Brucellar spondylitis: review of 25 cases

Comparison of two surgical interventions for lumbar brucella spondylitis in adults: a retrospective analysis

This retrospective study aimed to compare the clinical efficacy of the posterior procedure with the combined anterior and posterior procedure in the surgical management of lumbar Brucella spondylitis. From January 2015 to June 2020, a total of 62 patients presenting with lumbar Brucella spondylitis underwent either one-stage posterior pedicle fixation, debridement, and interbody fusion (Group A, n = 33) or anterior debridement, bone grafting, and posterior instrumentation (Group B, n = 29). All patients were followed up for an average of 25.4 ± 1.5 months and achieved complete resolution of lumbar Brucella spondylitis. No significant differences between the groups were observed in terms of age or pre-operative, three-month postoperative and final follow-up indices of the VAS, ESR, CRP, lordosis angle, ODI scores, fusion time, and time of serum agglutination test conversion to negative (P > 0.05). Each patient exhibited notable improvements in neurological function, as assessed by the JOA score rating system. Group A demonstrated significantly shorter operative duration, intraoperative blood loss, and hospital stay compared to Group B (P < 0.05). Superficial wound infection was observed in one case in Group A, whereas Group B experienced one case each of intraoperative peritoneal rupture, postoperative ileus, iliac vein injury, and superficial wound infection. This study supports the efficacy of both surgical interventions in the treatment of lumbar Brucella spondylitis, with satisfactory outcomes. However, the posterior approach demonstrated advantages, including reduced surgical time, diminished blood loss, shorter hospital stays, and fewer perioperative complications. Consequently, the one-stage posterior pedicle fixation, debridement, and interbody fusion represent a superior treatment option.

Red flags for the early detection of spinal infection in back pain patients

BACKGROUND

Red flags are signs and symptoms that are possible indicators of serious spinal pathology. There is limited evidence or guidance on how red flags should be used in practice. Due to the lack of robust evidence for many red flags their use has been questioned. The aim was to conduct a systematic review specifically reporting on studies that evaluated the diagnostic accuracy of red flags for Spinal Infection in patients with low back pain.

METHODS

Searches were carried out to identify the literature from inception to March 2019. The databases searched were Medline, CINHAL Plus, Web of Science, Embase, Cochrane, Pedro, OpenGrey and Grey Literature Report. Two reviewers screened article texts, one reviewer extracted data and details of each study, a second reviewer independently checked a random sample of the data extracted.

RESULTS

Forty papers met the eligibility criteria. A total of 2224 cases of spinal infection were identified, of which 1385 (62%) were men and 773 (38%) were women mean age of 55 (± 8) years. In total there were 46 items, 23 determinants and 23 clinical features. Spinal pain (72%) and fever (55%) were the most common clinical features, Diabetes (18%) and IV drug use (9%) were the most occurring determinants. MRI was the most used radiological test and Staphylococcus aureus (27%), Mycobacterium tuberculosis (12%) were the most common microorganisms detected in cases.

CONCLUSION

The current evidence surrounding red flags for spinal infection remains small, it was not possible to assess the diagnostic accuracy of red flags for spinal infection, as such, a descriptive review reporting the characteristics of those presenting with spinal infection was carried out. In our review, spinal infection was common in those who had conditions associated with immunosuppression. Additionally, the most frequently reported clinical feature was the classic triad of spinal pain, fever and neurological dysfunction. This is an Open Access article distributed in accordance with the Creative Commons Attribution Non-Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

Diagnosis and management of spinal tuberculosis combined with brucellosis: A case report and literature review

Tuberculosis combined with brucellosis is a very rare condition. Overlapping clinical presentation and laboratory parameters of tuberculosis and brucellosis may lead to misdiagnosis or delayed diagnosis of the condition. The current study presents the case of a 45-year-old male with symptoms of lower back pain, non-tender swelling in the right flank, intermittent hyperpyrexia, sweating, body aches and numbness and weakness of right lower limb. A lumbar computed tomograph (CT) scan and magnetic resonance imaging indicated vertebral destruction and the formation of sequestra and thecal sac compression. Tuberculosis was suspected, but subsequent culture of blood and pus revealed the co-infection of Mycobacterium tuberculosis and Brucella melitensis. The patient was treated with antibiotics, CT-guided percutaneous drainage of the abscess and posterior approach decompression, debridement, instrumentation and fusion. Co-existence of spinal tuberculosis and brucellosis is rare and clinicians should strengthen the awareness of such conditions in similar patients. CT-guided percutaneous drainage is effective in the diagnosis and management of spinal tuberculosis with abscess.

