Brucellar arthritis: a study of 39 Peruvian families

Brucellosis and Sacroiliitis Present as Acute Severe Hip Pain

Brucellosis is a zoonotic disease that is endemic in Saudi Arabia. It is transmitted to humans through direct contact with infected animals or by consuming unpasteurized dairy products. A 36-year-old Saudi man presented with left hip pain, fever, and a history of consuming unpasteurized milk. Sacroiliitis was documented by positive results from serological tests (ELISA) and magnetic resonance imaging. Treatment consisted of non-steroidal anti-inflammatory drugs (NSAIDs), doxycycline, rifampicin, and IV gentamicin.

Clinical Characteristics, Treatment, and Prognosis of Osteoarticular Brucellosis: A Retrospective Real-World Study in Shenyang, China, 2014-2019

This study aimed to assess the clinical characteristics, treatment, and prognosis of osteoarticular brucellosis. We conducted a retrospective study enrolling brucellosis patients from the Sixth People's Hospital of Shenyang between September 2014 and June 2019. A total of 1917 participants were admitted during this period. After applying propensity score matching, we retrospectively analyzed 429 patients with osteoarthritis and 429 patients without osteoarthritis. The primary outcome was treatment completion. The secondary outcome was symptom disappearance and seroconversion. Brucellosis patients with osteoarthritis had longer treatment course (160 [134.3-185.7] vs. 120 [102.3-137.7] d, p = 0.008) than those without osteoarthritis. The most common involved site was lumbar vertebrae (290 [67.6%]) in brucellosis patients with osteoarthritis. Longer symptom duration (90 [83.0-97.0] vs. 42 [40.2-43.8], p < 0.001) along with no significant difference in seroconversion (180 [178.8-181.2] vs. 180 [135.1-224.9], p = 0.212) was observed in osteoarthritis patients with treatment course >90 d. Peripheral joint involvement (adjusted hazard ratio [95% confidence interval] 1.485 [1.103-1.999]; p = 0.009) had a shorter symptom duration compared with shaft joint involvement. No significant differences were observed in treatment therapy between doxycycline plus rifampin (DR) or plus cephalosporins (DRC) in treatment course (p = 0.190), symptom persistence (p = 0.294), and seroconversion (p = 0.086). Lumbar vertebra was the most commonly involved site. Even if all symptoms disappeared, Serum agglutination test potentially remained positive in some patients. Compared with peripheral arthritis, shaft arthritis was the high-risk factor for longer symptom duration. The therapeutic effects were similar between DR and DRC. In summary, our study provided important insights into the clinical characteristics, treatment, and outcomes of osteoarticular brucellosis. Clinical Trial Registration number: NCT04020536.

The 2019 Pan American games: Communicable disease risks and travel medicine advice for visitors to Peru - Recommendations from the Latin American Society for Travel Medicine (SLAMVI)

The next Pan American Games will be held in Peru in the period July-August 2019. Around 6680 participants from 41 countries are expected to take part in the event. There will be a total of 62 sport disciplines. This event poses specific challenges, given its size and the diversity of attendees. Such gatherings also have potential for the transmission of imported or endemic communicable diseases, including measles in view of the global outbreak situation, but also tropical endemic diseases. In anticipation of increased travel, a panel of experts from the Latin American Society for Travel Medicine (SLAMVI) developed the current recommendations taking into consideration the epidemiology and risks of the main communicable diseases at potential destinations in Peru, recommended immunizations and other preventives measures. These recommendations can be used as a basis for advice for travelers and travel medicine practitioners. Mosquito-borne infections also pose a challenge. Although Lima is malaria free, travelers visiting Peruvian high-risk areas for malaria should be assessed regarding the need for chemoprophylaxis. Advice on the correct timing and use of repellents and other personal protection measures is key to preventing vector-borne infections. Other important recommendations for travelers should focus on preventing water- and food-borne diseases including travelers' diarrhea. This paper addresses pre-travel, preventive strategies to reduce the risk of acquiring communicable diseases during the Pan American Games and also reviews the spectrum of endemic infections in Lima and Peru to facilitate the recognition and management of infectious diseases in travelers returning to their countries of origin.

