A multicenter retrospective study of childhood brucellosis in Chicago, Illinois from 1986 to 2008

Treatment of Childhood Brucellosis: A Systematic Review

BACKGROUND

Proper treatment for brucellosis is crucial to eradicate the infection and prevent complications, but there is a notable gap in evidence for pediatric treatment. This study aims to address this gap by reviewing current literature, analyzing the efficacy and safety of brucellosis treatment in children, and identifying areas that require further investigation.

METHODS

A systematic review, following preferred reporting items for systematic reviews and meta-analyses and Cochrane Handbook guidelines, assessed antimicrobial regimens' efficacy and safety for treating human brucellosis in children. Original human studies with clinical outcomes after drug therapy intervention for children up to 10 years were included. Searches were conducted in Medline, Embase, Cochrane Library and LILACS databases for studies indexed until March 6, 2023. Study selection, data extraction, and bias risk assessment were performed by pairs of reviewers. The quality assessment used Joanna Briggs Institute tools and grading of recommendations assessment, development and evaluation system. Data were analyzed using R software.

RESULTS

A total of 1773 records were reviewed, yielding 11 eligible studies encompassing 1156 children. All included studies presented an observational design. The most reported treatment approaches included sulfamethoxazole-trimethoprim with rifampicin or aminoglycosides, with summarized failure rates of 2% (95% confidence interval: 0.0-0.49) and 13% (95% confidence interval: 0.06-0.29), respectively (very low certainty of evidence). Adverse events and time to defervescence were not reported.

CONCLUSIONS

Sulfamethoxazole-trimethoprim + rifampicin were the most prescribed antibiotics for brucellosis for pediatrics. The study highlights the need for more research with robust designs, and emphasizes uncertainty regarding the efficacy of antimicrobial regimens, emphasizing the importance of further investigations to guide specific treatment protocols for this population.

Osteoarticular Involvement in Childhood Brucellosis: Evaluation of Clinical, Laboratory and Radiologic Features of 185 Cases

BACKGROUNDS

Brucellosis is a systemic zoonotic disease. Osteoarticular (OA) system involvement is a common complication and the predominant manifestation of brucellosis in children. We aimed to evaluate the epidemiologic, demographic, clinical characteristics, and laboratory and radiologic findings of children with brucellosis and how these related to OA involvement.

METHODS

This retrospective cohort study consisted of all consecutive children and adolescents diagnosed as having brucellosis who were admitted to the pediatric infectious disease department of University of Health Sciences Van Research and Training Hospital between August 1, 2017, and December 31, 2018, in Turkey.

RESULTS

A total of 185 patients diagnosed as having brucellosis were evaluated, 50.8% had OA involvement (n = 94). Seventy-two patients (76.6%) exhibited peripheral arthritis involvement, among of them, hip arthritis (63.9%; n = 46) was the most common manifestation, followed by arthritis of knee (30.6%; n = 22), shoulder (4.2%; n = 3) and elbow (4.2%; n = 3). A total of 31 patients (33.0%) had sacroiliac joint involvement. Seven patients (7.4%) had spinal brucellosis. Erythrocyte sedimentation rate level above 20 mm/h at admission and age were independent predictor of OA involvement (respectively odds ratio [OR] = 2.82; 95% confidential interval [CI] = 1.41-5.64, OR peryear = 1.10; 95% CI: 1.01-1.19). Increasing age was associated types of OA involvement.

CONCLUSION

A half of brucellosis cases had OA involvement. These results can help physicians to make early identification and diagnosis of childhood OA brucellosis who present with arthritis and arthralgia to enable the disease to be treated in time.

Analysis of Brucellosis Cases Between 2010 and 2020 in Guangdong Province, China

Brucellosis is a zoonotic disease with more than half a million people diagnosed worldwide. In China, 99% of cases were historically reported in the northern part of the country, and few were diagnosed in Guangdong province. Recently, Guangzhou has become as an emerging focus for brucellosis, with personal awareness of brucellosis and inexperience of clinicians hindering timely clinical diagnosis. To improve clinical management of this disease, we retrospectively analyzed 60 brucellosis cases from 2010 to 2020 in Guangdong Provincial People's Hospital. There were no manifestation differences between southern and northern patients. However, 68.3% of patients lacked awareness of risk factors for Brucella infection. Therefore, to prevent its spread and avoid delays in diagnosis, implemented infected-animal control programs and enhanced education on brucellosis are necessary.

