to the extradural space. Surgical treatment must be undertaken when major neurological deficits are present. If antibiotic treatment is chosen as the initial therapy, the possibility of sudden neurological deterioration must be taken into account. Contrary to the high morbi-mortality rates reported in pyogenic or tuberculous SEA, BSEA has a good prognosis with early diagnosis and appropriate management.

Neurobrucellosis presenting as an intra-medullary spinal cord abscess

BACKGROUND

Of the diverse presentation of neurobrucellosis, intra-medullary spinal cord abscess is extremely rare. Only four other cases have been reported so far. We present a case of spinal cord intra-medullary abscess due to Brucella melitensis.

CASE PRESENTATION

A forty-year-old female presented with progressive weakness of both lower limb with urinary incontinence of 6 months duration. She was febrile. Neurological examination revealed flaccid areflexic paraplegia with T10 below sensory impairment including perianal region. An intramedullary mass was diagnosed on Magnetic Resonance Image (MRI) scan extending from T12 to L2. At surgery, a large abscess was encountered at the conus medullaris, from which Brucella melitensis was grown on culture. She was started on streptomycin and doxycycline for 1 month, followed by rifampicin and doxycycline for 1 month. At 2-year follow-up, she had recovered only partially and continued to have impaired bladder function.

CONCLUSION

Neurobrucellosis, if not treated early, can result in severe neurological morbidity and sequelae, which may be irreversible. Hence it is important to consider the possibility of neurobrucellosis in endemic region and treat aggressively.

Intramedullary abscess from group F Streptococcus

BACKGROUND

Intramedullary abscesses are rare and may be misdiagnosed. We report the case of a 54-year-old man with carcinoma of the gastroesophageal junction who presented after thoracotomy with hemiparesis and a ring-enhancing intramedullary lesion at C2-3 on magnetic resonance imaging.

METHODS

Individual case report and literature review.

RESULTS

Although the lesion was initially mistaken for metastasis, at surgery an intramedullary abscess was discovered, from which group F Streptococcus was isolated. Conclusions : Although other streptococcal species have been found in abscesses of the spinal cord, this particular strain has not been identified previously as a cause of such abscesses. Prompt surgical evacuation is recommended, and should be followed by appropriately tailored antibiotic therapy.

Brucellar spondylitis: a rare cause of spinal cord compression

STUDY DESIGN

A case report.

OBJECTIVES

To present and discuss some of the difficulties in the diagnosis of brucellar spondylitis.

SETTING

Ankara University, Ibni Sina Hospital, Turkey.

METHODS

We report a patient with paraplegia, misdiagnosed as having a malignancy or tuberculosis who actually suffered from brucellar spondylitis. Diagnosis was established by her history and a compatible clinical picture together with a standard tube agglutination (Wright test) titer of > or =1/160 of antibodies for brucellosis. The patient was treated with oral doxycycline, rifampicin, and ciprofloxacin combination.

RESULTS

At the end of the treatment, the blood Brucella Wright and anti-human globulin T titer levels decreased. Her lower limb weakness improved. She could walk, and climb stairs with the help of a cane. Urinary retention and fecal incontinence also resolved.

CONCLUSION

Brucellosis is a systemic infection involving the musculoskeletal and nervous systems. Spondylitis frequently occurs in elderly patients. An early diagnosis of brucellar spondylitis can often be difficult. In endemic regions, as in the case of our country, brucellar spondylitis should always be considered in the differential diagnosis of older patients with back pain and constitutional symptoms. An early diagnosis will help to prevent the development of more severe complications such as spinal cord compression.

Neurobrucellosis and a demonstration of its involvement in spinal roots via magnetic resonance imaging

OBJECTIVE

To present a neurobrucellosis case with spinal root involvement by means of magnetic resonance imaging (MRI).

METHODS

A case of neurobrucellosis resembling Guillain-Barré syndrome is being reported. This case is unique in a way that spinal root involvement because of brucellosis was for the first time confirmed by MRI.

SETTING

Spinal cord unit of a rehabilitation and care center in Ankara, Turkey.

RESULTS

The correct diagnosis was made with cerebrospinal fluid culture. The patient showed a significant improvement with antimicrobial therapy and rehabilitation.

CONCLUSION

Polyradiculopathy because of neurobrucellosis may mimic neurological syndromes. Rehabilitation should also be a part of its treatment.

Human neurobrucellosis with intracerebral granuloma caused by a marine mammal Brucella spp

We present the first report of community-acquired human infections with marine mammal-associated Brucella spp. and describe the identification of these strains in two patients with neurobrucellosis and intracerebral granulomas. The identification of these isolates as marine mammal strains was based on omp2a sequence and amplification of the region flanking bp26.