[Modern radiological diagnostics in spine surgery]

BACKGROUND

Radiological imaging is important in the preoperative diagnosis of many forms of spinal pathology and plays a fundamental role in the assessment of p.o. effects, which can be verified on the spinal column as well as on the surrounding soft tissues, depending on the imaging method used.

AIM

The article provides an overview of the current status and possibilities of radiological diagnostic methods for the verification of possibly recommended spine surgery in the context of degenerative, inflammatory-infectious, post-traumatic or p.o. pathologies and changes in the spine: X‑rays, computed tomography (CT), magnetic resonance imaging (MRI). The supplementary nuclear medicine procedures (scintigraphy, PET[-CT], SPECT, etc.) which may be required for special questions are not discussed.

MATERIAL AND METHODS

The merits and limitations of the techniques used in the investigation of advanced degenerative spinal pathologies and post-traumatic conditions are discussed, with multidetector CT being the focus of attention in spinal clearance for traumatic injuries. In most cases of spinal infection, MRI images, as a central diagnostic tool, show typical findings such as destruction of adjacent endplates, bone marrow and intervertebral disc abnormalities, and paravertebral or epidural abscesses. However, it is not always easy to diagnose a spinal infection, especially if atypical MR patterns of infectious spondylitis are present. Knowledge of them means misdiagnosis and improper treatment can be avoided.

RESULTS

It is shown that high-quality modern radiological examinations are essential for diagnosis and p.o. management, as these provide answers to the main questions in the treatment: Is the entity/injury stable or unstable, acute or old, benign or malign; is there a myelopathy or p.o. complication?

DISCUSSION

The main indications for p.o. diagnostic imaging, difficulties such as metal artefact formation, and potential pitfalls are analyzed. Entity-specific radiological image patterns, imaging algorithms and differential diagnostic peculiarities are presented and discussed based on current literature and selected case studies.

Sixteen Chinese pediatric brucellosis patients onset of fever in non-epidemic areas and 8 developed with osteoarticular involvement

The purpose of this study is to summarize the manifestations, diagnosis, differential diagnosis, and treatment of childhood brucellosis in non-epidemic areas of China. A retrospective review of 16 admitted children patients with brucella's disease who were diagnosed of brucellosis during the period from 2011 to 2016 was performed. Diagnostic criteria, clinical presentations, and outcomes were recorded. The most common symptom was fever. Osteoarticular involvement was found in 50% of the patients. They were infected by contacting with infected animals or consuming of unpasteurized milk or meat of sheep or goats, also. Standard agglutination test was positive in all patients and blood culture in 10 (62.5%) patients as well as medulloculture in 3 (18.8%) patients were positive. A combination of antibiotic treatment with rifampin plus cotrimoxazole showed good response and all clinical manifestations improved. Brucellosis is misdiagnosed frequently and should be considered in the differential diagnosis when patients do not respond to standard treatment. Blood culture, together with brucella serology test, is important and helpful in the diagnosis. MRI is a good method in differentiating those with symptoms of arthritis.

THE PREVALENCE OF BRUCELLOSIS IN CATTLE AND THEIR HANDLERS IN NORTH TONGU DISTRICT OF VOLTA REGION, GHANA

BACKGROUND

Brucellosis is a zoonotic pathogen responsible for great economic losses in most sub-Saharan nations. Although Ghana has successfully implemented the "One Health" initiative for the control of some emerging infectious zoonotic diseases with pandemic potential like Avian Influenza, there is very limited data available on brucellosis especially human brucellosis prevalence. He objective of his study is to determine the seroprevalence of human and bovine brucellosis as well as the predisposing factors at the community level in the North Tongu District of Ghana.

MATERIALS AND METHODS

Rose Bengal Plate test (RBPT) was used to analyze blood samples from 178 cattle farmers, and 315 cattle. The positive samples were further confirmed with cELISA. Predisposing factors were determined by questionnaires administered to cattle farmers. All sample sites were geo-referenced.