One-stage Surgical Management for Lumbar Brucella Spondylitis by Posterior Debridement, Autogenous Bone Graft and Instrumentation: A Case Series of 24 Patients

STUDY DESIGN

Clinical case series.

OBJECTIVE

The aim of this study was to explore the efficacy and safety of one-stage debridement, autogenous bone graft, and instrumentation for lumbar brucella spondylitis (LBS) via a posterior approach.

SUMMARY OF BACKGROUND DATA

Reports on LBS are sporadic, and the therapeutic effect and safety of surgical interventions have not been assessed in clinical studies.

METHODS

Between January 2012 and January 2014, 24 consecutive patients with symptomatic LBS who underwent a one-stage operation that combined debridement, autogenous bone graft, and instrumentation via a posterior approach were enrolled. Back pain was measured using the visual analog scale (VAS). The neurological status was evaluated with the American Spinal Injury Association (ASIA) scale. Bone healing was evaluated based on postoperative plain x-ray or computed tomography.

RESULTS

All cases were followed up for an average of 14.3 + 3.5 months. The VAS scores were significantly improved at every follow-up interval. An improvement of at least one grade level was observed in the ASIA score of each patient. The average time of bone fusion was 6.8 + 1.6 months. Significant improvements of the average segmental Cobb angle was observed from a preoperative value of 18.4° + 4.6° to a last follow-up value of 21.1° ± 3.7°. At the last follow up, the titers of antibodies against the standard tube agglutination test, erythrocyte sedimentation rate, and C-reactive protein were negative for all patients.

CONCLUSION

For LBS, systemic antibrucellosis chemotherapy is the cornerstone of treatment. When cauda equine syndrome, radiculopathy, spinal instability, and severe back pain caused by extradural nonabsorbable abscess or progressive collapse are present, surgical intervention is inevitable. One-stage debridement, autogenous bone graft, and instrumentation via a posterior approach could represent an alternative treatment for LBS, and the efficacy and safety of these techniques are satisfactory.

LEVEL OF EVIDENCE

4.

Comparison of Tuberculous and Brucellar Spondylitis on Magnetic Resonance Images

STUDY DESIGN

Retrospective cross-sectional study.

OBJECTIVE

To investigate the differences between tuberculous spondylitis (TS) and brucellar spondylitis (BS) on magnetic resonance images (MRI).

SUMMARY OF BACKGROUND DATA

Both TS and BS are common spinal affections and can cause deformities and permanent neurologic deficiencies without prompt diagnosis and treatment. However, differentiating the types of spondylitis clinically and radiographically is challenging. Despite the diagnosis studies on spine infection throughout the literature, the outcome has not been established. Our study about the different characteristics between TS and BS on MRI may be helpful.

METHODS

Eighteen patients with TS and 26 with BS were included in this study. MRI images were obtained and analyzed. For statistical analysis, the χ test was performed. Statistical significance was defined as P < 0.05.

RESULTS

There were statistically significant differences between TS and BS on the MRI images: (i) subligamentous spread to three or more vertebral levels [TS 54% (7/13) vs. BS 8% (1/12)]; (ii) subligamentous spread to fewer than three vertebral levels [23% (3/13) vs. 58% (7/12)]; (iii) thoracic spine involvement [50% (9/18) vs. 4% (1/26)]; and lumbar spine involvement [22% (4/18) vs. 77% (20/26)]; (iv) abnormal signal from the vertebral disc on T2-weighted images [33% (7/21) vs. 85% (30/35)]; (v) focal or fan-shaped hyperintense signals on middle sagittal fat-suppressed weighted images [14% (7/50) vs. 50% (31/62)] and especially fan-shaped hyperintense signal [0% (0/50) vs. 23% (14/62)]; (vi) spinal kyphosis [22% (11/50) vs. 3% (2/62)]; (vii) vertebral collapse [42% (21/50) vs. 2% (1/62)]; (viii) peridiscal bone destruction [22% (11/50) vs. 44% (27/62)]; and (ix) psoas abscesses [6% (3/50) vs. 0% (0/62)].

