case study of brucellosis presented with neck pain and upper limb weakness and discovered to have cervical spine abscess

1. INFECTIOUS DISEASE
A CASE STUDY

2. 22 year old male farmer developed neck pain and bilateral
upper extremity weakness for on month. He sought
medical advice with multiple providers, and was diagnosed
as cervicalgia.
He was given some analgesics and sent home

3. His symptoms progressed with the development of low
grade fever, generalized arthralgia, loss of weight, and
upper extremity weakness and parasthesias

4. HOW WILL YOU APPROACH?

5. History Examination Investigations Treatment

6. HISTORY ?

7. HISTORY
 22 y old farmer
 No special habits of medical importance
 No sexual relationships
 No contact with sick people recently
 No hx of travelling abroad
 There is contact with farm animals and used to drink unpasteurized milk

8. HISTORY
 The patient is not diabetic or HTN
 Not on any medications
 No hx of blood transfusion or surgical operations

9. HISTORY OF PRESENT ILLNESS
 The condition started one month ago with gradual onset and progressive
course of neck pain radiating to both arms
 The pain is shooting in nature, increases by neck movements and not
improving with analgesics associated with numbness and tingling in both
arms
 This was associated with weakness in his upper limbs
 There is night sweat, low-grade fever, weight loss, malaise and nausea
 No vomiting or abdominal pain
 No chest pain or SOB
 No other neurological symptoms

10. EXAMINATION ?

11. EXAMINATION
 Patient is Alert, conscious and oriented
 Normal complexion
 BP: 130/80
 Pulse: 70 regular
 Temperature : 37.5
 RR: 15
 Abdomen: soft, lax , palpated Lower liver border 2 fingers below the costal margin
 LL : unremarkable
 Local: neck tenderness at level of 5th cervical spine
 weakness in elbow flexion and wrist extension

12. INVESTIGATIONS?

13. LAB
 CBC normal except for plt 100
 RFT normal
 ALT 40, AST 40
 Bilirubin 20
 CRP 12, ESR 40
 HCV, HBV, HIV negative
 Blood, urine and sputum cultures negative

14. LAB
 Tuberculin negative
 Brucella Abortus Ab positive 1/320

15. IMAGING
 Normal CXR

16. MRI CERVICAL SPINE
 Inflammatory process at C4-C5 with
large significant intraspinal anterior
extranodal abscess (empyema)
measuring 4.9x0.9cm compressing
cervical cord

17. A Case Of
Brucellosis
With Cervical Spine Abscess

18. Treatment

19. TREATMENT
 C4-C5 anterior decompression, debridement and fusion was done
 intraoperative tissue cultures confirmed the diagnosis of Brucellosis
 The patient was started on ceftriaxone, doxycycline and rifampin for two
weeks post-operatively
 He made remarkable recovery and was discharged on triple therapy,
including doxycycline, ciprofloxacin and rifampin

20. brucellosis

21. BRUCELLOSIS
 Brucellosis is a zoonotic infection transmitted to humans by contact with
fluids from infected animals (sheep, cattle, goats, pigs, or other animals) or
derived food products such as unpasteurized milk and cheese
 It is one of the most widespread zoonoses worldwide and in Kuwait
 The incubation period is usually one to four weeks; occasionally, it may be
as long as several months
 Brucellosis is a systemic infection with a broad clinical spectrum, ranging
from asymptomatic disease to severe and/or fatal illness, and is hence
likened as a “Great Imitator”

22. BRUCELLOSIS
 Acute illness usually consists of the insidious onset of fever, night sweats,
arthralgia, myalgia, low back pain, and weight loss as well as weakness,
fatigue, malaise, headache, dizziness, depression, and anorexia
 A significant percentage of patients may have dyspepsia, abdominal pain,
and cough
 Localized infection occurs in about 30 percent of cases