RESULTS

Human and bovine brucellosis seroprevalence using RBPT were 10.1% and 22.9% respectively. Eighty six percent (62/72) of bovine cases were confirmed with ELISA. Delivery assistants were more likely to be infected (p=0.043) with odds ratio of 2.7. Out of the human cases (18), males constituted 88.9%. Ages 11-20 years recorded 77.7% seropositivity whilst cattle drovers represented 44.5% (8/18) of positives. Significant risk factors in cattle were herd size (p=0.037), history of retained placenta (0.000) and abortion (0.005).

CONCLUSION

Bovine and human brucellosis is prevalent in North Tongu district, Ghana. Close contact with parturient cows was a major predisposing factor for human infection. Early referral of positive persons to the Hospital for confirmation and treatment is required to comply with the "One Health" initiative on brucellosis and other zoonoses.

Analysis of IL-10 and IL-6 Gene Polymorphisms and Their Serum Levels in Patients with Brucellosis: A Case Control Study

BACKGROUND

It seems that polymorphism in the regulatory areas of cytokine genes affects the cytokine production capacity and may play a role in the development of infectious diseases. Interleukin-10 (IL-10) and Interleukin-6 (IL-6), which are cytokines of Th2, cause the macrophage become inactive and patient conditions get worse.

METHODS

In this case-control study, 60 patients with brucellosis and 60 healthy participants were recruited. IL-10 genotyping at positions -1082 (G/A), -819 (C/T), and -592 (C/A) and IL-6 genotyping at position -174 (G/C) were analyzed by amplification refractory mutation system-polymerase chain reaction (ARMS-PCR) and restriction fragment length polymorphism-polymerase chain reaction (RFLP-PCR) methods. The levels of IL-10 and IL-6 were determined by a sandwich enzyme-linked immunosorbent assay in sera of study population.

RESULTS

The AA and CC genotypes of the IL-10 gene at positions -1082 G/A and -819 C/T were significantly more frequent in patients in comparison to controls, respectively. The AG genotype of the IL-10 gene at positions -1082 G/A was significantly more frequent in control groups than the patients. Serum levels of IL-10 and IL-6 were significantly more frequent in the patients than in the control groups.

CONCLUSIONS

Our study showed that the AA and CC genotypes at positions -1082 and -819 are very important, respectively. These results suggest that IL-10 (-1082 G/A) GG genotype may be considered as a risk factor for brucellosis, while the AG genotype might be a protective factor against the disease.

A case of acute septic arthritis hip caused by Brucella melitensis in an adolescent child

Brucella is among the most common zoonotic diseases affecting humans. Although musculoskeletal involvement is seen in a large proportion of patients, the disease is often diagnosed late or misdiagnosed due to its subtle nature and rarity, and lack of awareness among clinicians. In this report, a 12-year-old girl was diagnosed with acute septic arthritis of the hip based on clinico-radiological features, and managed with standard treatment, including arthrotomy. However, the child did not respond to the treatment. Based on the histopathology and local endemicity, Brucella was suspected, and confirmed after serological testing. The child subsequently responded to treatment and, at latest follow-up at 1 year, had a full painless range of motion, with no relapse.

Septic arthritis caused by Brucella melitensis in urban Shenzhen, China: a case report

INTRODUCTION

Brucellosis is a systemic infectious disease which is still a challenging medical problem in rural areas such as northern China. It rarely occurs in urban areas such as Shenzhen in southern China. Osteoarticular involvements are frequently seen in brucellosis, and rarely is arthritis the only clinical presentation. We report a case of hip septic arthritis caused by Brucella melitensis in an urban area of Shenzhen, China.

CASE PRESENTATION

A 29-year-old Chinese woman, Han ethnical group presented to our hospital with left hip pain persisting for one month. She had a history of contact with goats one month before admission. Her clinical examination showed marked tenderness and limited movement of her left hip. Further imaging showed effusion of her left hip joint. Inflammatory markers including erythrocyte sedimentation rate (ESR) and c-reactive protein (CRP) were raised. Our clinical diagnosis was septic arthritis of the left hip. A left hip arthroscopy was performed and the culture was positive for Brucella melitensis. She returned to normal activity after completing a standard antibiotic regimen, including gentamicin at 120mg daily for 2 weeks, doxycycline at 100mg daily and rifampicin at 450mg for a total of 12 weeks.

