Paravertebral abscess formation due to brucellosis in a patient with ankylosing spondylitis

Brucellosis with rare complications and review of diagnostic tests: a case report

BACKGROUND

Brucellosis is one of the most common zoonotic diseases in the world. Osteoarticular complications, especially vertebral system involvement, are most commonly reported. However, reports and coreports of pulmonary complications and thoracal spondylodiscitis and epidural abscess are rare.

CASE PRESENTATION

Spondylodiscitis was detected at the T11-12 vertebral level, followed by epidural and paravertebral abscess, and then empyema was detected in a 17-year-old Asian female patient without any additional disease. The patient had used various antibiotics and the disease could not be proven bacteriologically. Also, the Rose Bengal test was negative. However, serologically high titer Brucella positivity was detected in the blood and pleural fluid sample. Drainage was required for bilateral empyema. Disease duration prolonged due to multiple complications. The patient was cured with combined long-term treatment for brucellosis.

CONCLUSIONS

Although some are rare, brucellosis is a zoonotic disease that can cause many complications. The gold standard for diagnosis is the growth of bacteria in blood culture or tissue culture. However, isolation of the microorganism can be very difficult. Clinical suspicion and serological tests are important guides.

When brucellosis met the Assessment of SpondyloArthritis international Society classification criteria for spondyloarthritis: a comparative study

OBJECTIVES

To distinguish brucellosis patients fulfilling the Assessment of SpondyloArthritis international Society (ASAS) classification criteria for spondyloarthritis (SpA) from SpA patients.

METHODS

Brucellosis patients diagnosed from September 2012 to December 2017 who met the ASAS classification criteria for SpA were analyzed with clinical characteristics and laboratory and imaging examinations. Axial or peripheral SpA patients were respectively included into the comparative analysis with a 4:1 ratio.

RESULTS

Twenty-two brucellosis (10 axial and 12 peripheral) patients (male, 16 cases; 72.72%; mean (S.D.) age, 40.23 (16.49) years) and 88 SpA patients were included. All brucellosis patients had been misdiagnosed or considered as SpA before admission to our center. The brucellosis patients had shorter disease duration (axial, P = 0.001; peripheral, P = 0.108). More than half (59.09%) of the patients had contact history with livestock. The low back pain (LBP) of brucellosis patients was generally less improved with exercise (axial, P = 0.001; peripheral, P = 0.008). More brucellosis patients had myalgia (axial, P < 0.001; peripheral, P = 0.071) or fever (axial, P < 0.001; peripheral, P = 0.107). None of them had positive HLA-B27. Blood culture tests were performed in all brucellosis patients and only 4 (18.18%) were positive. Twenty (90.91%) brucellosis patients were gold-immunochromatographic assay (GICA) positive. Bone marrow edema and bone erosion in sacroiliac joints were respectively detected in 100% (10/10) and 90% (9/10) axial brucellosis patients by MRI. Adjacent muscle involvement was found in 80% (8/10) of the patients.

CONCLUSIONS

Indicators including disease duration, contact history of livestock, features of LBP, myalgia, fever, and HLA-B27 can help the differential diagnosis of brucellosis and SpA. GICA test and sacroiliac joints MRI can furtherly confirm the diagnosis of brucellosis.

Human brucellosis mimicking axial spondyloarthritis: a challenge for rheumatologists when applying the 2009 ASAS criteria

Although the development of the 2009 SpA classification criteria by Assessment of SpondyloArthritis international Society (ASAS) represents an important step towards a better definition of the early disease stage particularly in axial spondyloarthritis (axSpA), the specificity of the criteria has been criticized these days. As the commonest zoonotic infection worldwide, human brucellosis can mimic a large number of diseases, including SpA. This study was performed to determine the frequency of rheumatologic manifestations in patients with brucellosis and the chance of misdiagnosing them as having axSpA in central China. The results showed that clinical manifestations of axSpA could be observed in brucellosis. Over half of patients had back pain, and one fifth of the patients with back pain were less than 45 years old at onset and had the symptom for more than 3 months. Two young males were falsely classified as suffering from axSpA according to the ASAS criteria, and one with MRI proved sacroiliitis was once given Etanercept for treatment. Therefore, differential diagnosis including human brucellosis should always be kept in mind when applying the ASAS criteria, even in traditionally non-endemic areas.

