Neurological complications of brucella spondylitis

Brucellosis of the spine - A global public health problem - An analysis of 37 patients from a 'high risk' region

Background

Brucellosis is a global public health issue. Brucellosis of the spine presents as a wide spectrum. The aim was to present the outcome analysis of patients treated for Spinal Brucellosis in the endemic region. Secondly to assess the accuracy of IgG and IgM Elisa in the diagnosis.

Results

A retrospective study of all patients who were treated for Brucellosis of the spine from 2010 to 2020 was conducted. Confirmed cases of Brucellosis of spine and who had adequate follow up after completion of treatment were included. The outcome analysis was based on clinical, laboratory and radiological parameters. There were 37 patients enrolled with a mean age of 45 and an average follow up of 24 months. All of them presented with pain and 30% had neurological deficits. Surgical intervention was done in 24%(9/37patients). All the patients were treated with triple drug regimen for an average duration of 6 months. Those patients with relapse had a 14month period of triple drug regimen. The sensitivity and specificity of IgM was 50% and 85.71%. The sensitivity and specificity of IgG was 81.82% and 7.69%.76% of them had good functional outcome and 82% of them had near normal neurological recovery and 97.3%(36 patients) were healed of the disease with relapse in one patient(2.7%).

Conclusions

Majority (76%) of the patients with Brucellosis of the spine were treated conservatively. Average duration of treatment of triple drug regimen was 6 months. The sensitivity of IgM & IgG was 50% and 81.82% The specificity of IgM and IgG was 85.71% and 7.69% respectively.

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.

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.

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.

Surgical management of cervical spinal epidural abscess caused by Brucella melitensis : report of two cases and review of the literature

Spinal epidural abscess, if especially caused by Brucellosis is a very rare disease which is usually a consequence of spondylodiscitis. The spinal column can be affected at any joint; however, the lumbar spine is the most common region, especially at the level of the L4-5 and L5-S1. The frequency of spinal involvement usually seen at the lumbar, thoracic and cervical spine respectively. As an occupational disease in farmers, veterinaries, butchers, laboratory staff and shepherds, brucellosis can also occur by direct contact to animals and infected materials or ingestion of raw cheese, milk or unpasteurized milk products. In this study, we presented two cases with cervical spinal epidural abscess caused by brucella melitensis, which was successfully treated by surgical approach. Initial treatment was combined with antibiotic therapy after the surgery for 3 months.

Brucellar discitis as a cause of lumbar disc herniation: a case report

Brucellosis is an infectious disease spread by consumption of non-pasteurized milk products or through contact with infected animals. Spinal involvement is one of the most important complications and the lumbar area is the most frequently affected site. Among the neurological consequences, nerve root compression can be a result of epidural abscess, granuloma or discitis secondary to vertebral body involvement. In this case report we present a 50-year-old male patient with brucellar discitis without spondylitis which caused lumbar disc herniation. We want to emphasize that discitis should also be considered in differential diagnosis of nerve root compression in suspected cases.

Brucella cervical spondylitis complicated by spinal cord compression: a case report

A case of 65-year-old farmer who presented with Brucella-related cervical spondylitis is described. Because of the advanced form of the infection resulted in neurological impairment, cervical vertebra corpectomy and debridement of the paravertebral granulomatous tissue deposits were performed followed by stabilization with anterior plating and bone grafting. In addition, double antimicrobial chemotherapy regimen was administered for 12 weeks. After one year, follow up evaluation demonstrated resolution of the infection. The authors recommend that brucellosis should be included in the differential diagnosis of cervical spondylitis, particularly in patients who reside in countries where the zoonosis is still endemic.