Bacteremic and Nonbacteremic Brucellosis in Children in Turkey

INTRODUCTION

Human brucellosis is one of the most common zoonotic infections in the world. The definitive diagnosis of brucellosis is based on cultured Brucella organisms from blood or other tissue samples. We aimed to compare bacteremic and nonbacteremic brucellosis patients with demographical, epidemiological, clinical and laboratory features and determine the predictive factors affecting blood culture positivity.

MATERIALS AND METHODS

Children aged 1 month to 18 years who were followed up with the diagnosis of brucellosis between January 2005 and March 2021 were included in this retrospective study. According to the isolation of Brucella melitensis in blood culture, the patients were divided into two groups as bacteremic and nonbacteremic and compared in terms of demographic, clinical and laboratory characteristics.

RESULTS

One hundred eighty-nine (116 male, 61.4%) patients diagnosed with brucellosis were included in the study. There were 76 (40.2%) bacteremic and 113 (59.8%) nonbacteremic patients. Bacteremic patients were younger than nonbacteremic patients. Fever, arthralgia, hepatomegaly and splenomegaly were significantly higher in the culture positive group. High levels of C-reactive protein (CRP), aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were found to be significant in the bacteremic group.

CONCLUSION

In our study, history of fever and arthralgia, hepatomegaly and splenomegaly in physical examination and high CRP, ALT and AST levels in the biochemical analysis were important factors determining blood culture positivity.

Risk factors, outcomes and time to detect positive blood culture among cases with acute brucellosis

BACKGROUND

Brucellosis causes a disabling human disease and loss of animals' lives. The clinical significance of Brucella bacteremia is still unclear and Brucella identification in blood culture is suboptimal.

METHODS

This was a retrospective study conducted in Medina in Saudi Arabia from August 2016 to May 2019. We included cases with brucellosis symptoms and a positive culture or serological evidence for brucellosis, comparing bacteremic with non-bacteremic brucellosis cases for the rates of complications, infection relapses and brucellosis development. Also, we estimated blood culture positivity rates and the time to detect Brucella in an automatic blood culture instrument.

RESULTS

Of the total number of 147 cases, 62 (42%) had a positive blood culture for Brucella, and the blood culture instrument (BACT/ALERT 3D) detected all positive blood cultures within 3 d of incubation. We found higher rates of chronic brucellosis in bacteremia than non-bacteremia cases (OR 7.25, 95% CI 1.41 to 37.23; p=0.018). Patients aged <15 y developed a higher rate of bacteremia than those aged ≥15 yr (OR 11.93 95% CI 1.37 to 103.75; p=0.025).

CONCLUSION

Brucella bacteremia is an independent predictor for the development of chronic infection. Brucella bacteremia cases may need long follow-up periods and a more thorough evaluation to exclude deep-seated infection.

An Outbreak of Brucellosis: An Adult and Pediatric Case Series

Background

Brucellosis is recognized as a neglected zoonotic disease and a major public health threat. The purpose of this study was to characterize epidemiological risk factors and healthcare utilization and compare clinical aspects of disease among adult and pediatric cases in North Texas.

Methods

A retrospective chart review of electronic medical records was completed at 3 large tertiary centers—Parkland Health and Hospital System, Clements University Hospital, and Children’s Medical Center—between January 1, 2007 and June 1, 2017. Demographic, clinical, and laboratory variables were collected. Cases were defined as confirmed or probable.

Results

Twenty-eight cases of brucellosis were identified: 26 confirmed (9 children, 17 adults) and 2 probable cases (1 child, 1 adult). Half (n = 14) were diagnosed in 2016 during an outbreak in Dallas County. Risk factors associated with infection were consumption of unpasteurized cheese (71%), recent travel (54%), close contact to a confirmed human brucellosis case (36%), and exposure to animals (11%). Median days of symptoms was 10 and 16 for children and adults, respectively. The majority (79%) of patients visited the emergency department before diagnosis and 93% were hospitalized. Fever was the most common symptom in children (80%) and adults (100%). Hepatitis (75% of children) and anemia (82% of adults) were the most common laboratory abnormalities. The most common complication in children was splenic lesions (40%), and the most common complication in adults was hepato/splenomegaly (39%).

Conclusions

The diagnosis of Brucella infection requires a high index of suspicion and should be considered in patients presenting with a febrile illness and a compatible exposure history.

Epidemiologic, clinical, and laboratory characteristics of childhood brucellosis : A study in an Iranian children's referral hospital

BACKGROUND

Brucellosis is endemic in Iran. Children constitute 20-25% of cases. We determined clinical, laboratory, and epidemiologic characteristics of pediatric brucellosis patients hospitalized at the Children's Medical Center from May 2011 to December 2016.