Spinal brucellosis

Spinal involvement in human brucellosis is a common condition and a significant cause of morbidity and mortality, particularly in endemic areas, because it is often associated with therapeutic failure. Most chronic brucellosis cases are the result of inadequate treatment of the initial episode. Recognition of spinal brucellosis is challenging. Early diagnosis is important to ensure proper treatment and decrease morbidity and mortality. Radiologic evaluation has gained importance in diagnosis and treatment planning, including interventional procedures and monitoring of all spinal infections.

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.

Brucellosis presenting as piriformis myositis: a case report

INTRODUCTION

Myositis is a rare bacterial muscle infection. Involvement of the piriformis muscle has been rarely reported in the literature. In this report we describe a case of piriformis myositis due to Brucella melitensis, which to the best of our knowledge is the first such case presented in the literature.

CASE PRESENTATION

We report the case of a 19-year-old Caucasian man who presented to our institution with fever and right hip pain. Brucellosis was suspected, but the clinical suspicion was for spondylodiscitis. A pelvic magnetic resonance imaging scan allowed prompt diagnosis of inflammatory involvement of the right piriformis muscle. Blood culture results were positive for B. melitensis. Our patient was treated with antibiotics, and follow-up magnetic resonance imaging scans showed resolution of the inflammation.

CONCLUSION

Brucellosis can present as piriformis myositis. The clinical diagnosis of piriformis myositis is difficult, as it can mimic other common entities such as referred back pain from spondylodiscitis. Magnetic resonance imaging is the method of choice for establishing the diagnosis in the early stages of the disease, as late diagnosis can lead to abscess formation and the need for drainage.

Origin, evolution and paleoepidemiology of brucellosis

Brucellosis is a worldwide disease. Although it has been eradicated in some countries, it continues to be an important disease in many farming areas. Previous works have described the evolution and diffusion of brucellosis in antiquity through direct analysis of ancient human remains collected by the University Museum of Chieti, Italy, and by using paleopathological and historical data. The earliest published case was reported in a skeletal individual dated to the Middle Bronze Age. However, our research group has diagnosed vertebral brucellosis in the partial skeleton of the late Pliocene Australopithecus africanus, demonstrating that this infectious disease occasionally affected our direct ancestors 2·3-2·5 million years ago. The frequency of brucellosis increased during the Roman period, when the disease would almost certainly have been endemic in Roman society, and during the Middle Ages. Most paleopathological cases involve adult male skeletal individuals, and lumbar vertebrae and sacroiliac joints are most commonly involved.

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.

Possible brucellosis in an early hominin skeleton from sterkfontein, South Africa

We report on the paleopathological analysis of the partial skeleton of the late Pliocene hominin species Australopithecus africanus Stw 431 from Sterkfontein, South Africa. A previous study noted the presence of lesions on vertebral bodies diagnosed as spondylosis deformans due to trauma. Instead, we suggest that these lesions are pathological changes due to the initial phases of an infectious disease, brucellosis. The macroscopic, microscopic and radiological appearance of the lytic lesions of the lumbar vertebrae is consistent with brucellosis. The hypothesis of brucellosis (most often associated with the consumption of animal proteins) in a 2.4 to 2.8 million year old hominid has a host of important implications for human evolution. The consumption of meat has been regarded an important factor in supporting, directing or altering human evolution. Perhaps the earliest (up to 2.5 million years ago) paleontological evidence for meat eating consists of cut marks on animal remains and stone tools that could have made these marks. Now with the hypothesis of brucellosis in A. africanus, we may have evidence of occasional meat eating directly linked to a fossil hominin.

