A case of brucella spondylodiscitis with extended, multiple-level involvement

The Role of Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in the Management of Brucellosis: An Observational Cohort Study

Background

Diagnosis of focal infection in brucellosis is important to direct optimal treatment. Fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) may be helpful in this aspect.

Methods

The clinical and imaging data of all patients with brucellosis, who underwent FDG PET/CT as part of the investigation in Rambam Health Care Campus, where FDG PET/CT became the recommended imaging modality for suspected focal infection in brucellosis since 2016, were analyzed retrospectively. The detection of focal infection as well as management modification before and after FDG PET/CT were recorded.

Results

FDG PET/CT was performed in 30 episodes of brucellosis occurring in 27 patients: 20 primary episodes and 10 suspected relapse episodes. The mean age of the patients was 50 ± 15.07 years. Focal disease was diagnosed in 18 of 30 (60%) episodes, of which 8 (26.6%) were diagnosed for the first time by FDG PET/CT, all of whom had spinal infection, with a concomitant additional focus in 5. Overall, multifocal disease was diagnosed in 10 of 18 (55.5%) of patients with focal disease. Management modification following FDG PET/CT was recorded in 17 of 30 (56.6%) episodes, mainly by treatment extension in spinal infection and withholding treatment in patients with suspected relapse but no evidence of active disease by FDG PET/CT.

Conclusions

FDG PET/CT was found to be helpful in the diagnosis of focal infection in brucellosis. Multifocal disease seems more prevalent than previously described. The clinical impact of adding FDG PET/CT to the diagnostic workup of brucellosis should be evaluated in future studies.

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.

Isolation of Brucella melitensis from Lumbar Vertebrae in Patient with Initial Misdiagnosis: A Rare Case with Spinal Epidural Abscess, Spinal Stenosis, and Brain Lesion

Introduction: Brucellar spondylodiscitis is among the most typical forms of osteoarticular involvement that still challenges clinicians and scientists for early diagnosis. Case Presentation: We describe the isolation of Brucella melitensis from vertebrae in a man with spondylodiscitis who had osteoarthritis as an underlying condition. The patient showed negative results on blood samples' serological, molecular, and culture tests and had low-back pain, restricted lumbar movements, headache, poor appetite, and fatigue for the past nine months. He had a history of regular ingestion of raw cow milk and milk products for a long time. First, he was misdiagnosed as lumbar disc herniation and then underwent nonsteroidal anti-inflammatory drugs and myorelaxants treatment. The lack of fast diagnosis and appropriate treatment led to severe complications of the disease. Three months after the first magnetic resonance imaging (MRI), the findings of the second MRI without intravenous contrast showed right lateral recess and canal stenosis at L4 - L5 with narrowing the thecal sac at the disc space. Abnormal enhancement of the endplates at L4 - L5 with relating epidural space-enhancing tissue in the setting of spondylodiscitis and the associated epidural abscess was seen behind L4. Moreover, extensive high signal abnormalities in paraspinal tissues at L3, L4, L5, S1, S2, and S3 were notable. The diagnosis was approved by isolating B. melitensis biovar 1 from the culture of the vertebrate body. The Brucella isolate was characterized by Bruce-ladder PCR, AMOS PCR, and classical biotyping. The patient was treated successfully with surgical intervention and triple-antibiotic, including oral doxycycline 100 mg/12 h plus oral rifampin 300 mg/12 h for three months and intramuscular streptomycin 1 g daily for the first two weeks. The patient’s general condition and low-back pain were remarkably improved in the follow-up. Conclusions: Patient histories and a series of different diagnostic procedures such as MRI, serology, molecular, and cultural tests are essential to make a rapid and accurate diagnosis of brucellar spondylodiscitis, thereby reducing the delay for brucellar spondylodiscitis treatment.

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.

Value of magnetic resonance imaging in brucellar spondylodiscitis

PURPOSE

The aim of this retrospective study was to evaluate magnetic resonance (MR) imaging in patients with brucellar spondylodiscitis.

MATERIALS AND METHODS

Sixty-three patients with spondylodiscitis were diagnosed based on positive clinical findings, ≥1/160 titres of brucella agglutination tests and/or positive blood cultures. MR imaging was performed in all of the patients with spondylodiscitis. Signal changes and enhancement of vertebral bodies, involvement of paravertebral soft tissues and epidural spaces, nerve root and cord compression and abscess formation were assessed.