EVALUATION OF BRAINSTEM AUDITORY POTENTIAL IN BRUCELLOSIS PATIENTS WITH AND WITHOUT NEUROLOGICAL INVOLVEMENT

This study investigated the changes in brainstem auditory evoked potentials (BAEPs) in acute phase of brucellosis. Twenty-two patients with brucellosis without neurologic involvement and seven patients with neurobrucellosis were included. BAEPs were evaluated before treatment. No patient had a symptom of hearing loss. Patients who had neurologic involvement did not show any abnormalities in their BAEPs recording. This study suggests that patients with brucellosis who are in the acute phase of the disease with or without neurological involvement may have normal BAEPs. BAEPs do not seem to be a sensitive method for central nervous system involvement of brucella patients in the acute phase of the disease.

Nonsurgically treated cervical brucellar epidural abscess causing spinal cord compression

Cervical spinal cord compression due to brucellar epidural abscess is extremely rare, with only 13 previously reported cases. We present another case of cervical spinal epidural abscess causing spinal cord compression. Diagnostic tools and treatment options are discussed.

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.

Brucellar spinal epidural abscesses. Analysis of eleven cases

Brucellar spinal epidural abscesses (BSEA) are rare and very few series of them have been reported. In order to evaluate the clinical characteristics, management and outcome of this entity, the clinical records and current status of a series of 11 patients have been retrospectively reviewed. A series of 11 patients treated for BSEA in our Service during a period of 12 years (1989-2000) have been retrospectively studied. Spinal epidural abscesses (SEA) were diagnosed by MRI, CT or at surgery. Brucellar aetiology of SEA was considered when seroagglutination tests were positive at a titre of 1/160 or higher, and/or Brucella spp. were isolated in the blood or sample cultures. Ten of the 11 cases were treated with rifampicin plus doxycycline and in the remaining patient streptomycin was added because of a poor initial response. Six patients underwent surgical decompression and debridement of the SEA. Outcome was excellent in nine cases and good in two. There was no mortality and only one patient recovered incompletely from preadmission neurological deficits. Although BSEA is considered to be an unusual complication of spondylitis, our findings show that in some cases it can follow direct haematogenous spread to the extradural space. Surgical treatment must be undertaken when major neurological deficits are present. If antibiotic treatment is chosen as the initial therapy, the possibility of sudden neurological deterioration must be taken into account. Contrary to the high morbi-mortality rates reported in pyogenic or tuberculous SEA, BSEA has a good prognosis with early diagnosis and appropriate management.

Brucellar spondylo-discitis with rapidly progressive spinal epidural abscess presenting with sciatica

STUDY DESIGN

Case report.

OBJECTIVE

To present a patient with spinal brucellosis, which was initially presented with sciatica and misdiagnosed as a lumbar disc herniation owing to nonspecific neurological and radiological findings. The delay in diagnosis led to rapid progression of the disease and complications.

SETTING

Department of Neurosurgery at a tertiary university teaching hospital (Sutcu Imam University Medical Center in Turkey).

CASE REPORT

A 57-year-old woman with a history of low-back pain for 6 months, fatigue, and severe left-sided sciatica for the last 3 months presented to our hospital. Three months earlier, at another hospital, she had had a negative Rose-Bengal test for brucellosis and a lumbar computed tomography performed at that time showed only minimal L4-5 annular bulging. For 2 months, she was treated with analgesics for 'lumbar disc herniation' without relief of pain. On presentation to our department, her magnetic resonance imaging (MRI) examination showed edema and minimal annular bulging at L3-4 and L4-5. When her Rose-Bengal test returned positive, she was started on triple antibiotics for presumed Brucella infection. When symptoms and neurologic signs worsened while taking antibiotics, repeat MRI scan showed a spinal epidural abscess at the L4-5 level. Emergent surgery and 8 weeks of antibiotics resulted in cure.

CONCLUSION

In areas endemic for brucellosis, subtle historical and exam features should be sought to exclude an infection such as brucellar sponylo-discitis. Appropriate serological tests should be readily available to confirm or exclude this diagnosis in selected patients, to avoid delays in antibiotic treatment.

