Discussion
In this article, we reported a 42-year-old woman who had no history of
livestock contact, sternoclavicular joint or left breast trauma, and
also there were not any risk factors of sternoclavicular arthritis such
as intravenous drug use, distant site of infection, diabetes mellitus,
trauma, and infected central venous line. She had experienced purulent
discharge from the left breast and underwent left breast abscess
drainage and antibiotic treatment on an outpatient basis one and a half
months before hospitalization, but there was no improvement so
occasional discharge continued following abscess evacuation.
Furthermore, two weeks before admission, pain and redness, and swelling
of the left sternoclavicular joint were added. So she was hospitalized
with the diagnosis of acute left sternoclavicular arthritis for further
examination. MRI showed signs of left sternoclavicular arthritis. In
addition, laboratory tests that were performed to rule out causes of
arthritis, including rheumatoid arthritis and systemic lupus
erythematosus, all were negative [2]. Since brucellosis is one of
the causes of arthritis in endemic areas, blood culture and serology of
brucellosis were requested. Blood culture × 2 was reported positive for
brucellosis and Wright agglutination test:1/160, Coombs Wright test:
1/320, 2-mercaptoethanol (2ME): 1/80 in favor of brucellosis
[5,10,11]. According to the patient’s complaint about purulent
discharge from the left breast and history of abscess drainage one and a
half months ago, at the same time as we were performing diagnostic tests
for left sternoclavicular arthritis, a breasts ultrasound was performed
which showed a fibrocystic change of both breasts and a mass in the left
breast then she underwent left breast abscess biopsy. The results of
pathology and immunohistochemistry (IHC) were not in favor of
malignancy. Breast abscess culture was reported as having few colonies
of coagulase-negative staphylococcus which is considered as
contamination because she did not have a fever, leukocytosis and other
systemic signs also colony count was low.
Breast abscess due to brucellosis is extremely rare. So to rule out
endocarditis and its metastatic abscess [11] to the breast and a
sternoclavicular joint, transthoracic echocardiography was performed and
its result was normal, without any vegetation or valve abnormality.
Fever, chills, sweating, fatigue, headache, splenomegaly, hepatomegaly,
arthralgia and musculoskeletal pain, which are seen in most patients
with generalized and localized brucellosis [1,5,11], were not
present in our patient and she also had no other positive findings
except left sternoclavicular arthritis and left breast abscess.
As reported in other studies, there were no specific hematological or
biochemical findings in our case [2,11,12]. There was no
leukocytosis in this patient and liver function tests were normal but
ESR and CRP were high.
As Since the diagnosis of brucellosis arthritis is confirmed by signs
and symptoms of arthritis (pain, tenderness, swelling of the
joint)[17,18] in the presence of an antibody titer greater than
1:160 in the tube agglutination test or by a positive culture
[10,11], brucellosis was diagnosed in our patient and considering
two very rare complications of brucellosis: left sternoclavicular
arthritis and left bursal abscess both simultaneously in this patient
due to the lack of history of trauma and external inoculation and
because she had no history of direct contact with livestock, we
concluded that these complications are hematogenous. Therefore, with the
diagnosis of localized brucellosis, which requires a combination of
antibiotics and a prolonged course of treatment to prevent failure or
relapse of brucellosis [2,10,11], the patient was treated with a
standard regimen (streptomycin and doxycycline for two weeks, then
rifampin and doxycycline for ten weeks). On the fourth day of treatment,
she responded and the joint symptoms improved significantly the
discharge from the patient’s left breast was stopped after starting the
treatment and she was discharged and recommended to continue the
outpatient treatment and follow-up. The prognosis of brucella arthritis
will be very good if appropriate and in time treatment is begun
[12,19]. Unlike spondylitis, both sacroiliitis and peripheral
arthritis are nondestructive and quickly curable with no sequelae
[2,12].
Thirty days after discharge at the follow-up visit, the patient did not
relate a feeling of stiffness or heaviness in the left breast and
occasional discharge from it which she had previously experienced, and
also left sternoclavicular arthritis completely was cured. She completed
treatment of two localized complications of brucellosis simultaneously
(sternoclavicular arthritis and left breast abscess) without any
complications.
Each of the complications of sternoclavicular arthritis and Brest
abscess due to brucellosis is solely a very rare complication of
brucellosis. However, we found both of these rare complications
simultaneously in one patient. Then, we could successfully treat her
using the standard treatment of streptomycin and doxycycline for two
weeks followed by rifampin and doxycycline for ten weeks.
Given that brucellosis is a thousand-face disease, especially in endemic
areas, clinicians in all regions of the world, especially endemic areas
should be familiar with rare complications of it so we reported this
patient with very rare complications of this zoonotic disease and its
successful treatment.