Long-standing, neglected sacroiliitis with remarked sacro-iliac degenerative changes as a result of Brucella spp. infection

BACKGROUND

Osteoarticular disease is universally the most common complication of brucellosis. Sacro-iliac joint (SIJ) is the most frequent osteoarticular location of involvement. Sacroiliitis (SI) usually is associated with acute form of the disease, thus frank SIJ destruction caused by brucellosis is rare.

PURPOSE

To report the case of a patient suffering from severe, prolonged lumbar pain with sciatica, refractory to medical treatment, in which the correct and misdiagnosed cause of her pain was a long-standing, neglected brucellar SI.

STUDY DESIGN

Case report.

METHODS

Scintigraphy and imaging methods (computed tomography, magnetic resonance imaging).

RESULTS

The result of the delayed diagnosis was a pronounced degeneration of the SIJ.

CONCLUSIONS

Sacroiliitis as a result of infection with Brucella might cause severe joint degeneration if left untreated.

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.

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.

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

Brucellosis is a zoonosis that affects several organs and has a protean presentation. The authors report the case of a 61-year-old male patient with brucellar spondylodiscitis involving several vertebrae and a paravertebral abscess localized in the erector spinae muscle. Diagnosis was made by positive blood culture and MRI. No relapse was seen with a combined treatment (doxycycline/rifampin) for 3 months, followed by doxycycline alone for 6 months. Almost all radiologic findings disappeared at the end of a 1-year follow-up without any further treatment.

Primary hydatid disease of sacrum affecting the sacroiliac joint: a case report

STUDY DESIGN

A case report of hydatid disease of the spine.

OBJECTIVE

To describe an unusual case of hydatid disease of the sacrum affecting the sacroiliac joint and to discuss imaging, differential diagnosis, and treatment.

SUMMARY OF BACKGROUND DATA

Hydatidosis or echinococcosis affecting the spine is rare and has a characteristic geographic distribution. Signs of sacroiliac joint involvement and accompanying neurologic deficits cause difficulties in differential diagnosis of this rare condition.

METHODS

A case of 38-year-old female patient with low back pain and sciatica was presented.

RESULTS

Plain radiographs, computed tomography, and magnetic resonance imaging scans revealed destructive expansive lesion located on the right sacrum and extended through the right sacroiliac joint. Surgical enucleation of the cysts was performed together with mebendazole treatment and histopathologic examination confirmed hydatidosis.

CONCLUSION

This unusual disease should be kept in mind in the differential diagnosis of sacroiliac pain and sciatica, especially in endemic areas.

Brucellar Spine Infection-Four Case Reports-

Brucellosis can be difficult to diagnose because of the nonspecific and variable clinical picture. This systemic disease is still an important public health problem in the Mediterranean Basin. These four cases of brucellar spine infection originated from rural areas around Aydin, Turkey. The systemic complaints of fever, profuse sweating, malaise, polyarthromyalgia, and weight loss indicated the final diagnosis of brucellosis and presumptive diagnoses were made based on agglutination testing for brucellosis. Computed tomography and magnetic resonance imaging indicated signs of bone infection and soft tissue involvement. Good outcomes were obtained with prolonged treatment with antibrucellar drugs including streptomycin, rifampicin, and tetracycline. Early diagnosis is important and prompt antibrucellar chemotherapy is effective in most cases, but prolonged follow up is necessary in all patients with spinal brucellosis.

Brucellar spondylodiscitis in the lumbar region

A 59-year-old male farmer presented with a rare case of spondylodiscitis as a manifestation of systemic brucellosis. The patient presented with radicular pain and restricted mobility of the spine due to localized muscle spasm in addition to systemic complaints. Magnetic resonance imaging demonstrated discovertebral involvement at the L4-5 intervertebral space, indicating infectious spondylodiscitis. The Rose-Bengal test was positive and the serum antibody titer was 1/1280. The patient was treated with streptomycin combined with tetracycline plus rifampicin, with complete recovery. Early diagnosis is important and prompt antibrucellar chemotherapy is effective in most cases. Therefore, spondylodiscitis due to brucellosis should be considered in the differential diagnosis of spinal infections.