Noncontiguous dual segment thoracic brucellosis with neurological deficit

BACKGROUND CONTEXT

Brucellosis can affect the musculoskeletal system, and bony involvement ranges from 2% to 70% in the literature. Spinal brucellosis is generally localized to the sacroiliac region; thoracic brucellosis is rarely seen.

PURPOSE

To present a case with noncontiguous multilevel thoracic brucellosis with spinal cord compression.

STUDY DESIGN

Case report.

METHODS

The patient underwent aggressive surgical debridement (posterior decompression, fusion and stabilization, and two noncontiguous level anterior corpectomy and fusion procedures with titanium mesh cages).

RESULTS

At the latest follow-up of 2 years, her clinical, radiological, and laboratory examination showed no recurrence of infection. The neurological examination was completely normal.

CONCLUSION

Early aggressive debridement and stabilization together with medical treatment, especially in the elderly and immunocompromised patients, would be the most beneficial treatment for eradication of pathology.

Surgical treatment of spinal brucellosis

We retrospectively reviewed 10 patients with spinal brucellosis of the thoracic and lumbar spine who were treated successfully with a combination of surgery and antibiotics. All patients had back pain; six patients had radiculopathy and one patient had paraparesis. Patients with spondylodiscitis without epidural abscesses (n = 3) had transpedicle discectomy and drainage. Epidural abscesses in the lumbar area caused by spondylodiscitis (n = 3), spondylitis (n = 2), and discitis with infected disc herniation (n = 1), were drained using a posterior approach combined with posterolateral fusion in two patients with spondylodiscitis and discectomy in the patient with a herniated disc. One patient presented with a pathologic fracture and neural compression and was treated with anterior corpectomy and reconstruction. Antibiotic treatment was given for 3 to 9 months. Mean followup was 3 years. Back pain improved soon after surgery. Recovery from radiculopathy and paraparesis was complete. One patient had recurrence of infection 9 months after initial treatment. Clinical manifestation of spinal brucellosis can include spondylitis, spondylodiscitis, discitis, epidural abscess, paraspinal abscess, and vertebral collapse. Transpedicle drainage allows tissue diagnosis and facilitates treatment. Because brucellosis usually responds to antibiotics, surgery is considered as the last resort in treating spinal brucellosis, but severe neurologic deficit and incapacitating back pain often necessitate surgical intervention.

LEVEL OF EVIDENCE

Therapeutic study, level IV (case series). Please see the Guidelines for Authors for a complete description of levels of evidence.

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.

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.

Brucellosis in San Diego: epidemiology and species-related differences in acute clinical presentations

Although aggressive public health measures have greatly reduced the number of brucellosis cases in the United States, there is a resurgence of interest in this worldwide zoonosis because of its potential as a bioweapon and its 8-fold higher incidence in California, Texas, and the other borderlands between the United States and Mexico compared with the national rate. Accordingly, we reviewed the clinical records of 28 patients diagnosed at a university hospital in San Diego, CA, between 1979 and 2002 to look for new epidemiologic trends and to test the hypothesis that there are species-specific differences in clinical presentations. In contrast to the latest California-wide study completed in 1992, Brucella abortus infections were more common (73%) than Brucella melitensis after 1992, and women were more commonly infected (77% compared with 39%) than men. Major risk factors remained Hispanic ethnicity, travel to Mexico, and ingestion of nonpasteurized dairy products. Analysis of diagnostic procedures suggested that the traditional practice of prolonged incubation of blood cultures increased their sensitivity for Brucella, even in automated radiometric systems. Direct comparison of the clinical manifestations of infections with B. abortus and B. melitensis strongly supported differences in acute presentations. B. melitensis presented more acutely as fevers of unknown origin with statistically significant higher rates of abdominal tenderness, hepatomegaly, splenomegaly, thrombocytopenia, pancytopenia, and hepatic dysfunction. These results suggest that the epidemiology of brucellosis in California may be evolving, and they show, to our knowledge for the first time in a single series, that species-specific differences in presentations may account for some of the protean manifestations of brucellosis. Familiarity with manifestations of brucellosis and the optimal laboratory techniques for its diagnosis could help physicians protect the public against this reemerging, under-recognized zoonosis.

