Childhood brucellosis in Babol, Iran

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.

Brucellosis: A Rare Cause of Febrile Neutropenia in a Child

We report a case of brucellosis-induced severe neutropenia in a 2-year-old girl who presented with a 2-week history of fever. On clinical examination, the patient was febrile with mild aphthous stomatitis. However, her general condition was stable, and systemic examination did not show involvement of any other organ. Laboratory test results revealed severe neutropenia, mild anemia, and an elevated serum C-reactive protein level. Flow cytometry of peripheral blood leukocytes revealed no malignancy, and blood film morphology was unremarkable except for mild microcytosis and hypochromia. Antineutrophil antibody and Coombs test results were negative. We administered intravenous cefuroxime; however, therapy was switched to meropenem plus clarithromycin because fever persisted for 5 days, despite treatment. On the 10th day after admission, Brucella serology tests showed positive results, and trimethoprim-sulfamethoxazole plus rifampicin therapy was prescribed for 8 weeks. The fever defervesced, and the child was discharged in a good state of health. Neutropenia persisted for several months but gradually resolved. Neutropenia, defined as an absolute neutrophil count (ANC) < 1.5 cells × 10 9 /L beyond the first year of life, is a benign transient condition associated with an intercurrent infection (usually viral illnesses or infections) in immunocompetent children. However, severe neutropenia (ANC < 0.5 × 10 9 /L) associated with fever necessitates hospitalization and administration of broad-spectrum antibiotics to avoid the high risk of sepsis, particularly in children. Brucellosis is rarely associated with hematologic abnormalities such as neutropenia. Early diagnosis of hematologic complications of brucellosis is essential for prompt initiation of specific and aggressive treatment.

Osteoarticular manifestations of human brucellosis: A review

Brucellosis is a common global zoonotic disease, which is responsible for a range of clinical manifestations. Fever, sweating and musculoskeletal pains are observed in most patients. The most frequent complication of brucellosis is osteoarticular involvement, with 10% to 85% of patients affected. The sacroiliac (up to 80%) and spinal joints (up to 54%) are the most common affected sites. Spondylitis and spondylodiscitis are the most frequent complications of brucellar spinal involvement. Peripheral arthritis, osteomyelitis, discitis, bursitis and tenosynovitis are other osteoarticular manifestations, but with a lower prevalence. Spinal brucellosis has two forms: focal and diffuse. Epidural abscess is a rare complication of spinal brucellosis but can lead to permanent neurological deficits or even death if not treated promptly. Spondylodiscitis is the most severe form of osteoarticular involvement by brucellosis, and can have single- or multi-focal involvement. Early and appropriate diagnosis and treatment of the disease is important in order to have a successful management of the patients with osteoarticular brucellosis. Brucellosis should be considered as a differential diagnosis for sciatic and back pain, especially in endemic regions. Patients with septic arthritis living in endemic areas also need to be evaluated in terms of brucellosis. Physical examination, laboratory tests and imaging techniques are needed to diagnose the disease. Radiography, computed tomography, magnetic resonance imaging (MRI) and bone scintigraphy are imaging techniques for the diagnosis of osteoarticular brucellosis. MRI is helpful to differentiate between pyogenic spondylitis and brucellar spondylitis. Drug medications (antibiotics) and surgery are the only two options for the treatment and cure of osteoarticular brucellosis.

A systematic review and meta-analysis of the prevalence of osteoarticular brucellosis

BACKGROUND

Infection of bones and joints remains one of the most commonly described complications of brucellosis in humans and is predominantly reported in all ages and sexes in high-risk regions, such as the Middle East, Asia, South and Central America, and Africa. We aimed to systematically review the literature and perform a meta-analysis to estimate the global prevalence of osteoarticular brucellosis (OAB).