RESULTS

Of 63 patients with spinal brucellosis, eight had thoracic, 35 had lumbar, ten had cervical vertebral, seven had both thoracic and lumbar, and three had both lumbar and sacral vertebral involvement. Thirteen patients had cord compression and six had root compression. Four patients had facet-joint involvement, and one had erector spinae muscle involvement. Twenty-four had intervertebral disc narrowing. Seventeen patients were in the acute stage, 32 in the subacute stage and 14 in the chronic stage. Vertebral bodies, vertebral end plates and intervertebral disc spaces were hypointense and hyperintense in the acute stage, whereas they were hypointense and heterogeneous in the subacute and chronic stages on T1- and T2-weighted images, respectively.

CONCLUSION

Brucella is still a public health problem in endemic areas. MR imaging is a highly sensitive and noninvasive imaging technique which should be first choice of imaging in the early diagnosis of spondylodiscitis.

Brucellar spondylodiscitis affecting non-contiguous spine levels

Brucellosis is a zoonosis that affects several organs. The spine is the most common site of musculoskeletal involvement. However, multiple-level spinal involvement is rare in brucella spondylodiscitis. The authors report a case of a 56-year-old male shepherd who had developed a spondylodiscitis affecting simultaneously the cervical, thoracic and lumbar regions. The diagnosis was established by using MRI after the brucella-agglutination test was found to be positive. A high degree of suspicion in the diagnosis of brucellar spondylodiscitis is essential to reduce the delay for the treatment. Thus, it should be essentially included in the differential diagnosis of longstanding cervical, thoracic or back pain, particularly in regions where brucellosis is endemic. Screening serological tests for brucella should be used more widely in cases with low index of suspicion, especially in endemic areas.

Spondylodiscitis associated with multiple level involvement and negative microbiological tests: an unusual case

STUDY DESIGN

A case report.

OBJECTIVE

To report an unusual case of spondylodiscitis with multiple level involvement.

SUMMARY OF BACKGROUND DATA

Spondylodiscitis, an infection of the intervertebral disc space, vertebral bodies, or the paraspinal epidural space can be a serious disease because of diagnostic delay and inadequate treatment.

METHODS

A previously healthy, 52-year-old man was presented to our outpatient clinic with a complaint of acute, atraumatic onset of severe back pain for more than 1 month. Initially, he was misdiagnosed at another clinic as myofascial pain and treated with nonsteroidal anti-inflammatories and physical therapy, which he did not benefit from. He never complained of fever; however, laboratory tests revealed raised erythrocyte sedimentation values, increased C-reactive protein values but normal leukocyte count. Thoracal and lumbal plain radiographs were nonspecific. Magnetic resonance imaging demonstrated increased signal intensity in vertebral bodies and intervertebral disc space through T12-L4 and in the paravertebral musculature at L2-L3 with contrast enhancement. Blood cultures and computed tomography-guided needle biopsy and cultures were negative.

RESULTS

The patient was treated with oral amoxicillin and clavulanate and responded very well clinically; however, imaging examinations were repeated up to 6 months because of multilevel involvement. Follow-up magnetic resonance imaging findings at 3 months and 6 months showed decreased signal intensity, and luckily, there was no evidence of vertebral destruction.

CONCLUSION

Diagnosis of spondylodiscitis could be challenging and commonly missed; however, it should always be included in the differential diagnoses of back pain in the middle aged and healthy population.

Brucellar spondylodiscitis: magnetic resonance imaging features with conventional sequences and diffusion-weighted imaging

PURPOSE

In this retrospective study, we evaluated the contribution and role of diffusion-weighted imaging (DWI) in differentiating acute and chronic forms of brucellar spondylodiscitis. We also describe the characteristics and some indistinguishable features of brucellar spondylodiscitis on magnetic resonance imaging (MRI) to emphasise the importance and limitations of MRI.

MATERIALS AND METHODS

MRI examinations of 25 patients with brucellar spondylodiscitis were retrospectively reviewed and analysed by two experienced radiologists. Signal and morphological changes were assessed. The imaging characteristics of acute and chronic forms of spondylodiscitis were compared. Both discriminative imaging findings of brucellar spondylodiscitis and some uncommon findings were interpreted.