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.

Spinal infections

Spinal infections have an increasing prevalence among the general population. Definitive diagnosis based solely on clinical grounds is usually not possible and radiological imaging is used in almost all patients. The primary aim of the authors is to present an overview of spinal infections located in epidural, intradural and intramedullary compartments and to provide diagnostic clues regarding different imaging modalities, particularly MRI, to the practicing physicians and radiologists.

Spinal infections

Spinal infections can be thought of as a spectrum of disease comprising spondylitis, discitis, spondylodiscitis, pyogenic facet arthropathy, epidural infections, meningitis, polyradiculopathy and myelitis. Radiological evaluations have gained importance in the diagnosis, treatment planning, treatment and treatment monitoring of the spinal infections. Conventional radiographs are usually the initial imaging study. The sensitivity and specificity of the plain radiographs are very low. The sensitivity of CT is higher while it lacks of specificity. Conventional CT has played minor role for the diagnosis of early spondylitis and disc space infection and for follow-up, researches are going on the value of MDCT. MRI is as sensitive, specific and accurate as combined nuclear medicine studies and the method of choice for the spondylitis. Low signal areas of the vertebral body, loss of definition of the end plates and interruption of the cortical continuity, destruction of the cortical margins are typical on T1WI whereas high signal of affected areas of the vertebral body and disc is typical on T2WI. Contrast is mandatory and increases conspicuity, specificity, and observer confidence in the diagnosis and facilitates the treatment planning. Contrast enhancement is the earliest sign and pathognomonic in the acute inflammatory episode and even in the subtle infection then persists to a varying degree for several weeks or months. The outcome of the treatment is influenced by the type of infection and by the degree of neurologic compromise before treatment. There is an increasing move away from surgical intervention towards conservative therapy, percutaneous drainage of abscess or both. It is therefore critical to monitor treatment response, particularly in the immuno-deficient population.

Brucellar spondylitis: a rare cause of spinal cord compression

STUDY DESIGN

A case report.

OBJECTIVES

To present and discuss some of the difficulties in the diagnosis of brucellar spondylitis.

SETTING

Ankara University, Ibni Sina Hospital, Turkey.

METHODS

We report a patient with paraplegia, misdiagnosed as having a malignancy or tuberculosis who actually suffered from brucellar spondylitis. Diagnosis was established by her history and a compatible clinical picture together with a standard tube agglutination (Wright test) titer of > or =1/160 of antibodies for brucellosis. The patient was treated with oral doxycycline, rifampicin, and ciprofloxacin combination.

RESULTS

At the end of the treatment, the blood Brucella Wright and anti-human globulin T titer levels decreased. Her lower limb weakness improved. She could walk, and climb stairs with the help of a cane. Urinary retention and fecal incontinence also resolved.

CONCLUSION

Brucellosis is a systemic infection involving the musculoskeletal and nervous systems. Spondylitis frequently occurs in elderly patients. An early diagnosis of brucellar spondylitis can often be difficult. In endemic regions, as in the case of our country, brucellar spondylitis should always be considered in the differential diagnosis of older patients with back pain and constitutional symptoms. An early diagnosis will help to prevent the development of more severe complications such as spinal cord compression.