METHODOLOGY

Major bibliographic databases were searched using keywords and suitable combinations. All studies reporting the incidence and clinical manifestations of osteoarticular brucellosis in humans, and demonstrated by two or more diagnostic methods (bacteriological, molecular, serological, and/or radiographic) were included. Random model was used, and statistical significance was set at 0.05.

PRINCIPAL FINDINGS

A total of 56 studies met the inclusion criteria and were included in the systematic review and meta-analysis. There was an evidence of geographical variation in the prevalence of osteoarticular disease with estimates ranging from 27% in low-risk regions to 36% in high-risk regions. However, the difference was not significant. Thus, brucellosis patients have at least a 27% chance of developing osteoarticular disease.

CONCLUSIONS

The prevalence of OAB is not dependent on the endemicity of brucellosis in a particular region. Hence, further research should investigate the potential mechanisms of OAB, as well as the influence of age, gender, and other socioeconomic factor variations in its global prevalence, as this may provide insight into associated exposure risks and management of the disease.

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

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

Epidemiological and Clinical Features of People with Malta Fever in Iran: A Systematic Review and Meta-Analysis

Objectives

Numerous studies have reported the epidemiological and clinical features of Malta fever incidence in Iran. Review and synthesis of the related literature through meta-analysis can provide an appropriate measurement for aforementioned indices. Therefore, the present study aimed to determine the epidemiological and clinical features of people with Malta fever in Iran.

Methods

The required documents were obtained through searching national and international databases. In each study, standard deviation of the indices was calculated using binomial distribution formulas. Finally, the heterogeneity index was determined between studies using Cochran (Q) and I² tests.

Results

Combining the results of 47 articles in the meta-analysis indicated that 57.6% (55.02–60.1%) and 42.3% (49.8–44.9%) of the patients were male and female, respectively. Most of the patients lived in rural areas; 68.4% (63.6–73.2%) compared to 31.4% (26.7–36.3%). In addition, 20.8% (17.4–24.2%) of the patients were ranchers and farmers, 16.9% (14.5–19.4%) were students, and 31.6% (27–36.2%) were housewives. Of the patients studies, 50.5% (35.6–65.2%) experienced contact with animals and 57.1% (46.4–67.9%) used unpasteurized dairy products. Fever, joint pain, and sweating were detected among 65.7% (53.7–77.8%) and 55.3% (44.4–66.2%), respectively.

Conclusion

The present study revealed that the frequency of male patients with brucellosis was considerably more than that of female patients. The number of patients with Malta fever in rural areas was significantly more than in urban areas. High-risk behavior, unprotected contact with animals, and using unpasteurized dairy products were among the most significant factors affecting Malta fever incidence in Iran. Fever, joint pain, and sweating were detected among most of the patients with Malta fever.

Brucellosis Suspicion is the Most Important Criterion for Diagnosis Particularly in Endemic Regions

Introduction:

Brucellosis is a zoonotic infectious disease that remains endemic in developing countries. The purpose of this study is to emphasize the need for considering brucellosis as a diagnosis, since this disease has a high risk of complications among young patients when not treated appropriately.

Methodology:

A total of 88 brucellosis cases with blood cultures that were positive for the pathogen were evaluated retrospectively in this study.

Results:

The patients included 33 males (37.5%) and 55 females (62.5%) with a median age of 8.9 years (range: 5-14 years). A total of 43.1% (n=38) of the cases included occupational exposure to animals as a possible infection source. The consumption of raw milk products, especially cheese, was present in 52.2% (n=46) of the cases. Clinically, 55 of the cases were acute (62.5%), 23 of the cases were subacute (26.2%) and 10 of the cases were chronic (11.3%). The distribution of the joint pain complaints was as follows: 62.5% (n=55) of patients reported hip pain, 22.7% (n=20) of patients reported knee pain, 11.4% (n=10) of patients reported lumbar-back pain and 3.4% (n=3) of patients reported pain in other joints. A total of 59.1% (n=52) of the cases had been examined by another doctor at least once and mistreated.

