Secondary infection of a total hip replacement with Brucella abortus

Periprosthetic hip infections caused by Brucella: a rare case report and literature review

Periprosthetic hip infection caused by Brucella abortus is rare and only a few cases have been reported. This current case report presents a case of a man in his early 50s who developed periprosthetic hip infection 2 years after right hip arthroplasty. There was no fever or pain, the usual cardinal signs of infection, except for a sinus tract at the previous surgical incision. Laboratory and arthrocentesis culture examinations (done twice) confirmed infection with B. abortus. Accordingly, a two-stage revision surgery was performed accompanied by antibiotic treatment with doxycycline and rifampicin after each stage. There was no recurrence at the 2-year follow-up, with good functional recovery of the hip joint. Clinically, this case serves to highlight the fact that periprosthetic hip infections caused by B. abortus might not present with the typical symptoms such as fever or hip pain. Furthermore, this current case involved a chronic sinus tract, so the diagnostic and therapeutic course of this case offers useful insights for managing similar cases in the future. In addition, a review of the literature on the diagnosis and treatment of Brucella-caused periprosthetic hip infection is presented.

Brucella infection following total joint arthroplasty: A systematic review of the literature

INTRODUCTION

The aim of this systematic review was to analyze the results of published treatment options in Brucella infection following total joint arthroplasty (TJA).

METHODS

We performed a systematic review of the literature regarding outcomes of Brucella infection after TJA (hip and knee). We searched multiple databases for articles in the area published from 1950 to 2016.

RESULTS

A total of 18 patients (12 male and 6 female; mean age 59 years) from 14 published studies were identified. The minimum follow-up time was 6 months (range, 6-120 months). Seven patients were treated with debridement or antibrucella treatment only. Eleven patients (61%) underwent removal of the prosthesis and were treated with one or two-stage exchange arthroplasty. The mean duration of antibiotic therapy was 5.8 months. There was no relapse of infection.

CONCLUSIONS

In the absence of loosening of the components of the prosthesis, an attempt to treat Brucella infection medically might be a reasonable choice. One or two-stage exchange arthroplasty could provide successful results without relapse of infection when combined with appropriate antibiotherapy.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Brucella melitensis prosthetic joint infection

Periprosthetic joint infection (PJI) due to Brucella spp. is rare. We report a case in a 75-year-old man and review 29 additional cases identified in a literature search. The diagnosis of Brucella PJI is challenging, in particular in non-endemic countries. Serological tests prior to joint aspiration or surgical intervention are reasonable. Involvement of infection control and timely information to laboratory personnel is mandatory upon diagnosis. There is no uniform treatment concept, neither with respect to surgical intervention nor for the duration of antimicrobials. Most cases have a successful outcome, irrespective of surgical modality, and with an antimicrobial combination regimen for 12 or more weeks.

Brucella melitensis prosthetic joint infection in a traveller returning to the UK from Thailand: Case report and review of the literature

BACKGROUND

Brucella spp. prosthetic joint infections are infrequently reported in the literature, particularly in returning travellers, and optimal treatment is unknown.

METHOD

We describe a prosthetic joint infection (PJI) caused by Brucella melitensis in a traveller returning to the UK from Thailand, which we believe to be the first detailed report of brucellosis in a traveller returning from this area. The 23 patients with Brucella-related PJI reported in the literature are summarised, together with our case.

RESULTS

The diagnosis of Brucella-related PJI is difficult to make; only 30% of blood cultures and 75% of joint aspiration cultures were positive in the reported cases. Culture of intraoperative samples provides the best diagnostic yield. In the absence of radiological evidence of joint loosening, combination antimicrobial therapy alone may be appropriate treatment in the first instance; this was successful in 6/7 [86%] of patients, though small numbers of patients and the likelihood of reporting bias warrant caution in drawing any firm conclusions about optimal treatment. Aerosolisation of synovial fluid during joint aspiration procedures and nosocomial infection has been described.

CONCLUSIONS

Brucella-related PJI should be considered in the differential of travellers returning from endemic areas with PJI, including Thailand. Personal protective equipment including fit tested filtering face piece-3 (FFP3) mask or equivalent is recommended for personnel carrying out joint aspiration when brucellosis is suspected. Travellers can reduce the risk of brucellosis by avoiding unpasteurised dairy products and animal contact (particularly on farms and abattoirs) in endemic areas and should be counselled regarding these risks as part of their pre-travel assessment.

Brucella infection in total knee arthroplasty. Case report and revision of the literature

Brucella infection in arthroplasties is a rare event. An unspecific clinical symptomatology is associated with unclear radiographic peri-prosthetic signs of bone halisteresis. Only a positive anamnesis, combined with an antibiogram of the joint liquid and a high serum antibody titre, can lead to a definitive diagnosis. We report a case of Brucella melitensis infection in a total knee arthroplasty implanted 2 years earlier. With the absence of radiological signs of prosthetic loosening and thanks to a systemic antibiotic combined therapy (rifampicin + doxycycline) extended for 8 weeks, we were able to solve the infection avoiding surgery.

Prosthetic hip infection due to Brucella melitensis: case report and literature review

Prosthetic joint infection (PJI) due to Brucella spp. is extremely rare. We report the case of a prosthetic hip infection due to Brucella melitensis in a 51-year-old male patient. The initial presentation was a gluteal abscess. There was radiographic evidence of implant loosening. The patient was cured after prolonged treatment with streptomycin, rifampicin, and doxycycline, followed by 2-stage exchange of the prosthesis. Brucella spp. should be considered in the differential diagnosis of PJI in countries where brucellosis is endemic. The review of all cases previously reported shows that a conservative approach using antibiotics alone can be followed in patients without signs of implant loosening. In contrast, prolonged antibiotic treatment and prosthetic joint revision should be considered in patients with evidence of implant loosening.