Comparison of five antimicrobial regimens for the treatment of brucellar spondylitis: a prospective, randomized study

Brucellosis, a zoonosis with worldwide distribution, is a systemic infection and still an important public health problem in Turkey. The best antimicrobial combination and schedule for the treatment of brucellosis with spondylitis has not yet been clearly determined. In a prospective and randomized study, we compared the efficacy of five antimicrobial regimens for treatment of 102 patients with lumbar brucellar spondylitis. Patients were randomly assigned to receive antimicrobial combination therapy. Twenty patients received streptomycin 1 g/day intramuscularly for 15 days and tetracycline-HCl, 500 mg every 6 h orally for 45 days (ST), 21 patients received streptomycin 1 g/day i.m. for 15 days and doxycycline 100 mg every 12 h orally for 45 days (SD), 20 patients received doxycycline 100 mg every 12 h orally for 45 days and rifampicin 15 mg/kg per day in a single morning dose orally for 45 days (DR), 19 patients received ofloxacin, 200 mg every 12 h orally for 45 days and rifampicin 15 mg/kg per day in a single morning dose orally for 45 days (OR), and 22 patients received streptomycin 1 g/day i.m. for 15 days and doxycycline 100 mg every 12 h orally for 45 days plus rifampicin 15 mg/kg per day in a single morning dose orally for 45 days (SDR). Initial therapeutic failure occurred in 2 patients (10%) in the ST regimen group, 4 patients (19%) in the SD group, 3 patients (15%) in the DR group and 5 patients (26%) in the OR regimen. In addition, 2 patients (10%) in the DR group and 5 patients (26%) in the OR regimen relapsed during the follow-up period. There was no relapse in any patients in the ST, SD, and SDR groups. The response rates were 90% in the ST and 81% in the SD groups. In contrast, there was a maximum good response (100%) and no relapse in the SDR group. In conclusion, a combination of doxycycline, streptomycin, and rifampicin can be recommended as therapy for brucellar spondylitis and to reduce relapse rates.

Spinal brucellosis: case report in the United States

STUDY DESIGN

Case report.

OBJECTIVE

To increase awareness of spinal brucellosis and discuss demographics, diagnosis, and treatment.

SUMMARY OF BACKGROUND DATA

Brucellosis is a rare cause of spinal infections in the United States, although there have been regional increases in its prevalence.

METHODS

Retrospective review of a patient with spinal brucellosis. She underwent a protracted course of treatment, with a long delay in diagnosis. History ultimately revealed regular consumption of unpasteurized goat cheese. Appropriate testing subsequently led to the diagnosis.

RESULTS

After multiple surgeries and medications, the condition responded well to definitive antibiotic therapy.

CONCLUSION

Brucellosis is rare in the United States and thus often overlooked in the differential diagnosis of back pain. The changing risk pattern for this disease requires a high index of suspicion, which can result in early diagnosis and predictably favorable results to treatment.

Brucellar spondylodiscitis: MRI diagnosis

Early diagnosis of brucellar spondylodiscitis is often difficult because of the long latent period. Radiographs of the spine, bone scan, and computed tomography (CT) scan provide insufficient data. Among 25 patients with brucellar spondylodiscitis studied by magnetic resonance imaging (MRI), 9 were in the acute stage and 16 were in the chronic stage. MRI is the investigation method of choice in diagnosing brucellar spondylodiscitis.

Medically treated intraspinal "Brucella" granuloma

BACKGROUND

Although there have been reports of Brucella granuloma or abscess in the literature, they were all localized extradurally except one, and most patients underwent surgery.

CASE REPORT

A 40-year-old female presented with urinary and fecal incontinence and a two-month history of progressive weakness of the right leg and numbness of the left leg. Four months previously, she had been diagnosed with systemic brucellosis with a period of radiculomeningoencephalitis; she was treated successfully with rifampicin, doxycycline, trimethoprim/sulfamethoxazole (TMP/SMZ), and streptomycin, and was discharged symptom-free on rifampicin and doxycycline. Neurological examination revealed spastic paraparesis, globally hyperactive deep tendon reflexes (DTRs) and sensory level at T6. Magnetic resonance imaging (MRI) of the spinal cord revealed a 10 x 30 mm intradural-intramedullary mass lesion at the T5 level with surrounding edema that enhanced with contrast. The cerebrospinal fluid (CSF) was xanthochromic with lymphocytic pleocytosis and elevated levels of albumin, immunoglobulins, and antibody titers for Brucella. The medications were modified to rifampicin 1200 mg, doxycycline 400 mg, and TMP/SMZ 480/2400 mg daily, and methylprednisolone 100 mg in decremental doses (for 6 weeks). After 2 months, the patient was almost symptom-free and her medication doses were decreased. After 5 months, the mass lesion resolved almost completely. The treatment was discontinued after 2 years.