CONCLUSIONS

Brucellosis is endemic in some rural areas of China, but rare in urban areas such as Shenzhen in southern China. However, more cases will be expected in urban areas due to increasing migration within China. Physicians should consider brucellosis as one of the differential diagnosis of arthritis. Early surgical intervention is recommended to prevent further joint destruction.

Osteomyelitis variolosa: A probable mediaeval case combined with unilateral sacroiliitis

Osteoarticular sequelae of smallpox (osteomyelitis variolosa) are uncommon today. Such lesions may be observed occasionally, however, in countries where the disease has been endemic. Without other forms of documentation, it is possible to suggest a diagnosis of smallpox in ancient skeletal remains and thus make a significant contribution to understanding the history of this disease. We have examined a subadult male (Skeleton 833), 15-17 years old at the time of death, who presents bilateral bone manifestations of the elbows suggestive of smallpox. No other bone is similarly affected. In addition, he presents a left sacroiliitis deemed to be a brucellar manifestation. Skeleton 833 is one of at least 730 individuals from an exhaustive excavation of a mediaeval necropolis at Pont-sur-Seine (Aube, north-eastern France). Radiocarbon dating of his bones yields a date of between AD 1022 and 1155 (calibrated), thus apparently the oldest case described to date. The other published cases correspond to more recent periods with a well established historical context. We argue that this example of osteomyelitis variolosa.

Skeletal Involvement of Brucella melitensis in Children: A Systematic Review

Brucellosis is a protean disease and should be excluded in any febrile child with a constellation of symptoms such as fever, malaise, sweating, arthralgia, and joint swelling in endemic areas. Skeletal system involvement is the most common source of complaints in brucellosis. The frequency of skeletal involvement in children is 6.4% to 73.5%. There are some controversies regarding the most common sites of involvement: sacroiliac versus peripheral joints. In the vast majority of cases, peripheral joint involvement in pediatric brucellosis has a monoarticular pattern, although there is no agreement about the most commonly involved peripheral joint. In this systematic review, published articles that describe the bone involvement of Brucella melitensis, as the most prevalent kind of the microorganism in the region, in children are evaluated.

Osteoarticular involvement in childhood brucellosis: experience with 133 cases in an endemic region

AIM

To describe the main clinical and laboratory characteristics, frequency and distribution of osteoarticular involvement, therapeutic options and outcome in children with osteoarticular brucellosis.

METHODS

This descriptive study includes 133 pediatric patients with osteoarticular brucellosis who were treated at the University Clinic for Infectious Diseases and Febrile Conditions in Skopje, Republic of Macedonia, during the period between 1989 and 2011. Brucellosis was presumptively diagnosed on the basis of clinical signs and confirmed by the detection of specific antibodies at significant titers.

RESULTS

The median age of patients was 9 years (range, 2-14 years) and 63.9% were males. Family history of brucellosis was present in 54.1%. The dominant clinical symptoms were arthralgia and fever in 77.4% and 73.7%, respectively, and the dominant sign was hepatomegaly in 73.7% of patients. The main laboratory abnormalities were elevated C-reactive protein (81.0%) and circulating immunocomplexes (80.7%). In 71.4% of patients, the osteoarticular involvement was monoarticular. Hip arthritis was present in 49.6%, followed by the knee in 30.1%. Various therapeutic regimens with a duration of 6 weeks were used. In 87 patients during a follow-up of at least 6 months, relapse occurred in 13.8%.

CONCLUSIONS

Osteoarticular involvement is frequent in children with brucellosis. It is most often manifested with monoarthritis of the large weight-bearing joints. Brucellosis should be included in the differential diagnosis of childhood arthritis in endemic countries, especially in the presence of family history, contact with infected animals or ingestion of unpasteurized food products, fever and hepatomegaly.

