Brucellar spondylitis: a rare cause of spinal cord compression

Noncontiguous multifocal Brucella spondylodiscitis with paravertebral abscess: a case report

Background

Human brucellosis is the most frequently contracted zoonotic infection worldwide. Although being an old disease that carries minimal risks of mortality, it remains a source of considerable sequelae and disability. However, noncontiguous multifocal spinal involvement is an exceptional presentation of brucellosis; additionally, an associated paravertebral abscess is extremely rare.

Case presentation

This paper focuses on a 67-year-old Lebanese woman with noncontiguous multifocal Brucella spondylodiscitis, involving the T12–L1 and L3–L4 segments, with paravertebral abscess formation. She presented with a 3-week history of acute severe lumbar back pain, radiating to the lower extremities and associated with impaired mobility and lower extremity weakness. The patient complained of night sweating but had no fever. No lymphadenopathy, hepatomegaly, or splenomegaly could be observed. She had painful percussion of the lumbar spine, painful passive mobilization, and paravertebral tenderness, yet her neurological examination was completely normal. BrucellaCapt test was positive at a titer of 1/5120 (reference range 1/180). The patient was treated with an inpatient regimen for 2 weeks, which was followed by an outpatient oral antibiotic regimen with doxycycline, rifampin, and ciprofloxacin to complete a total treatment duration of 3 months. Magnetic resonance imaging was performed at the end of the treatment and showed a complete resolution of the paravertebral abscess.

Conclusion

Noncontiguous multifocal Brucella spondylodiscitis with paravertebral abscess is an extremely rare presentation. It may be effectively managed by antibiotic therapy, without surgery or drainage, in the absence of neurological complications. Nonetheless, the principal challenge to an efficient management is establishing the diagnosis of Brucella in the first place. In endemic countries, a strong suspicion of spinal involvement of brucellosis should be elicited in front of back pain presentations—even in the absence of fever and other related symptoms.

Spinal brucellosis

Spinal involvement in human brucellosis is a common condition and a significant cause of morbidity and mortality, particularly in endemic areas, because it is often associated with therapeutic failure. Most chronic brucellosis cases are the result of inadequate treatment of the initial episode. Recognition of spinal brucellosis is challenging. Early diagnosis is important to ensure proper treatment and decrease morbidity and mortality. Radiologic evaluation has gained importance in diagnosis and treatment planning, including interventional procedures and monitoring of all spinal infections.

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.

False negative serological tests may lead to misdiagnosis and mismanagement in osteoarticular brucellosis

Non-specific clinical presentations and paraclinical findings in osteoarticular brucellosis may mimic many other diseases and other causes of arthritis which could lead to misdiagnosis and mismanagement. We studied retrospectively the records of 232 patients with osteoarticular brucellosis who were admitted to the three teaching hospitals of Babol Medical Sciences University from April 2001 to September 2006. The distribution of osteoarticular involvement and their management were evaluated to determine if any cases had been misdiagnosed because of false negative serologic tests and who had, as a result, undergone inappropriate surgical interventions. Of 232 patients, 138 (59%) were male and 94 (41%) were female. Polyarthritis, monoarthritis, spondylitis and sacroilitis were seen in 91 (39%), 60 (26%), 43 (18.5%) and 38 (16.5%) patients, respectively. Two hundred and twenty-nine (98.7%) patients were diagnosed correctly and treated successfully; three (1.3%) were misdiagnosed and had been given inappropriate surgical interventions. Of these three patients, two (3.3%) were suffering from monoarthritis (hip joint) and one (2.3%) had spondylitis.

Long-standing, neglected sacroiliitis with remarked sacro-iliac degenerative changes as a result of Brucella spp. infection

BACKGROUND

Osteoarticular disease is universally the most common complication of brucellosis. Sacro-iliac joint (SIJ) is the most frequent osteoarticular location of involvement. Sacroiliitis (SI) usually is associated with acute form of the disease, thus frank SIJ destruction caused by brucellosis is rare.