METHODS

Medical records were reviewed retrospectively. For each patient, a questionnaire was provided containing demographic characteristics (sex, age, nationality, date of admission, city of residence, history of ingestion of unpasteurized dairy products, family history of brucellosis, history of contact with suspicious animals) and clinical information (signs and symptoms, laboratory findings, history of disease relapse, treatment).

RESULTS

Included were 43 patients diagnosed with brucellosis (26 males, 60.5%; age 1-13 years, mean ± SD: 7.02 ± 3.5). A history of ingestion of raw or unpasteurized dairy products was present in 88% (N = 38) and 11 patients (26%) had had contact with a suspicious animal. Highest frequencies of brucellosis were recorded in 2013 (N = 10, 23%) and 2015 (N = 11, 26%). Most cases were admitted in the summer (N = 14, 33%) and spring (N = 12, 28%). Fever (N = 39, 91%), arthralgia (N = 33, 77%), and malaise (N = 33, 77%) were the main complaints. Anemia (65%), lymphocytosis (51%), and elevated erythrocyte sedimentation rate (86%) and C‑reactive protein (67%) were the most prominent blood anomalies. Blood culture was positive in 30% (N = 11/37), bone marrow culture in 31% (N = 4/11). A positive Wright, Coombs Wright, and 2 ME test was observed in 67% (N = 29), 92% (N = 34/37), and 85% (N = 34/40) of cases, respectively. Median length of antibiotic therapy was 12 weeks (2-24 weeks). The most frequent drug regimen was combined trimethoprim-sulfamethoxazole and rifampicin (N = 24, 56%). Relapse occurred in 9 patients (21%), there were no deaths.

CONCLUSIONS

Physicians should be aware of the manifestations, diagnosis, and treatment protocols of childhood brucellosis. Control programs and preventive measures, e.g., regular examination of domestic animals, mass vaccination of livestock, slaughter of infected animals, control of animal trade and migration, pasteurization of milk and milk products, training and increased public awareness of the dangers of consumption of unpasteurized dairy products, are highly recommended.

Pediatric brucellosis. An update review for the new millennium

Brucellosis remains the most common bacterial zoonotic infection in many countries worldwide. Despite being long recognized and controllable, the disease still causes substantial morbidity, affecting especially the young population. The aim of this review is to provide insight to the epidemiology, etiology, clinical features, diagnosis, and management of childhood brucellosis.

Imported brucellosis: A case series and literature review

BACKGROUND

Brucellosis is one of the main neglected zoonotic diseases. Several factors may contribute to the epidemiology of brucellosis. Imported cases, mainly in travellers but also in recently arrived immigrants, and cases associated with imported products, appear to be infrequently reported.

METHODS

Cases of brucellosis diagnosed at a referral unit for imported diseases in Europe were described and a review of the literature on imported cases and cases associated with contaminated imported products was performed.

RESULTS

Most imported cases were associated with traditional risk factors such as travel/consumption of unpasteurized dairy products in endemic countries. Cases associated with importation of food products or infected animals also occurred. Although a lower disease incidence of brucellosis has been reported in developed countries, a higher incidence may still occur in specific populations, as illustrated by cases in Hispanic patients in the USA and in Turkish immigrants in Germany. Imported brucellosis appears to present with similar protean manifestations and both classical and infrequent modes of acquisition are described, leading on occasions to mis-diagnoses and diagnostic delays.

CONCLUSIONS

Importation of Brucella spp. especially into non-endemic areas, or areas which have achieved recent control of both animal and human brucellosis, may have public health repercussions and timely recognition is essential.