Diagnostic value of serum concentrations of high-mobility group-box protein 1 and soluble hemoglobin scavenger receptor in brucellosis

Both cluster of differentiation (CD)4(+) and CD8(+) T lymphocytes play key roles in immunity to Brucella, in part because they secrete interferon (IFN)-γ and activate bactericidal functions in macrophages. Therefore, use of markers of macrophage activation may have diagnostic and prognostic significance. High-mobility group-box 1 protein (HMGB1), a late-onset pro-inflammatory cytokine, is secreted by activated macrophages. Soluble hemoglobin scavenger receptor (sCD163) is a specific marker of anti-inflammatory macrophages. The aim of this study was to investigate the diagnostic value of HMGB1 and sCD163 concentrations in brucellosis and its various clinical forms. Serum HMGB1 and sCD163 concentrations in 49 brucellosis patients were compared with those in 52 healthy control subjects. Both serum HMGB1 and sCD163 concentrations were significantly higher in brucellosis patients than in healthy controls (P < 0.001). There were no statistically significant differences in serum concentrations of HMGB1 and sCD163 between cases of acute, subacute and chronic brucellosis. Additionally, serum HMGB1 concentrations were positively correlated with sCD163 concentrations, whereas neither HMGB1 nor sCD163 concentrations were correlated with C-reactive protein concentrations, white cell counts or erythrocyte sedimentation rates. Therefore, serum concentrations of HMGB1 and sCD163 may be diagnostic markers for brucellosis, but neither can be used to differentiate the three different forms of this disease (acute, subacute and chronic).

Brucellar spondylitis: review of 25 cases

OBJECTIVE

: Brucellar spondylitis is one of the most serious complications of brucellosis. It should be considered in patients who have back pain and neurologic disorders as well as systemic symptoms and findings in or from endemic areas such as Turkey. This report describes important features of the disease.

METHODS

: Twenty-five patients with brucellar spondylitis were retrospectively evaluated in terms of their clinical, laboratory, and radiologic features and their response to different treatment regimens.

RESULTS

: The most common symptoms of brucellar spondylitis were back pain, fever, and sweating. Rose Bengal tests were positive in all of these patients. Brucella species was isolated from blood cultures of 8 (32%) patients. Magnetic resonance imaging (MRI) showed that the lumbar segment was the most frequently involved region. Different combination regimens including 2 or 3 antibiotics were used. Combination of tetracycline (especially doxycycline) and streptomycin was the most widely used therapy regimen. Trimethoprim-sulfamethoxazole, ciprofloxacin, ofloxacin, and rifampin were also included in some combination therapies. In this series, the mean duration of antimicrobial therapy was 130 +/- 45.6 days (range, 77-281 days), and 92% of patients received therapy for >/= 90 days. There were no mortalities in this study.

CONCLUSIONS

: Brucellar spondylitis should be considered in patients with back pain and neurologic disorders as well as systemic symptoms and findings in endemic areas. MR imaging is recommended in suspected cases. The patients can be treated effectively treated with appropriate antibiotic combinations. Follow up is important because relapses can occur.

Human brucellosis in Macedonia - 10 years of clinical experience in endemic region

AIM

To present our 10-year clinical experience with brucellosis patients at the University Clinic for Infectious Diseases and Febrile Conditions in Skopje, Republic of Macedonia.

METHODS

A total of 550 patients with brucellosis treated between 1998 and 2007 were retrospectively assessed for their demographic, epidemiological, and clinical characteristics and outcomes.

RESULTS

Of the 550 patients, 395 (72%) were male. The median age was 34.5 years (range, 1-82). Direct contact with infected animals was recorded in 333 (61%) patients and positive family history in 310 (56%). The most frequently seen symptoms were arthralgia (438, 80%), fever (419, 76%), and sweating (394, 72%). The most common signs were fever and hepatomegaly, which were verified in 357 (65%) and 273 (50%) patients, respectively. Focal brucellosis was found in 362 patients (66%) and osteoarticular in 299 (54%). Therapeutic failures were registered in 37 (6.7%) patients. Of the 453 (82%) patients who completed a follow-up period of at least 6 months, relapses occurred in 60 (13%).

CONCLUSION

Due to non-specific clinical manifestation and laboratory parameters, brucellosis should be considered one of the differential diagnoses of any patient suffering from obscure involvement of various organs in a brucellosis-endemic region. High percentage of relapses and therapeutic failures in spite of the use of currently recommended therapeutic regimens indicates the seriousness of this zoonosis and the need to control it.

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.