RESULTS

Of 25 patients with spinal brucellosis, eight had thoracic, ten had lumbar, five had both thoracic and lumbar and two had both lumbar and sacral vertebral involvement. We detected posterior longitudinal ligament elevation in 11 patients, epidural abscess formation in 11 and paravertebral abscess formation in nine. Ten patients had cord compression and eight had root compression. Three patients had facet-joint involvement, and one had erector spinae muscle involvement. Eight patients (32%) were in the acute stage, six (24%) in the subacute stage and 11 (44%) in the chronic stage. Vertebral bodies, vertebral end plates and intervertebral disc spaces were hypointense and hyperintense in the acute stage, whereas they were hypointense and heterogeneous in the subacute and chronic stages on T1- and T2-weighted images, respectively. In the acute stage on the DWI series, vertebral bodies, end plates and discs were all hyperintense but hypointense in the chronic stage.

CONCLUSIONS

Although conventional MRI has several advantages over other imaging modalities and is very useful in the differential diagnosis between brucellar spondylodiscitis and other spinal pathologies, it has some difficulties in discriminating acute and chronic forms of spondylodiscitis. DWI is a sensitive, fast sequence that has the potential for differentiating acute and chronic forms of spondylodiscitis, which makes it crucial in spinal imaging.

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.

Medical Screening for Red Flags in the Diagnosis and Management of Musculoskeletal Spine Pain

When a patient presents with pain in the different regions of the spine, the clinician executes a region-appropriate basic examination that includes appropriate historical cues and specific physical examination tests that can be used to identify red flags. The clinical tests include a specific examination of the sensory and motor systems. Test outcomes are best interpreted in context with the entire examination profile, where the sensitivity and specificity of these tests can influence their utility in uncovering red flags. These red flags can be categorized based on the nature and severity or the specific elements of the patient's presentation. Many general red flags can be observed in any region of the spine, while specific red flags must be categorized and discussed for each spinal region. This categorization can guide the clinician in the direction of management, whether that management is aimed at redirecting the patient's care to another specialist, reconsidering the presentation and observing for clusters of findings that may suggest red flags, or managing the patient within the clinician's specialty in context with the severity of the patient's presentation.

Brucellosis epidemiological and clinical aspects (Is brucellosis a major public health problem in Bosnia and Herzegovina?)

Brucellosis is primarily an animal disease, and in them it passes as an asymptomatic chronic infection. In humans, brucellosis can be acute, sub-acute and/or chronic disease, but its geographical distribution follows the pattern found in animals. After the last war, the first Brucella cases in Bosnia and Herzegovina were reported in 2000, in returnees, owners of donated livestock. The objective of this paper was to address an increased public health problem regarding brucellosis in Bosnia and Herzegovina and to initiate better cooperation among epidemiologists, veterinarians, microbiologists and infectologists and responsible authorities toward elimination and eradication of this severe disease. Retrospective analysis of Brucella case histories and treatment protocols of all the cases hospitalized in Clinic for Infectious Diseases, University of Sarajevo Clinics Center (CCUS) was conducted. All the patients hospitalized between 1 January 2000 and 1 July 2005 were included. The diagnoses were confirmed by laboratory tests, chemo culture or serologically. The Rose Bengal agglutination and ELISA tests were used as laboratory confirmation methods. The number of hospitalized cases over the last 5 years was compared with total number of reported cases in the first 6 months of 2005. The results of this study showed that Brucella infections in humans, compared to other zoonoses, was represented with 11.8%. Brucellosis was the second zoonose in a ranking of zoonotic diseases cases with steady increase in the number of reported cases each year. The number of cases treated in the first 6 months of 2005 already exceeded half of the total number of cases treated in the last 5 years. Human brucellosis is an increasing public health problem in Bosnia and Herzegovina, and it reflects spreading of the same disease in animals. The applied prevention measures have been insufficient, so it is necessary to mobilize all the available resources of human and veterinary medicine, as well as the authorities, microbiological laboratory diagnostics in order to identify foci of epidemics and to try to eliminate and eradicate this complicated disease.

Brucellar spondylodiscitis: noncontiguous multifocal involvement of the cervical, thoracic, and lumbar spine

Brucellosis is a zoonosis of worldwide distribution presenting with a wide clinical spectrum. Brucellosis can involve any organ or system. The axial skeleton is the most common site of involvement with a frequency ranging from 2% to 53%. Multiple-level spinal involvements are rare. This report describes the first case of noncontiguous synchronous multifocal involvement of all cervical, thoracic, and lumbar regions in a patient with brucellar spondylodiscitis.