Conclusion:

Complication rates and the rate of chronic infection increase with delayed diagnosis, and clinical doubt is the most important criterion for diagnosis, particularly in endemic regions.

Hematological findings in children with brucellosis

BACKGROUND

Brucellosis produces a variety of non-specific hematological abnormalities. The aim of the present study was to evaluate the hematological findings in childhood brucellosis.

METHODS

Medical records of children with brucellosis admitted to a tertiary hospital in a 1 year period, were analyzed retrospectively.

RESULTS

Sixty-nine patients (mean age, 14.5 ± 3.3 years) were diagnosed with brucellosis. The most common hematological finding was thrombocytopenia (n = 11, 15.9%). Thrombocytosis was detected in five patients (7.3%), leukopenia in four (5.8%), anemia in three (4.3%), and bicytopenia in three (4.3%). None of the patients had pancytopenia. Blood culture was positive for Brucella spp. in 41 patients (59.4%). Among those patients with positive blood culture, six (14.6%) had serum agglutination test titer ≤1/80. Platelet (PLT) count was significantly lower in the bacteremia-positive group. The OR (95%CI) of bacteremia for PLT cut-off 200,000/mm(3) was 0.148 (95%CI: 0.031-0.718) and relative risk was 1.718 (95%CI: 1.244-2.372; P = 0.010).

CONCLUSIONS

Brucellosis should be kept in mind in the differential diagnosis of isolated thrombocytopenia in pediatric patients from endemic areas.

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

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

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.

Epidemiological and clinical features of Brucella arthritis in 24 children

BACKGROUND AND OBJECTIVES

Brucellosis is considered the leading zoonotic disease of the Middle East. The disease has a wide spectrum of clinical manifestations and can result in complications with severe morbidity. The aim of this study was to evaluate the frequency, distribution and characteristics of arthritis in Iranian children with brucellosis.

DESIGN AND SETTING

A retrospective descriptive study conducted in a referral children center in Tehran from 1997 to 2005.

PATIENTS AND METHODS

Arthritis in children with brucellosis who were admitted to a specialized hospital was detected by clinical signs of the involved joint(s) and characteristics of joint fluid aspiration. Socio-demographic information was recorded.

RESULTS

Of 96 patients diagnosed with brucellosis, 24 (25%) had Brucella arthritis 14 (58.3%) males and 10 (41.7%) females. Most common manifestations were fever in 21 patients (87.5%) and fatigue in 18 patients (75%). Monoarthritis was recorded in 15 patients (62.5%) of the cases with involvement of the knee in 8 (45%) and hip in 5 (29%), the ankle in 2 (8%) patients while 9 (37.5%) patients suffered from polyarthritis. None of the patients had axial joints involvement. Seventy-five percent of the subjects (18 patients) were from urban areas and 66.7% (16 patients) had consumed un-pasteurized cheese. Recurrence was not seen in any of the 24 patients who received a combination of co-trimoxazole for 6 weeks and gentamicin for 5 days.

CONCLUSION

Childhood brucellosis is a challenging disease in Iran that has serious complications like arthritis. Therefore all physicians who work in endemic areas should be familiar with this disease and consider the possibility of brucellosis in all children who present with arthritis and arthralgia.

Brucellosis serology in HIV-infected patients

BACKGROUND

An accelerated evolution of HIV to AIDS has been reported with brucellosis co-infection. The seroprevalence of brucellosis co-infection with HIV has not been investigated in a brucellosis endemic country like Iran.

METHODS

We performed a cross-sectional survey of brucellosis serology in HIV-infected patients attending a university hospital, as well as in healthy controls. A total of 90 HIV-positive patients and 100 healthy age-matched controls were recruited. The clinical characteristics, hemoglobin, and red blood cell, platelet, white blood cell, and CD4+ T cell counts were evaluated.