A report of two cases of brucellar sacroiliitis without systemic manifestations in Greece

We report 2 cases of sacroiliitis in a 13-year-old girl and an 11-year-old boy as the sole manifestation of Brucella melitensis infection. This is a rare condition. Throughout the course of the disease, neither the girl nor the boy had other signs of brucellosis. Sacroiliitis was documented by positive results of technetium 99m scintigraphy and magnetic resonance imaging. Isolation of B. melitensis from the blood and positive results of serologic methods established the diagnosis. Treatment consisted of bed rest and a combination of rifampin plus co-trimoxazole with gentamicin. Brucellar sacroiliitis is uncommon in children, and accurate diagnosis is frequently delayed because of nonspecific clinical presentation. In the appropriate clinical setting, we suggest that the index of suspicion for brucellar sacroiliitis be raised in an unusual joint, especially in endemic regions.

MR imaging assessment of the spine: infection or an imitation?

Magnetic resonance (MR) imaging is a powerful diagnostic tool that can be used to help evaluate spinal infection and to help distinguish between an infection and other clinical conditions. In most cases of spinal infection, MR images show typical findings such as vertebral endplate destruction, bone marrow and disk signal abnormalities, and paravertebral or epidural abscesses. However, it is not always easy to diagnose a spinal infection, particularly when some of the classic MR imaging features are absent or when there are unusual patterns of infectious spondylitis. Furthermore, noninfectious inflammatory diseases and degenerative disease may simulate spinal infection. It is necessary to be familiar with atypical MR imaging findings of spinal infection and features that may mimic spinal infection to avoid misdiagnosis and inappropriate treatment.

Clinical and MRI findings of brucellar spondylodiscitis

OBJECTIVE

The aim of this retrospective study was to report the clinical features and MR imaging findings of patients with brucellar spondylodiscitis.

MATERIALS AND METHODS

Twenty-two patients with spondylodiscitis, recruited among 152 patients with brucellosis referred from the Department of Infectious Diseases. Patients were diagnosed based on positive clinical findings, > or =1/160 titers of brucella agglutination tests and/or positive blood cultures. Magnetic resonance imaging (MRI) was performed to 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

All of the patients (n=22; 7 F, 15 M) had > or =1/160 titers of brucella agglutination test and blood culture was positive in 9. A great majority of the patients had involvement at only one vertebrae level (n=21, 95.5%), whereas one patient (4.5%) had multilevel involvement. In MRI, eight patients had soft tissue involvement and three had abscess formation. All cases had vertebral and discal enhancement. Additionally epidural extension was detected in four cases, posterior longitudinal ligament (PLL) elevation in five cases and root compression in two cases.

CONCLUSION

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

IL-10 and IL-6 gene polymorphisms as potential host susceptibility factors in Brucellosis

Several genes encoding for different cytokines may play crucial roles in host susceptibility to Brucellosis, since the cytokine production capacity varies among individuals and depends on the cytokine gene polymorphism. The association of the cytokine gene polymorphisms with the development of Brucellosis was investigated in this study. DNA samples were obtained from a Turkish population of 40 patients with Brucellosis, and 50 healthy control subjects. All genotyping (IL-6, IL10, IFN-gamma, TGF-beta and TNF-alpha) experiments were performed using sequence-specific primers PCR (PCR-SSP). When compared to the healthy controls, the frequencies of high/intermediate producing genotypes of IL-10 and high producing genotype of IL-6 were significantly more common in the patient group. These results suggest that IL-10 and IL-6 gene polymorphisms may affect susceptibility to Brucellosis and increase risk of developing the disease. In order to confirm the biological significance of our results, further studies should be performed in larger population groups.

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.

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.

Acute brucellosis in Saudi families: relationship between brucella serology and clinical symptoms

OBJECTIVE

To determine if screening family members of patients with acute brucellosis will enhance the detection rate of brucellosis and also to determine the relationship between symptoms and brucella serology.

MATERIALS AND METHODS

Family members from patients with acute brucellosis were interviewed and serologically screened. All seropositive family members were clinically and serologically followed for six months.