Fungi, mycobacteria, zoonotic and other organisms in prosthetic joint infection

A systematic review of the presentation and management of prosthetic joint infection (PJI) due to zoonotic microorganisms, fungi, mycobacteria and other unusual microorganisms is not available. We therefore sought to provide a resource for the practicing orthopaedic surgeon which will serve as a guide for making appropriate decisions in managing such rare, but potentially problematic conditions. We conducted a Medline search of all case reports of PJI due to these unusual microorganisms. Our review of the current literature showed the diagnosis of PJI due to zoonotic microorganisms, fungi, mycobacteria and other unusual microorganisms typically necessitates specialized diagnostic tests. Maintaining a high index of suspicion in diagnosis of such unusual microorganisms and requesting the appropriate laboratory tests at the time of surgical débridement is crucial for determining the microbiologic etiology of these infections. The appropriate medical and surgical management of such infections is complex and often requires the use of special antimicrobials with which the orthopaedist may not be familiar. Collaboration with an infectious disease specialist is advisable when treating these infections.

Total hip arthroplasty infected by Brucella: a report of two cases

Infection caused by Brucella following total joint arthroplasty is very rare. We present 2 cases of brucellar infection following total hip arthroplasty (THA). A 66-year-old woman who had prolonged contact with cattle presented with pain at the thigh and groin areas. The patient had undergone an uncemented THA for a hip fracture 3 years previously. Cultures of articular liquid were positive for Brucella abortus. The implant was loosened and was managed with a 2-stage re-implantation. A 71-year-old man presented with painless suppuration of the hip joint through the scar from previous surgeries. Radiography demonstrated a well-integrated THA. When postoperative cultures were found positive for Brucella melitensis, antibiotic treatment of rifampicin 900 mg, streptomycin 1 g, and doxycycline 200 mg daily were prescribed. At 5.5-year and 5-year follow-up, respectively, both patients were asymptomatic and free of infection with well-integrated implants. As the Brucella pathogen is highly susceptible to antibiotics, standard 2-stage revision arthroplasty for loosened implant or debridement and antibiotic treatment for well-fixed implant should suffice.

Hip arthritis in brucellosis: a study of 33 cases in the Republic of Macedonia (FYROM)

Prospectively were studied clinical characteristics, diagnostic tools and outcome in 33 patients with hip arthritis during brucellosis that were treated at the clinic for infectious diseases in Skopje, Republic of Macedonia (FYROM). Thirty-six hip involvements were noted. The patient's age was mean (SD) 23.7 (19.9) years, 18 were male. Twenty-one of them acquired the disease through direct contact with infected animals. In five patients, hip arthritis was the unique manifestation of the disease. Concomitant affection of other osteoarticular localisation was found in 18 patients. The diagnosis of hip arthritis was achieved using radionuclide bone scan and ultrasound examination in 17 and 16 cases, respectively. During the follow-up period, six relapses, three therapeutic failures and one sequela were noted. Brucellar aetiology should be considered in all patients from endemic areas, who have manifest symptoms of hip joint involvement.

Brucella prosthetic joint infection: a report of 3 cases and a review of the literature

We report 3 cases of Brucella melitensis infection of prosthetic hips and knees, and we summarize data about 4 cases reported in the literature. Six of the 7 affected patients were men. The median duration from prosthesis implantation to the onset of symptoms was 38.7 months. Five patients had only local symptoms. Preoperative joint aspirates yielded negative culture results for 3 patients, and blood culture results were negative for 6 patients. Excisional arthroplasty was the initial intervention for 3 patients. Three others responded well to medical therapy alone. One patient had relapse while receiving tetracycline and underwent total hip replacement. All patients were treated with combined antibiotic therapy for 6 weeks to 19 months. All had favorable long-term responses. The 3 patients we treated underwent a 2-staged resection arthroplasty. Antibiotics alone can be used to treat Brucella prosthetic joint infection, but loosening of the joint and clinical or microbiological failure must be treated with a 2-staged excisional arthroplasty and 3 months of treatment with doxycycline and rifampicin.

Brucellar prosthetic arthritis in a total knee replacement

The infecting pathogens most commonly implicated in prosthetic joint infections are staphylococci, streptococci, and gram-negative rods. Prosthetic infections caused by Brucella spp. are rarely described in the literature. Treatment of prosthetic infections remains complex and controversial, the most accepted course being antibiotic treatment with removal or retention of prosthetic components. The case of a 60-year-old man who developed Brucella septic arthritis of the right knee in a total knee replacement is reported. Conservative treatment using a three-drug therapy was employed, with excellent results.

Fever of undetermined origin: not what it used to be

Eighty cases of fever of undetermined origin seen at Dallas VAMC from 1979 to 1985 were analyzed. Infectious etiology was the cause in one half, with equal numbers of localized infections or systemic infections. In contrast to older series, viral infections were frequently seen, but tuberculosis and malaria were less commonly noted. Solid tumors were the most frequently diagnosed non-infectious cause of fever. Fevers secondary to malignancy commonly responded to non-steroidal anti-inflammatory agents. Patterns of illness were helpful in defining certain diseases such as adult Still's disease and polymyalgia rheumatica. Diagnostic tests of value are discussed.

Brucella sacroiliitis. A case report

Brucellosis is an uncommon infectious disease in the United States though it remains endemic in many parts of the world. Signs and symptoms of the disease are highly variable, with musculoskeletal complaints occurring frequently. The combination of an uncommon infection presenting with protean manifestations often results in missed or delayed diagnosis in the Western world.