Brucellosis Outbreak in Children and Adults in Two Areas in Israel

Two parallel outbreaks of Brucella melitensis infection occurred in 2014 in two geographical areas in Israel. In two medical centers in northern Israel and one medical center in Jerusalem, 102 patients (58 children, 47 adults) were diagnosed with brucellosis. Most patients (N = 76, 72%) were Muslim Arabs, 28 (27%) were Druze, and one was Jewish. The source of infection was often traced to cheese from the Palestinian Authority. Biovar-1 was evident in 98% in northern Israel but only in 42% in Jerusalem. Most common manifestations were fever (82%) and osteoarticular symptoms (49%). The major differences between the geographic areas were ethnicity and duration until diagnosis. Compared with adults, children had higher rates of hospitalization (93% versus 64%, P = 0.001), osteoarticular symptoms (60% versus 36%, P = 0.05), elevated alanine aminotransferase (12% versus 0%, P = 0.01), and lower C-reactive protein (2.28 ± 2.08 versus 5.57 ± 6.3l mg/dL, P = 0.001). Two unrelated brucellosis outbreaks occurred in 2014 in two different geographic areas of Israel and were limited to sections of the Arab and Druze populations. Most of the demographic and clinical aspects of patients were not affected by geographic variability. Clinical and laboratory differences were found between children and adults emphasizing the nonuniformity of the disease in different age groups. Effective control of unpasteurized dairy foods, health education programs, and improved regional cooperation are required to control brucellosis in Israel.

Childhood brucellosis: Review of 317 cases

OBJECTIVE

To describe the main epidemiological, clinical, and laboratory features, treatment options and outcome in children with brucellosis.

METHODS

Retrospectively evaluated data were obtained from 317 pediatric patients with brucellosis that were treated at the University Clinic for Infectious Diseases and Febrile Conditions in Skopje, during the period from 1989 to 2011. The medical records and follow-up protocols were used for evaluation.

RESULTS

Childhood brucellosis composed 317 (18.7%) of 1691 patients with brucellosis. The patients were median 9 years old, ranging from 7 months to 14 years, and 201 (63.4%) were males. Family history was present in 197 (62.1%), and direct contact with animals occurred in 140 (44.2%) of the children. The dominant manifestations were fever in 248 (78.2%), joint pain in 228 (71.9%) and hepatomegaly in 216 (68.1%). Organ affection was present in 206 (65.0%) of the patients. One hundred and six (33.4%) of the patients were treated with combination composed of two, and 211 (66.6%) with three antimicrobial agents. Relapses were registered in 21 (6.6%), and therapeutic failures in 3 (0.9%) of the children.

CONCLUSIONS

In endemic regions childhood brucellosis represents a significant part of human cases. Wide spectrum of clinical manifestations, frequent affection of various organ systems and possibility of relapses show that brucellosis could be a serious disease in this age group. The presence of fever, joint pain, sweating, and affection of various systems in children from endemic regions should alert pediatricians for the possibility of brucellosis.

Prevalence of Asymptomatic Brucellosis in Children 7 to 12 Years Old

Background. Brucellosis is one of the most common diseases of humans and animals and its clinical manifestations differ from asymptomatic infection to chronic illness associated with recurrence of symptoms. This study aimed to evaluate the prevalence of brucellosis in asymptomatic children 7 to 12 years old in Kahak, Iran. Methods. In this study, 186 children 7 to 12 years old were evaluated. Demographic data and exposure to the brucellosis agent were recorded and blood samples for the Wright, Coombs, and 2ME tests were collected. All the study subjects were followed up for one year about the appearance of symptoms. Results. The mean age was 10 ± 1.72 years and 51% were boys. Family history was positive for brucellosis in 15% of children. A total of 8 children were brucellosis seropositive and, in subsequent follow-up, 6 of them showed the disease symptoms. Conclusion. This study showed that approximately 4.3% of children in endemic areas can have asymptomatic brucellosis and many of these children may be symptomatic in short term.

Targeted Mutation of Nuclear Bone Morphogenetic Protein 2 Impairs Secondary Immune Response in a Mouse Model

We recently identified a nuclear variant of the BMP2 growth factor, called nBMP2. In an effort to understand the function of this variant protein, we generated a mouse line in which BMP2 is expressed and functions normally, but nBMP2 is excluded from the nucleus. This novel mutation allows the study of nBMP2 without compromising BMP2 function. To determine whether nBMP2 plays a role in immune function, we performed a series of experiments in which we compared mouse survival, organ weights, immune cells numbers, and bacterial load in wild type and nBmp2NLS^tm mice following primary and secondary challenges with Staphylococcus aureus. Following primary challenge with S. aureus, wild type and nBmp2NLS^tm mice showed no differences in survival or bacterial load and generated similar numbers and types of leukocytes, although mutant spleens were smaller than wild type. Secondary bacterial challenge with S. aureus, however, produced differences in survival, with increased mortality seen in nBmp2NLS^tm mice. This increased mortality corresponded to higher levels of bacteremia in nBmp2NLS^tm mice and to a reduced enlargement of mutant spleens in response to the secondary infection. Together, these results suggest that the recently described nuclear variant of BMP2 is necessary for efficient secondary immune responses.

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.