DISCUSSION
One of the most widespread zoonotic diseases is brucellosis.(4) Dairy
(unpasteurized) products, diseased animals’ close contact, or the
products of an animal’s conception can all lead to infection. Rare
instances of mother-to-child transmission of brucellosis during
pregnancy and breastfeeding have been documented.(5) Because of its high
infectivity by inhalation, brucellosis has the potential to be used as a
biological weapon.(6)
Infections with B. melitensis continue to be an urgent public
health concern in Mediterranean nations, southern, central, and western
Asia, as well as certain portions of South and Central America, and many
African countries. More than 100/100,000 person-years have been
documented in the Middle East region, including Jordan, Iraq, and
KSA.(7, 8) Despite appearing to be on the decline in some regions of
Saudi Arabia, brucellosis is nevertheless an endemic disease, with
prevalence peaking in those between the ages of 40 and 49.(9)
Brucellosis patients frequently experience a variety of symptoms,
including splenomegaly, arthralgia, high fever, and malodorous
perspiration. In some situations, the onset may be gradual or there may
be a predominance of one organ over others (focal brucellosis). One of
the brucellosis symptoms that occurs most frequently is osteoarticular
involvement. There have been reports of peripheral arthritis,
spondylitis, sacroiliitis, bursitis, and osteomyelitis among other
conditions. The wrist and ankle tendons are the most frequently
affected, and tenosynovitis comparable to the first documented case in
1908.(10) In a relatively recent meta-analysis, 26% of the infected
individuals had arthritis, compared to 65% of patients with arthralgia.
Spondylitis and sacroiliitis were seen in 12 to 36% of individuals
overall.(11)
Especially in nonendemic locations, brucella arthritis diagnosis might
be difficult. In endemic locations, serology—often in conjunction with
conventional agglutination tests (SAT) is the mainstay of diagnosis.(8)
Blood cultures often require a long incubation period and have variable
sensitivity ranging from 53% to 90%. Blood cultures may come back
negative when the disease is limited to a single joint, so serology
continues to serve as the foundation for laboratory diagnosis. Despite
negative blood cultures, synovial fluid cultures can nonetheless be
positive.
Blood culture sensitivity has increased with the use of automated
systems, reaching up to 95%, while incubation times have decreased to
just 7 days, (93.3%, 14/15) BACTEC cultures, (75.0%, 6/8) isolator
cultures, and (57.1%, 4/7) conventional cultures all supported B.
melitensis growth.(12) Leukocyte counts in synovial fluid analysis
often show an exudative process with values between a few hundred and a
few thousand.(2)
Although the two can occasionally coexist, synovial fluid analysis aids
in differentiating crystal arthropathy from viral arthritis.(13)
Although these approaches have decreased incubation, a faster and more
accurate analysis is still required. Compared to conventional methods,
PCR has demonstrated great sensitivity and specificity, enabling quicker
and more accurate identification of the Brucella. However, because of
issues with standards, its use is still infrequent.(14) Recent study has
shown that MALDI-TOF MS is a simple, rapid, and highly accurate approach
for identifying brucella.(15)
Because monotherapy is associated with significant recurrence rates, a
two-drug combination is used. When compared to combination treatment,
monotherapy had more than double the probability of overall failure
(relative risk, 2.56).(16) The recommended course of treatment includes
doxycycline 100 mg twice daily for six weeks and injectable streptomycin
0.75–1 gm once a day for a maximum of 3 weeks. In cases of serious
brucellosis, triple therapy for a course lasting longer than 3 months is
advised. With a shorter period of fewer than six weeks, both treatment
failure (3.02, 1.03-8.80) and relapse (1.70, 1.19-2.44) were
substantially more frequent. Contrarily, the aminoglycoside/doxycycline
combination had a lower relapse rate than the combination of rifampicin
and doxycycline, especially in cases of osteoarticular disease.(16)
According to a meta-analysis, 5-7% of patients treated with
doxycycline-streptomycin and 11-17% with doxycycline-rifampin
experienced treatment failure or relapse.(8) The simultaneous
administration of rifampicin and doxycycline may have lowered the blood
level of the drug, which could be one explanation.(7) Rifampicin
resistance was not proven by molecular detection techniques or in vitro
susceptibility tests. Overall, this low success rate is more likely
attributable to poor compliance or a lack of time than to rifampicin
resistance. Except for co-trimoxazole, other drugs’ minimum inhibitory
concentrations remain reassuringly low. Notably, avoiding rifampicin
will eliminate the possibility of inducing resistance in tuberculosis in
regions where TB and brucellosis are both widespread, particularly when
TB is misdiagnosed as the underlying cause.
Compared to septic arthritis brought on by pyogenic organisms, B
melitensis patients experience modest joint inflammation, and erythema
of the overlying skin is rare.(10) Having said that, making a clinical
diagnosis based solely on local inflammatory symptoms may be
challenging. The most common sign of brucellosis that should notify a
doctor is a fever, which is typically undulant.