CONCLUSIONS

The case is presented because of its uniqueness. In cases of Brucella granuloma, the authors recommend a trial of medical treatment with adequate dosages for a reasonable length of time before considering surgical intervention.

Brucellar spondylitis: review of 35 cases and literature survey

Thirty-five patients aged 14-74 years (average, 54 years) who had brucellar spondylitis were treated between January 1991 and December 1997. The time from onset of symptoms to diagnosis of spondylitis ranged from 1 week to 8 months (median, 9 weeks). Back or neck pain (100% of patients), fever (66%), and constitutional symptoms (57%) were the most common symptoms. Cultures of blood specimens from 26 patients (74%) were positive for Brucella melitensis. The duration of antimicrobial therapy (median, 120 days; range, 45-535 days) varied according to clinical response and the presence of epidural and paravertebral masses. One of the 35 patients underwent surgical treatment of a spinal epidural abscess. Therapy failed for 9 patients (26%; 95% confidence interval [CI], 12%-43%), and 5 (14%; 95% CI, 5%-30%) had a relapse. There were no deaths or severe sequelae in this study. Brucellar spondylitis causes considerable suffering and absenteeism from work, but long-term clinical responses are favorable.

Brucellar spinal epidural abscess

Spinal epidural abscesses account for approximately one of every 10, 000 admissions to tertiary hospitals. The midthoracic vertebrae are the most frequently affected, whilst the cervical spine is involved in fewer patients. Staphylococcus aureus is identified as the cause in most cases of epidural abscess; other bacteria responsible include Gram-negative bacteria, Streptococcus species and Brucella species. We report the case of a patient with cervical spondylodiscitis at level C4-C5 and an epidural abscess which was compressing the spinal cord and the retropharyngeal space. The previous symptoms of brucellosis were atypical. We discuss the clinical manifestations, diagnosis, treatment and prognosis of the case.

Lumbar spinal root compression caused by Brucella granuloma

STUDY DESIGN

A case report of rarely seen extradural brucellosis granuloma causing spinal root compression in the lumbar region.

OBJECTIVE

To point out the possibility of extradural compression caused by brucellosis.

SUMMARY OF BACKGROUND DATA

Many investigators have indicated that myelopathy or radiculopathy caused by irritation or compression by tiny abscess, disc herniation, or extradural granuloma may occur in brucellosis. Failure to make the correct diagnosis is possible because of the absence of such symptoms of brucellosis as fever, sweating, or fatigue and because findings of physical examination, radiography, and myelography indicate intervertebral disc herniation.

METHODS

Review and discussion of the case history are presented.

RESULTS

Brucella granuloma compressing the right L5 root and dural sac was diagnosed on computed tomographic scans and was excised subtotally after laminectomy and facetectomy.

CONCLUSION

The possibility of extradural compression caused by brucellosis should be considered in endemic areas and must be differentiated from an intervertebral disc herniation by means of agglutination testing and bone scan.