CONCLUSION

MRI is a sensitive imaging technique and can clearly define the different features between TS and BS, so it should be the first choice for imaging in the diagnosis of spondylodiscitis.

LEVEL OF EVIDENCE

4.

Review of brucellosis in Nepal

Brucellosis is an abortifacient zoonotic disease that remains prominent in third world countries like Nepal. Brucellosis poses a public health concern, because its incidence in livestock can present substantial economic and health burdens for herders and health professionals. Several cases of bovine and human brucellosis have been reported and the prevalence is higher among livestock than among humans in Nepal. Lack of awareness, unhealthy food habit, traditional husbandry practices, and a lack of surveillance and immunization have been the major factors in maintaining a vicious cycle of propagation of the disease in human and animals. The aim of this paper is to evaluate the current status of the disease, the mechanism of infection, and pathogenesis, its zoonotic potential, diagnostic advances, treatment regimens, and the preventive measures that can be adopted in managing human brucellosis in under-developed countries such as Nepal.

Review of Brucellosis in Nepal

OBJECTIVES

The aim of this paper is to evaluate the current status of the disease, the mechanism of infection, and pathogenesis, its zoonotic potential, diagnostic advances, treatment regimens, and the preventive measures that can be adopted in managing human brucellosis in under-developed countries such as Nepal.

METHODS

We performed a systematic review of all the available literture through Google Scholar, PubMed, Gideon Informatics, World Health Organization and other legitimate sources. Other secondary informations were collected from the government agencies such as department of livestock services and Ministry of Health. The obtained information was then re-analysed and summarized.

RESULTS

Few publications have addressed brucellosis in Nepal and most of those publications have focused on bovine brucellosis with sparse information available on brucellosis in humans and small ruminants. Brucella abortus is the most predominant causative agent followed by B. suis. B. abortus is predominant in cattle accounting for a substantial portion of bovine abortion in the country. Lack of awareness, unhealthy food habit, traditional husbandry practices, and a lack of surveillance and immunization have been the major factors in maintaining a vicious cycle of propagation of the disease in human and animals. Unfortunately, nothing has been done to identify the species of Brucella at the biovar level.

CONCLUSIONS

Although brucellosis has been reported to be endemic in Nepal, neither the distribution nor the economic and public health impact of this disease is well characterized. Robust and well-designed nationwide survey is warranted to assess the prevalence and distribution of disease in livestock and humans. Such data would facilitate the design of appropriate control programmes.

Brucellosis in Nepal - A Potential Threat to Public Health Professionals

Brucellosis is a prominent zoonotic disease affecting humans and animals which with the lack of proper diagnosis and treatment remains dangerous in third world countries like Nepal. Currently, Brucellosis poses a public health concern, whose incidences among entire herds of animals can present substantial economic and health burdens for herders and health professionals. Additionally, factors such as close contact with animals, poor animal husbandry, and unhygienic feeding habits can exacerbate the spread of Brucella and related zoonotic agents. In Nepal, serious cases of bovine and even human brucellosis have been reported, although the topic is yet to be extensively reviewed. This paper evaluates the literatures on human and animal brucellosis in Nepal and other countries, with an emphasis on the impact of Brucella outbreaks on public health professionals. Herein, we summarize the current status of the disease, the mechanism of infection, pathogenesis, zoonotic potential, diagnostic advances, treatment regimens, and the preventive measures that can be adopted in managing human brucellosis in under-developed countries such as Nepal.

Granulomatous Vertebral Osteomyelitis: An Update

A granulomatous infection of the spine is characterized by an infectious process within the spinal elements that results in the formation of a granuloma, an organized collection of transformed macrophages (ie, epithelioid cells), matrix, and other inflammatory cells. Causative organisms include various bacteria, fungi, or other parasites; however, the most frequently encountered causative organism is Mycobacterium tuberculosis (ie, Pott disease). The onset of these infections is often insidious, frequently leading to a delay in diagnosis. Left untreated, this disease process may lead to a compromise in the structural integrity of the spine and subsequent spinal deformity that may eventually result in compression of neural elements. Successful treatment of a granulomatous infection requires timely diagnosis, prompt medical management, and potential surgical intervention directed at the decompression of neural elements and the correction of spinal malalignment. Of granulomatous infections, tuberculous infections are the most thoroughly understood and serve as the standard to which other less commonly reported organisms are compared.