RESULTS

Twenty-five acute brucellosis patients and their 178 family members were enrolled from January 2001 to February 2002. Of the 178 family members, 40 (23%) manifested various symptoms, 138 (77%) were asymptomatic, with an overall seroprevalence rate of 34 (19%). The rate of seropositivity among the symptomatic family members was 23 (58%) and for the asymptomatic was 11 (8%) (P<0.001). The majority of the symptomatic family members (13 (57%)) had a high Brucella titer in comparison to one (9%) of the asymptomatic group (P<0.001). Acute brucellosis was diagnosed and treated in 18 (78%) of the symptomatic seropositive family members and in four (36%), of the asymptomatic seropositive family members with an acute brucellosis prevalence rate of 22 (12%). All family members with acute infection recovered without sequelae; one patient relapsed (5%).

CONCLUSION

Symptomatic family members are more likely to be seropositive with a high titer in comparison to the asymptomatic members.

Scintigraphic findings in osteoarticular brucellosis

AIMS

To describe the distribution of bone and joint involvement in 197 patients with brucellosis, and to detail a spectrum of findings on bone scintigraphy in 38 patients with brucellar spondylitis.

METHODS

One hundred and ninety-seven patients (141 females, 56 males; age range, 5-77 years) with osteoarticular brucellosis were studied. Patients were classified into acute (62%) and chronic (38%) stages of the disease, and into age groups of less than 16 (1%), 16-30 (17%), 31-45 (29%), 46-60 (37%) and over 60 (16%) years. All patients were evaluated with Tc-methylene diphosphonate bone scanning. Quantification of sacroiliac joint uptake was performed to improve the sensitivity for the detection of sacroiliitis. Plain radiography and computed tomography (CT) or magnetic resonance imaging (MRI) were performed, when required, to evaluate the areas of the skeleton that showed abnormal uptake on the bone scan. MRI and single photon emission computed tomography (SPECT) were performed in all patients who had spinal lesions.

RESULTS

The sites most commonly affected were the sacroiliac joints (53%) and spine (19%), followed by the shoulders (16%). Osteoarticular involvement was more common in females (72%) than in males (28%), and the acute stage (62%) was observed more than the chronic stage (38%). Bone and joint involvement occurred at any age, but the most common age group was 46-60 years. Eight scintigraphic patterns were identified in spinal involvement.

CONCLUSION

Brucellosis may affect the musculoskeletal system at any site. Bone scan is a useful method to detect osteoarticular involvement in cases of relapse and progression. Spine involvement has the widest range of scintigraphic findings. A knowledge of the location and distribution of osteoarticular involvement as revealed on the bone scan of patients with brucellosis may be valuable in patient treatment and management.

Treatment of brucella spondylitis: lessons from an impossible meta-analysis and initial report of efficacy of a fluoroquinolone-containing regimen

Although spondylitis is the most common of the complications of brucellosis, and is often debilitating and difficult to treat, there is no consensus on the preferred combination of antibiotics used. We attempted to perform a meta-analysis based on series on brucellar spondylitis published in the last 22 years. Meta-analysis was aborted largely due to insufficient data recorded in most series. However, useful conclusions could be drawn, such as the importance of prolonged treatment, usually more than 12 weeks. No antibiotic combination was proven to be superior, but 14 different regimens were used in the series studied. The authors propose the use of a combination of doxycycline and ciprofloxacin for a period of 3 months, and report the successful use of such a combination in five patients with brucellosis and spondylitis.

[Brucella spondylodiscitis: case report]

Vertebral localization of Brucellosis has a low occurrence nowadays. Because of its rarity, it is essential to pay attention to structural modifications of the vertebral segment caused by bacterial spondylodiscitis. Based on a clinical case, with radiological, anatomicopathological and labatorial aspects related to the diagnostic and also the treatment of this disease, the authors underscore the importance and serious consequences arising from a late diagnostic definition.

Thrombocytopenic purpura associated with brucellosis: report of 2 cases and literature review

Mild hematologic abnormalities are common in the course of human brucellosis; however, they generally resolve promptly with treatment of the disease. Occasionally, thrombocytopenia is severe and can be associated with bleeding into the skin (purpura) and from mucosal sites. We describe 2 patients infected with Brucella melitensis who presented with thrombocytopenic purpura, and we review 41 additional cases from the literature. Patients ranged in age from 2 to 77 years, and both sexes were affected equally. In the majority of cases, examination of the bone marrow revealed abundant megakaryocytes. Possible mechanisms involved in thrombocytopenia include hypersplenism, reactive hemophagocytosis, and immune destruction of platelets. Recognition of this complication is essential, since hemorrhage into the central nervous system is associated with a high mortality rate.

