Vol 43 # 3 September 2011 - Kma.org.kw

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Complications of Brucellosis in Adults: An Experience from a State Hospital ...
September 2011
The clinical manifestation of brucellosis is very
great, ranging from asymptomatic infection to serious
debilitating disease. Organ involvement can be
assigned as focal involvement or as a complication. For
the most part, brucellosis is a systemic infection that
can involve any organ of the body [1] . The most common
systems affected are the locomotor, gastrointestinal,
genitourinary, hematologic, cardiovascular, respiratory,
and central nervous systems [5,6] . Symptoms are nonspecific
and may include fever, arthralgia, myalgia,
chills, sweats, headache, and fatigue [14] . However,
routine laboratory data reported in most studies have
been of little diagnostic value [3,12] .
Complications of brucellosis are a major medical
problem in countries where brucellosis is still
endemic, as in our region of southeastern Anatolia in
Turkey. Osteoarticular involvement with a prevalence
varying from 5.2 to 69% is the most common frequent
complication of brucellosis [3,4,10,11,15-18] . The enormous
range between reports in the literature may be
due to characteristics of the study populations, the
radio-diagnostic methods used, and the different
diagnostic criteria employed. Brucellosis may also
affect the musculoskeletal system at any site [4,14] . We
observed osteoarticular involvement in 33.8% of 78
patients. As can be seen in Table 3, we found that
the most commonly affected site was the sacroiliac
joint, a finding in agreement with those recently
reported by some authors [10, 11,18,19] . In this study,
unilateral sacroiliitis (n = 8, 72%) was very common
and it is similar to that reported by Geyik et al [14] and
Calmenero et al [20] . However, Tasova et al [21] found
a high rate of bilateral sacroiliitis (60%). Peripheral
arthritis, especially presenting as monoarthritis, is the
predominant involvement in some brucellosis series,
and large joints such as the hips, knees and ankles
are the most frequently affected [3,19,20] . In this study,
peripheral arthritis was the second most frequent type
of osteoarticular involvement, although the rate (34.6%)
was higher than the Calmenero et al study(12%) [20] . On
the other hand, the incidence of spondylitis reported
in the literature varies significantly, ranging from 6%
to greater than 50% [3,20,21] . In the present study, the rate
of spondylitis was 7.8%.
Hematological alterations in brucellosis are
common, but they rarely constitute a true complication
and resolve promptly with treatment [3] . The
hematological manifestations of brucellosis include
anemia, leucopenia, thrombocytopenia and clotting
disorders [8] . Anemia in patients with brucellosis results
from alteration in iron metabolism secondary to
infection, hypersplenism, bleeding, and bone marrow
suppression or autoimmune hemolysis [22] . The incidence
of anemia has been reported as 44 to 74% in adult series
in brucellosis [8,23] . This ratio was 55%, 56% and 54.6%
cases in studies by Akdeniz et al [24] , Dilek et al [8] and
Aygen et al [23] respectively. In our group, incidence of
anemia was 44.2% and it is similar to the other studies.
Earlier literature has emphasized the characteristic
picture of a normal or reduced leukocyte count with
relative or absolute lymphocytosis in patients with
brucellosis [8, 22] . Leukopenia has been found to occur in
30 - 68% of the reported cases [22] . In this study, 80% of
the patients had a normal leukocyte count and 14.3%
has leucopenia. Leucopenia was detected 7.7%, 16%
and 52% cases in the Aygen et al [23] , Gur et al [3] and Dilek
et al [8] studies, respectively. The cause of leucopenia
seems to be multifactorial. Thrombocytopenia is less
common, having been reported in only 1 - 8% of cases,
and it is rarely severe enough to cause bleeding [18] .
Although the mechanism of the thrombocytopenia
in brucellosis is not yet entirely known, it may be
hypersplenism, bone marrow suppression due to
septicemia, hemophagocytosis, granulomas and
peripheral immune destruction of thrombocytes [8] .
Thrombocytopenia was detected in 33.8% of patients
in this study and it is higher than reported by Akdeniz
et al [24] (26%) and Dilek et al [8] (14%). Pancytopenia has
been described as between 3 - 21% in patients with
brucellosis in the published series [8,22] . In this study, the
incidence of pancytopenia was 2.6% and it is similar to
that reported by Ertek et al[ 18] and Gur et al [3] . On the
other hand, Sarı et al [25] reported the rate as 14.9%.
In the present study, cutaneous complications
were the third most frequent (3.9%). Cutaneous
lesions occur in approximately 1 - 17% of patients
with brucellosis [3,4,10,11,15-18] . Patients exhibit non-specific
skin symptoms, such as erythema, papules, petechiae,
urticaria, impetigo, eczematous rash, erythema
nodosum, subcutaneous abscess, and cutaneous
vasculitis [5] . Cutaneous findings in this study were
similar to other reported studies [18,26,27] . It is important
to emphasize that cutaneous lesions are not specific
to brucellosis and may be seen in a variety of other
dermatologic diseases caused by many agents.
Genitourinary involvement occurs in 2 - 40% of
patients with brucellosis [3] . In this study, 2.6% (n = 2,
epididymo-orchitis and abortion) out of 78 patients
had genitourinary complications. In men, various
genitourinary infections including epididymo-orchitis,
prostatitis, cystitis, pyelonephritis, interstitial nephritis,
exudative glomerulonephritis, renal and testicular
abscess, and seminal vasculitis have been attributed
to brucellosis [6] . The most frequent genitourinary
complication of brucellosis is epididymo-orchitis,
affecting 2 - 20% of males with brucellosis [6, 28] .
Although the prognosis of brucellar epididymoorchitis,
as in our patient, is usually good, delay in
diagnosis or inappropriate management may result
in serious complication, such as testicular abscess,
which may require orchiectomy [29] . It is well known
that the effect of Brucella infection on pregnancy is no