23. BRUCELLOSIS
LOCALIZED INFECTION
brucellosis can affect any organ system (great imitator) :
 Osteoarticular involvement is the most common presentation
 Spondylitis is a serious complication of brucellosis
 Genitourinary involvement occurs in 2 to 20 % of cases; orchitis and/or
epididymitis are the most common. Less commonly prostatitis, cystitis, interstitial
nephritis, glomerulonephritis, and renal, testicular, or tubo-ovarian abscess
 Pulmonary involvement occurs in up to 7 % of patients: Bronchitis, interstitial
pneumonitis, lobar pneumonia, lung nodules, pleural effusion, hilar
lymphadenopathy, empyema, or abscesses
 Gastrointestinal involvement can present with clinical hepatitis (3 to 6 %), Rarely,
other manifestations include hepatic or splenic abscess, cholecystitis, pancreatitis,
ileitis, colitis, and spontaneous peritonitis

24. BRUCELLOSIS
LOCALIZED INFECTION
 Hematological abnormalities, including anemia, leukopenia, thrombocytopenia,
pancytopenia, and/or DIC, are relatively common
 Neurological involvement occurs in 2 to 7 % of cases. Manifestations include
meningitis (acute or chronic), encephalitis, myelitis, radiculitis, and/or neuritis
 cardiac involvement is relatively rare but may include endocarditis, myocarditis,
pericarditis, endarteritis, thrombophlebitis, and/or mycotic aneurysm of the aorta or
ventricles. Of these, endocarditis occurs most frequently (1 to 2 percent of cases) and
is the main cause of death due to brucellosis
 Ocular involvement most commonly presents with uveitis. Other manifestations
include keratoconjunctivitis, corneal ulcers, iridocyclitis, nummular keratitis,
choroiditis, optic neuritis, papilledema, and endophthalmitis
 Dermatologic manifestations occur in up to 10 % of patients. may include macular,
maculopapular, scarlatiniform, papulonodular, and erythema nodosum-like eruptions,
ulcerations, petechiae, purpura, granulomatous vasculitis, and abscesses

25. BRUCELLOSIS
 Relapse: The rate of relapse following treatment is about 5 to 15 percent. Relapse
usually occurs within the first six months following completion of treatment but
nay occur up to 12 months
 chronic brucellosis: refers to patients with clinical manifestations for more than
one year after the diagnosis of brucellosis.
 Chronic brucellosis is characterized by localized infection (generally spondylitis,
osteomyelitis, tissue abscesses, or uveitis) and/or relapse in patients with
objective evidence of infection (elevated antibody titers and/or recovery of
brucellae from blood or tissues).

26. BRUCELLOSIS INVESTIGATIONS
 The laboratory findings should be interpreted together with clinical
manifestations, exposure history, occupation, and history of past infection
 Laboratory tools for diagnosis of brucellosis include culture and serology.
Ideally, the diagnosis is made by culture of the organism from blood or other
sites, such as bone marrow or liver biopsy specimens
 PCR is a promising tool for rapid and accurate diagnosis of human brucellosis but
not yet routine
 Imaging: Patients with spine symptoms should undergo MRI examination to rule
out spinal cord compromise

27. BRUCELLOSIS PREVENTION
 Brucellosis may be prevented via
 vaccination, which is effective for cattle, sheep, and goats, but requires a
sustained vaccination program over several years.
 quarantine of herds and slaughter of infected animals.
 Pasteurization of milk

28. BRUCELLOSIS TREATMENT
 For adults with nonfocal disease, we suggest treatment with doxycycline and
rifampin. Dosing is doxycycline 100 mg orally twice daily plus rifampin 600 to 900
mg (15 mg/kg) orally once daily for six weeks.
 For adults with spondylitis, we suggest treatment with doxycycline and
streptomycin (Grade 2B). Dosing is doxycycline 100 mg orally twice daily for at
least 12 weeks, plus streptomycin 1 gram intramuscularly once daily for the first 14
to 21 days.
 For adults with neurobrucellosis, we suggest treatment with two or three drugs
that cross the blood-brain barrier such as doxycycline, rifampin, trimethoprim-
sulfamethoxazole (TMP-SMX), or ceftriaxone. The duration of therapy is generally
prolonged and needs to be individualized according to clinical signs and symptoms;
in general, it should be continued until cerebrospinal fluid parameters have
returned to normal.
 Most adults with Brucella endocarditis require valve replacement together with
a prolonged course of antimicrobial therapy. We suggest a combination of
doxycycline, rifampin, and an aminoglycoside
 For pregnant patients, we suggest treatment with rifampin, with or without TMP-
SMX.