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.