Foreign-Body Osteoarticular Infection by Brucella melitensis: A Report of Three Cases

Abstract

rucellosis, a zoonosis, is an important cause of human disease in many parts of the world. Brucellae are small, gram-negative nonsporulating rods or coccobacilli that are transmitted from infected animals, mainly cattle and other domesticated ruminants (e.g., camels). Brucellae are shed in the feces, milk, and urine of infected animals and are transmitted to humans through the ingestion of contaminated dairy products or through the inhalation of aerosolized infected fecal particles. They can also be directly transmitted through wounds in exposed individuals such as farmers, veterinarians, and laboratory workers. Travelers usually acquire the infection after consuming contaminated foods. Dairy products, especially soft cheeses, unpasteurized milk, and ice cream, are the most frequently implicated sources. Various Brucella species can produce human disease, including Brucella melitensis, Brucella abortus, Brucella suis, and, rarely, Brucella canis. Brucella melitensis is, by far, the most common cause of human disease and is mainly acquired from sheep, goats, and camels. In Spain, where brucellosis is still present in some rural communities, 861 new cases were diagnosed in 2002 1 . Brucella melitensis was the main causative agent; Brucella abortus and Brucella suis rarely cause disease in swine and cattle in our environment.The most common clinical features of human brucellosis are undulant fever, sweats, arthromyalgias, lymphadenopathy, and hepatosplenomegaly 2 . Focal infection can be life-threatening when the heart or the central nervous system is involved. However, bone and joint infections are the most common localized sites and account for up to 85% of these cases 3,4 . Brucella melitensis infection around medical implants has rarely been described in patients with mechanical heart valves 5-13 , pacemakers 14 , and breast implants 15 .We describe the cases of three patients with Brucella melitensis infection around an orthopaedic medical implant, and we also briefly review the cases that have been reported previously.Case Reports ASE 1. A fifty-year-old man with a two-year history of progressive mechanical pain in the left hip was found to have aseptic necrosis of the femoral head. He had a history of intermittent fevers, each of which had lasted for two to three days and had been attributed to respiratory tract infection. The patient underwent total hip arthroplasty in April 1989. Macroscopic examination of the hip suggested an inflammatory process, and cultures of specimens from the synovium and capsule were positive for Brucella melitensis. Blood cultures were positive, as were the results of the rose bengal test, which is a qualitative test that rapidly identifies the presence of agglutinating antibodies in sera and has a high sensitivity and specificity. The patient also had very high titers of specific agglutinin antibodies with a high quantitative result (1:320). The erythrocyte sedimentation rate was 123 mm/hr. The patient had a history of working with cattle for more than two years prior to admission.

Infected Total Knee Arthroplasty by Brucella melitensis: A Rare Case Report

“…All patients who had been checked were strongly positive for Brucella specific serum tests. Nevertheless, this infection is very unusual in periprosthetic joint infection of the knee and only nine cases were reported in the literature (2,3,5,(17)(18)(19). In this case, if the authors had been aware of this infection, the serum indicators of brucellosis could have tested and the cultures incubated in a longer time period to detect the Brucella spp.…”

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

“…Until now, only 12 cases of joint arthroplasty infected by Brucella have been described in the literature; 5 in the hip and 7 in the knee [3,[5][6][7][22][23][24]. There was bilateral involvement of the knee prostheses in only one case [3].…”

“…The growth of Brucella was shown by cultures obtained from the intraoperative sample (aspirate or drainage of the pus) only after prolonged incubation. Antibiotic treatment lasted from 6 weeks [23,25] to a maximum of 19 [7] or 26 months [6]: four patients were treated with a combination of three antibiotics (doxycycline, rifampicin and streptomycin) [5,6,24], three treated with a combination of doxycycline and streptomycin [6,22,23], four with doxycycline and rifampicin [7] and only one with rifampicin and cotrimoxazole [3]. In six cases out of thirteen (46%) the infection resolved with the sole use of antibiotic therapy without having to resort to surgical revision [3,5,6,23].…”

“…In one case it was necessary to remove the prosthetic implant followed by prolonged antibiotic therapy [22]. Only one case underwent prosthetic revision in a single stage, but only because the infection had not been suspected from the beginning [6]. In the remaining five cases a two-stage prosthetic revision was performed [6,7,24].…”

“…[3][4][5] is extremely rare. In the literature there are only 12 cases of total joint arthroplasty (7 knees and 5 hips) infected by Brucella [6].…”