Bacterial infections: osteoarticular brucellosis

Osteoarticular brucellosis has been documented extensively from the Middle East and Spain in the last 5 years, but it has only been reported infrequently from the UK and USA. Brucella melitensis from goat and sheep is the most frequently isolated organism. Peripheral articular pain, particularly of the large joints, is the commonest osteoarticular manifestation, while effusions that seldom yield organisms on culture, also occur frequently. Sacroiliitis which most frequently is unilateral, often presents acutely and dramatically with severe pain that is poorly localized to the lower back and buttock, leading to difficulty in walking and even standing. Tapping the heel and springing the sacrum is probably the best way of localizing the pain to the sacroiliac joint in this acute stage. Lack of awareness of this pattern of presentation could lead to misdiagnosis. Spondylitis is the third major manifestation of osteoarticular brucellosis. It occurs in older patients and is insidious and chronic in onset and course. The lumbar spine is most frequently involved, although cervical involvement is frequently associated with more complications, particularly compressive neurological deficits. Osteomyelitis occurs unusually. Several large series have been reported among children. In them peripheral large joint involvement in association with systemic features predominate while sacroiliitis may occur unusually. Plain X-rays often demonstrate vertebral damage, involving the upper anterior margin most frequently. CT scans define better vertebral damage that is characterized by bony sclerosis and the less frequently encountered extradural extension and para-vertebral abscess formation. Technetium bone scan is the most sensitive technique for detecting acute sacroiliitis and other sites of early osteoarticular involvement. A four-fold rise in Brucella agglutination titre is the most frequently utilized diagnostic aid. A 6 week culture in a CO2-enriched medium is recommended for growing Brucella. Tetracycline or doxycycline 200 mg per day for 6 weeks is the mainstay of most medical treatment schedules. Combination with streptomycin for 3 weeks or rifampicin for 6 weeks is recommended, to reduce significantly the failure and relapse rate. Spinal involvement is associated with an increased failure and relapse rate while they occurred least among those with no osteoarticular involvement. Surgical intervention to stabilize the spine and relieve neurological compression may become necessary. With the use of these various measures, the outlook for complete recovery is good.

Brucellosis of the spine

The spinal form of brucellosis is still a disabling disease in many countries outside North America and northern and central Europe. Fifteen consecutive cases of spinal brucellosis diagnosed and treated over a 20-year period were reviewed retrospectively. Six patients were farmers, while 10 patients had a history of ingestion of unpasteurized milk or other dairy products. A high index of suspicion is necessary for the diagnosis, since there are no pathognomonic signs or symptoms. Radiological assessment of the disease was reviewed and highlights in the differential diagnoses were stressed. The diagnosis was based on actual culture of Brucella bacilli in seven patients. The principal treatment of brucellosis of the spine is conservative, namely, immobilization and antimicrobial therapy. We have found both a combination of ofloxacin and rifampin and ofloxacin monotherapy efficient as the early regimens used in this series. Three patients had to undergo surgery, since a diagnosis could not be made in any other way.

Clinical course and prognosis of Brucella spondylitis

A multicentre prospective study of 593 patients with brucellosis, of whom 58 (9.7%) had spondylitis, was performed in order to evaluate the possible clinical, radiological and evolutionary differences in the different segments of the spinal column. Five of the patients with cervical spondylitis (71%) had compression of the medulla or roots, versus just two (11%) in the dorsal group and nine (21%) in the lumbar group (p less than 0.05). There were no other clinical, haematological or biochemical differences between the three spinal segments, and both the serological response and the percentage of positive blood cultures were also similar in the three groups. The patients with cervical and dorsal spondylitis had a significantly higher number of paravertebral and/or epidural masses than those with lumbar spondylitis (p less than 0.05). Seventy-one percent of the patients with cervical spondylitis made unsatisfactory progress, versus 11% and 5% of those in the dorsal and lumbar groups, respectively (p less than 0.05 and p less than 0.001). In conclusion, given the high incidence of paravertebral and/or epidural masses, the neurological involvement, and the high rate of important functional disabilities, cervical spondylitis should be considered to be a very severe complication of brucellosis, and its treatment and follow-up must therefore be energetic and rigorous in order to detect and correct as early as possible compressions of the neural axis and its roots.