RESULTS

Positive brucellosis serology was significantly higher in HIV-infected patients than in controls (73.3% vs. 30%, respectively, odds ratio 6.42, p<0.001). It was also higher in males than females, p=0.001. Brucellosis-infected patients had significantly lower hemoglobin and white blood cell counts compared with brucellosis-uninfected patients (p<0.001). In HIV-positive patients, white blood cell count was significantly lower in brucellosis-infected than brucellosis-uninfected patients (p<0.05).

CONCLUSIONS

Our findings show that brucellosis infection is an important infection in HIV-infected patients. The treatment of brucellosis may be of great clinical importance in the management of HIV infection in a brucellosis endemic country like Iran.

Presentation, complications, and treatment outcome of brucellosis in Turkish children

BACKGROUND

Brucellosis constitutes a public health problem in Turkey. In endemic Brucella melitensis areas such as Turkey, children represent 20-25% of cases.

METHODS

Hospital records of 90 children with brucellosis admitted during a 9 year period, 1997-2006, were evaluated retrospectively.

RESULTS

Of 90 patients, 27 (30%) were female and 63 (70%) were male (P < 0.05). Patients were aged between 1 and 16 years of age. The mean age was 9.02 +/- 3.59 years. Fifty-two patients (57.8%) were from rural areas of Turkey. The mode of transmission was consumption of unpasteurized milk and milk products in 64 patients (71.1%). Parents of 41 patients (45.6%) worked in animal breeding. A positive family history for brucellosis was noted in 14 patients (15.6%). The most frequently involved joint with arthralgia was the knee joint. Arthritis was found in six patients (6.7%), and five of the six had monoarthritis. Serum agglutination test was >or=1/160 in 82 patients (91.1%). The joint symptoms rapidly responded to the treatment and the majority of the patients had significant improvement. The duration of treatment was 6 weeks in 81 patients (90%). Six patients experienced relapse. Four patients presented with complications that included neurobrucellosis, discitis and sclerosis of the hip joint.

CONCLUSIONS

Treatment of childhood brucellosis with co-trimoxazole + rifampicin or doxycycline + rifampicin, according to patient age, is effective and has low relapse rates. Complications and relapse were successfully treated with triple-drug regimens with a low sequelae rate.

Epidemiology and antibacterial susceptibility patterns of bloodstream infections, 2001-2004: an experience with BACTEC 9240 in Southern Iran

This study was conducted to determine the prevalence of bacteria recovered from bloodstream samples by Bactec 9240 at our hospital wards and to evaluate their antibacterial susceptibility patterns. During January 2001 through December 2004, 9407 referred blood samples in Bactec bottles from admitted patients at three main wards, neonates, pediatrics and adults at Nemazee Hospital, affiliated to Shiraz University of Medical Sciences in Shiraz were processed. Positive cultures were purified and identified according to standard methods. Sensitivity of bacteria to different antibiotics was determined by Kirby-Bauer disk diffusion method. Staphylococcus aureus 132(25%), Escherichia coli 64(12.1%) and Pseudomonas aeruginosa 52(9.8%) were the most pathogenic bacteria which were recovered from the blood samples. Pathogenic microorganisms were isolated from blood samples of 305 (57.8%) at pediatrics, from 181 (34.2%) at adults and from 42 (8%) at neonates wards. The highest antibiotics activities against gram positive isolates observed for vancomycin (98.4%), chloramphenicol (86.4%) and ciprofloxacin (77.4%), while in gram negative bacteria imipenem (96.1%), ciprofloxacin (83%) and amikacin (77.9%), were effective antibiotics. Frequency of isolated bacteria at pediatrics compared to adults and neonates wards were approximately two and seven folds high, respectively which indicates special attention should be paid to pediatrics patients both in prevention and treatment aspects. Vancomycin and imipenim are the effective antibiotics and could cover majority of gram positive and negative bacteria. Therefore, combined administrations of these antibiotics seems mandatory for empirical therapy.