Acute brucella sacroiliitis: clinical features

Although back pain is very common, the differential diagnosis may sometimes be very difficult. Both inflammation and infections of spinal or sacroiliac joints are examples of such causes. We report three cases of brucella sacroiliitis resembling acute low back pain or lumbar disc herniation. All patients had had a recent infection and were referred complaining of acute back pain with a suspicion of lumbar disc herniation. The complaints of all patients reduced dramatically after proper medication. Radiographs of all patients and bone scans of two patients revealed sacroiliitis. One of the patients was positive for HLA-B27; in the other two patients HLA-B27 could not be determined.

Musculoskeletal manifestations of brucellosis: a study of 90 cases in Israel

Rheumatological manifestations are frequently reported in patients with brucellosis. In a retrospective study of 90 patients diagnosed with brucellosis over a period of 18 years, 83 (92%) patients were Bedouins, 55 of whom (61%) reported ingestion of unpasteurized goat milk and goat milk products. The male/female ratio was 1:1, and the adult to child ratio was 3:2. The mean age of the patients was 25 years (range, 1-72 years). Rheumatological manifestations (myalgia, arthralgia, and arthritis) were reported in more than half of the patients. These manifestations started on days 3 and 4 of the disease and were mild to moderate in severity. Myalagia was evident in 49 (54%) patients and was more common in adults than in children (67% versus 37%; P < .01) and in men (67%) than in women (42%; P < .01). Arthralgia was the most common musculoskeletal manifestation, found in 55 (61%) patients, and occurred more often in children than in adults (74% versus 52%; P < .05). Arthritis was detected in 37 (41%) patients. The hip and knee joints were the most common sites of arthritis (31% each) followed by sacroiliac involvement (17%) and shoulder or spine involvement (5% each). Arthritis was also more common in children (63% versus 29%; P < .01). The prevalence of arthritis was similar in men and women. Cure was achieved in all patients after antibiotic therapy.

Osteoarticular complications of brucellosis

Two hundred and sixty three patients with a diagnosis of brucellosis between January 1984 and December 1987 were studied prospectively. Sixty five patients (25%) developed osteoarticular complications. These patients had a more prolonged course than those with no complications. Spondylitis in 38 (58%) and sacroiliitis in 29 (45%) were the most prevalent. There were no significant laboratory, serological, or bacteriological differences between patients with and without osteoarticular complications. At diagnosis 47 patients (72%) showed radiographic abnormalities, commonly in axial sites but rarely in peripheral sites. Radionuclide bone scan was positive with no radiographic abnormalities in 17 (26%) of cases. Fifty seven patients received medical treatment alone, 51 (89%) being cured with a single course of treatment. Treatment failed or there was a relapse in six patients (11%), of whom five had spondylitis. Eight of the 65 patients (12%), all of whom had spondylitis and paravertebral or epidural abscesses, also required surgical treatment.

Osteoarticular brucellosis in children

The findings in 40 children (24 female, 16 male) with osteoarticular complications of brucellosis are presented. Raw milk was the main source of infection. Most patients had acute onset of fever, arthralgia, and myalgia. Arthritis was the presenting symptom in all patients, of whom two also had osteomyelitis. Arthritis was monoarticular in 28 (70%) of 40 cases with predilection for large weight-bearing joints. Spine and small joints were spared. Brucella melitensis was detected in 23/31 (74%) cases. Mild anaemia, leucopenia, increased liver enzymes, positive acute phase reactants, and low titres of autoantibodies were prominent non-specific laboratory findings. Bone scintigraphy was more helpful than conventional radiography in detecting hip and sacroiliac joint disease. Treatment with a combination of antibiotics for six weeks or more resulted in a cure rate of 92.5%. Early recognition of infection, prolonged treatment, and long term follow up should improve the outcome of patients.