PURPOSE

To report the case of a patient suffering from severe, prolonged lumbar pain with sciatica, refractory to medical treatment, in which the correct and misdiagnosed cause of her pain was a long-standing, neglected brucellar SI.

STUDY DESIGN

Case report.

METHODS

Scintigraphy and imaging methods (computed tomography, magnetic resonance imaging).

RESULTS

The result of the delayed diagnosis was a pronounced degeneration of the SIJ.

CONCLUSIONS

Sacroiliitis as a result of infection with Brucella might cause severe joint degeneration if left untreated.

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.

Clinical assessment and medical treatment of spine infections

Spinal infections affect the vertebral bodies, the intervertebral disks, the spinal canal, and the paravertebral soft tissues and structures. A delay in diagnosis can result in spine deformity, substantial neurologic complications, and even death. Because of this, a high level of awareness is required by physicians in order to diagnose infections of the spine promptly. Advances in medical microbiologic testing and newer imaging methods have contributed considerably to the medical treatment of these infections. Through careful followup, less invasive approaches orchestrated by a multidisciplinary team that includes a spine surgeon, an infectious diseases specialist, and a neuroradiologist may be sufficient to treat patients with these infections. Research done through multidisciplinary collaborations will further advance our knowledge for the successful treatment of spinal infections.

LEVEL OF EVIDENCE

Level V (expert opinion). Please see the Guidelines for Authors for a complete description of levels of evidence.

Could remembering the prozone phenomenon shorten our diagnostic journey in brucellosis? A case of Brucella spondylodiscitis

We reviewed a case of Brucella spondylodiscitis admitted to a referral, university hospital, in Ankara, Turkey. A 75-year-old female was referred to our hospital with low back pain. Previous magnetic resonance imaging yielded cortical destruction of T9-10 and T12-L2 vertebral bodies, focal infectious foci at discs within this range, significant microabscesses at paravertebral areas, which lead to the diagnosis of spondylodiscitis. History of consumption of unpasteurized dairy products led us to first suspect brucellosis yet, the serum agglutination test and blood culture were negative and did mislead us to several other, sometimes invasive, diagnostic tests. The final diagnosis was reached by culturing the specimen obtained through fine-needle aspiration from the paravertebral microabscesses. The exhausting diagnostic journey that started with the suspicion of tuberculosis or malignancy ended with a diagnosis of brucellosis. Brucellosis should be considered in all patients with osteoarthritic complaints in endemic regions, and the "prozone phenomenon" should be kept in mind, before proceeding to high-tech lab tests, imaging, or invasive procedures.

Neuroimaging of infections

Neuroimaging plays a crucial role in the diagnosis and therapeutic decision making in infectious diseases of the nervous system. The review summarizes imaging findings and recent advances in the diagnosis of pyogenic brain abscess, ventriculitis, viral disease including exotic and emergent viruses, and opportunistic disease. For each condition, the ensuing therapeutic steps are presented. In cases of uncomplicated meningitis, cranial computed tomography (CT) appears to be sufficient for clinical management to exclude acute brain edema, hydrocephalus, and pathology of the base of skull. Magnetic resonance imaging (MRI) is superior in depicting complications like sub-/epidural empyema and vasculitic complications notably on FLAIR (fluid-attenuated inversion recovery)-weighted images. The newer technique of diffusion-weighted imaging (DWI) shows early parenchymal complications of meningitis earlier and with more clarity and is of help in differentiation of pyogenic abscess (PA) from ring enhancing lesions of other etiology. Proton magnetic resonance spectroscopy (PMRS) seems to produce specific peak patterns in cases of abscess. The presence of lactate cytosolic amino acids and absence of choline seems to indicate PA. Also in cases of suspected opportunistic infection due to toxoplasma DWI may be of help in the differentiation from lymphoma, showing no restriction of water diffusion. In patients with herpes simplex and more exotic viruses like West Nile and Murray Valley virus DWI allows earlier lesion detection and therapeutic intervention with virustatic drugs.