Administration of a triple versus a standard double antimicrobial regimen for human brucellosis more efficiently eliminates bacterial DNA load

The effects of doxycycline-streptomycin-rifampin versus a standard doxycycline-streptomycin regimen on residual Brucella DNA were compared in 36 acute brucellosis patients. At admission, all patients given triple (n = 22) and double (n = 14) regimens had detectable Brucella DNA with similar mean loads (P = 0.982). At follow-up, 14 to 20 months postpresentation, significantly more patients receiving triple than double regimens had undetectable Brucella DNA (P = 0.026). The doxycycline-streptomycin-rifampin regimen eliminates Brucella DNA more efficiently than doxycycline-streptomycin, which may result in superior long-term clearance of Brucella.

Spinal brucellosis in South of Tunisia: review of 32 cases

BACKGROUND CONTEXT

Brucellosis remains an important economic and public health problem in some parts of the world. The spine is the most common site of musculoskeletal involvement of brucellosis.

PURPOSE

Assess the clinical, laboratory, radiological findings, and outcomes of vertebral involvement in brucellosis.

STUDY DESIGN

A retrospective study.

PATIENT SAMPLE

Thirty-two patients with spinal brucellosis during a period of 21 years (1990-2010) were included.

OUTCOME MEASURES

Clinical and radiological improvement.

METHODS

Diagnosis made on clinical presentation, laboratory findings, radiographic evidence, and the Brucellar etiology was considered when seroagglutination tests were positive at a titer of 1/160 or higher, and/or Brucella spp were isolated in the blood or sample cultures.

RESULTS

The mean age of patients was 51±15.85 years (23 males, 9 females; age range, 19-74 years). The median diagnostic delay was 3 months. Back or neck pain (100% of patients), fever (78%), and sweats (68.6%) were the most common symptoms. Cultures of blood specimens from five patients (15.6%) were positive for Brucella melitensis. Four patients (12.5%) had motor weakness or paralysis. Magnetic resonance imaging was performed in 24 (75%) cases. Paravertebral masses, epidural masses, and psoas abscesses were detected in 65.6%, 59.4%, and 28.1% of patients, respectively. The lumbar vertebra was the most frequently involved region with the rate of 68.7%, followed by thoracal (18.7%), cervical (6.3%), lumbosacral (6.3%), and thoracolumbar (3.1%) segments. The duration of antimicrobial therapy of brucellosis (median, 6 months; range, 3-13 months) varied according to clinical response and the presence of epidural and paravertebral masses. There were no deaths or severe sequelae in this study.

CONCLUSIONS

Brucellar spondylitis should be considered in patients with back pain and fever in endemic areas. A high index of suspicion and clinical, laboratory, and radiological examinations help to confirm the diagnosis of vertebral involvement.

Update on treatment options for spinal brucellosis

We evaluated the efficacy and tolerability of antibiotic regimens and optimal duration of therapy in complicated and uncomplicated forms of spinal brucellosis. This is a multicentre, retrospective and comparative study involving a total of 293 patients with spinal brucellosis from 19 health institutions. Comparison of complicated and uncomplicated spinal brucellosis was statistically analysed. Complicated spinal brucellosis was diagnosed in 78 (26.6%) of our patients. Clinical presentation was found to be significantly more acute, with fever and weight loss, in patients in the complicated group. They had significantly higher leukocyte and platelet counts, erythrocyte sedimentation rates and C-reactive protein levels, and lower haemoglobulin levels. The involvement of the thoracic spine was significantly more frequent in complicated cases. Spondylodiscitis was complicated, with paravertebral abscess in 38 (13.0%), prevertebral abscess in 13 (4.4%), epidural abscess in 30 (10.2%), psoas abscess in 10 (3.4%) and radiculitis in 8 (2.7%) patients. The five major combination regimens were: doxycycline 200 mg/day, rifampicin 600 mg/day and streptomycin 1 g/day; doxycycline 200 mg/day, rifampicin 600 mg/day and gentamicin 5 mg/kg; doxycycline 200 mg/day and rifampicin 600 mg/day; doxycycline 200 mg/day and streptomycin 1 g/day; and doxycycline 200 mg/day, rifampicin 600 mg/day and ciprofloxacin 1 g/day. There were no significant therapeutic differences between these antibiotic groups; the results were similar regarding the complicated and uncomplicated groups. Patients were mostly treated with doxycycline and rifampicin with or without an aminoglycoside. In the former subgroup, complicated cases received antibiotics for a longer duration than uncomplicated cases. Early recognition of complicated cases is critical in preventing devastating complications. Antimicrobial treatment should be prolonged in complicated spinal brucellosis in particular.

Efficacy evaluation of some antibiotics against syrian brucella spp isolates, in vitro

Brucellosis is an endemic zoonosis in Syria, affecting large numbers of animals and there are an increasing number of cases in humans. The aim of this study is to investigate the in vitro efficacy of various traditional and new antibiotics against 89 Brucella isolates (isolated from domestic animals) collected from different Syrian regions. Minimum inhibitory concentrations (MICs) of seventeen antibiotics were determined. Ciprofloxacin and ofloxacin were the most effective antibiotics, whereas sparfloxacin, levofloxacin, doxycycline and tetracycline had a moderate activity. In contrast, moxifloxacin and rifampicin had a low activity, while streptomycin, spiramycin and cephalosporines were ineffective. As a result, we come to the conclusion that a combination between one effective quinolone and doxycycline has a good efficacy against Brucella. Further in vivo studies are necessary to support this suggestion.

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.

Back pain secondary to Brucella spondylitis in the lumbar region

Brucellosis is a systemic, infectious disease caused by the bacterial genus Brucella and a common zoonosis that still remains a major health problem in certain parts of the world such as the Mediterranean region, the Middle East, and Latin America. It may involve multiple organs and tissues. Osteoarticular involvement is the most frequent complication of brucellosis, in which the diagnosis of brucellar spondylitis is often difficult since the clinical presentation may be obscured by many other conditions. There are only a few reports on brucellar spondylitis in Korea. Here, we report a case of spondylitis due to brucella in an elderly male.

Rheumatologic manifestations of brucellosis

Brucellosis, an endemic disease in certain parts of the world is usually accompanied by osteoarticular involvement. The present study was performed to determine the types and frequency of rheumatologic manifestations in patients with brucellosis diagnosed in the north of Iran. Diagnosis of active brucellosis was based on the serological tests along with compatible clinical findings. Musculoskeletal involvement of brucellosis was confirmed by clinical and radiographic examinations; 51 (32 males, 19 females) patients with mean (SD) age of 35 (19) years old were studied. Rheumatological manifestations were observed in 94% of patients. The most frequent skeletal findings in order of frequency were peripheral arthritis, sacroiliitis; and spondylitis which occurred in 37; 31 and 8% of patients, respectively. Back pain, arthralgia, myalgia, and enthesopathy were also reported in 49, 34, 11.7% of patients, respectively. Based on the findings of this study, rheumatologic manifestations are common in brucellosis; therefore, in the endemic areas, brucellosis should be considered in the differential diagnosis of patients who present with any type of rheumatologic manifestations.

Brucellar spondylitis

The incidence of Brucellosis is increasing in Korea. Spondylitis is the most frequent complication, but it is difficult to diagnose because its clinical symptoms are non-specific. It should therefore be included in the differential diagnosis of back pain. We report three rare cases of brucellar spondylitis successfully treated by medical and surgical therapy.

Brucellar spondylodiscitis: case report

Brucellosis is a common zoonosis which still remains a major health problem in certain parts of the world. Osteoarticular involvement is the most frequent complication of brucellosis, in which the diagnosis of brucellar spondylodiscitis is often difficult since the clinical presentation may be obscured by many other conditions. Herein, we report an uncommon case of spondylodiscitis due to Brucella in a male who presented with abdominal pain. The diagnosis was established by positron emission tomography combined with computed tomography (PET/CT scan) and magnetic resonance followed by a confirmation on Brucella-agglutination test and positive culture of computed tomography (CT) guided punction fluid. This case report illustrates an atypical presentation of spondylitis and points out the difficulties in diagnosing the aetiological agens Brucella and differentiating its specific features from tuberculosis.