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Clinical study of childhood
brucellosis in Jordan Sami M Magableh MD
..........................................................................................................................
Hussein
A Bataineh MD
From the pediatric department at Prince Rashed
Hospital (PRH) 2006.
Address correspondence
to:
Dr Hussein Bataineh
PO Box: 260, Aidoun 21166, Irbid, Jordan
Tel: 00962777243881
Fax: 0096227100797
E-mail: Hussein_azzam@yahoo.com
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ABSTRACT
Objective:
The present study was carried out to
obtain the prevalence of childhood brucellosis
among patients attending the pediatric department
at PRH.
Material
and Methods: A total of 5726 blood specimens
(from children aged 14 years and younger)
were studied for the serological evidence
of brucellosis.
Results:
Ninety-three (1.6 per cent) showed diagnostic
agglutinin titres. Forty-three (59.7 per
cent) blood specimens yielded the growth
of Brucella melitensis. Thirty-nine patients
(41.93 per cent) were shepherds. More than
60 per cent of the patients had a history
of both consumption of fresh goat's milk
and close animal contact. Seventy-three
(78.49 per cent) were males and 20 (21.51
per cent) were females, with a male to female
ratio of 3:1. The disease occurred mainly
in the school age group (mean age 10.3 years).
All the patients had an acute history of
less than 2 months. Forty-nine (52.68 per
cent) patients presented with persistent
fever, 19 (20.43 per cent) with joint pain.
Pityriasis Alba was the consistent physical
finding, with fever in the majority of the
patients. The major joint found to be involved
was the knee (52.77 per cent). Eight patients
presented with complications. In 15 cases
(16.13 per cent) brucellosis was suspected
clinically whereas 78 (83.87 per cent) cases,
only serological evidence of brucellosis
confirmed the diagnosis. None of the cases
relapsed. In our experience an initial combination
therapy two-drug regimen for a minimum of
6 weeks was given.
Conclusion:
In our series, pediatric brucellosis
is quite common since this area is endemic
to B. melitensis where a strong clinical
suspicion or laboratory routine screening
has to be done to diagnose and institute
specific therapy.
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Key
words:
prevalence, brucellosis.
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Brucellosis
constitutes a major health and economic problem
in many parts of the world, including countries
of the Mediterranean Basin, the Middle East and
the Arabian Gulf.1, 2. It remains an uncontrolled
problem in regions of high endemicity such as
the Mediterranean, Middle East, Africa, Latin
America and parts of Asia.3, 4.
Humans
are infected accidentally by close animal contact
or consumption of animal products infected by
bacteria of the genus Brucella.5 Six species are
recognized, and four are well-established human
pathogens. Human infection can occur through consumption
of infected raw milk, raw milk products, or raw
meat.6 Other means of infection include skin abrasions
7 or inhalation of airborne animal manure particles.8
Brucellosis can affect any age including children.
The incidence of childhood brucellosis varies.
Some authors have concluded that brucellosis in
children is rare.9
Brucellosis is an endemic disease in Jordan as
evidenced by a marked increase in the number of
reported cases by the Jordanian Ministry of Health.10,
11
Brucellosis,
especially related to Brucella abortus is not
frequent in children.12 in endemic B. melitensis
areas; children represent 20-25 per cent of cases.13
The present study was carried out to obtain the
prevalence of childhood brucellosis among patients
attending PRH for clinical profile determination.
During
the period from August 1996 to September 2006,
all 5726 serum samples referred to the microbiology
laboratory were examined for evidence of brucellosis.
All the sera were screened for B. agglutinins
by slide agglutination test using B. abortus colored
antigen. The positive samples (97) found with
the slide method, were analysed further for the
levels of antibodies by standard tube agglutination
employing B. abortus-plain antigen. Of the 93
blood specimens' positive for diagnostic titres
(160), blood cultures were carried out in 72 cases.
The blood specimens were inoculated onto two Castaneda's
biphasic media consisting of trypticase soy agar
and broth. The media were incubated at 37°C
with and without CO2 for 1 month. The slide agglutination
test was performed using B. abortus and B. melitensis
monospecific antisera.
The
tube agglutination test, with the help of same
antisera, was also carried out wherever it was
indicated. The antisera were obtained from Murex
Biotech Ltd, Dartford, England.
The
synovial fluid and CSF specimens were also subjected
for B. agglutinins demonstration with both slide
and tube tests as mentioned above. Additional
specimens such as synovial fluid, CSF, and skin
were cultured using the above techniques. A detailed
clinical history including epidemiological features
and examination findings were recorded and analysed.
Of
the 5726 serum samples studied, 93 (1.6 per cent)
demonstrated B. agglutinins in diagnostic titres.
The titres ranged between 160 and 5120, (Table
1). Forty-three blood specimens (59 per cent)
grew B. melitensis; 42 were biotype 1 and one
isolate was biotype 3. Shepherds (39 patients)
were the major occupational group affected in
the present study. Of the 93 patients, 58 gave
a history of both animal contact and raw milk
ingestion. Males (73 patients) were predominant
in our study with a male to female ratio of 3:1
(Table 2). The major age group
affected was 11-14 years, followed by 6-10 years
(Table 2).
The
youngest age recorded with brucellosis was 33
months, a female child who had a history of raw
milk ingestion. The patients presented with fever,
joint pain, and low backache; fever being the
main presentation (Table 3).
One patient had involuntary movements of limbs
alone and one presented with burning feet only.
Pityriasis Alba was the consistent physical finding,
with fever in the majority of patients.
Hepatosplenomegaly
was noticed in 48 patients, splenomegaly alone
in nine, and hepatomegaly alone in five patients.
Single joint involvement was found in 29 patients,
the knee joint (19 patients) being the major joint
affected (Table 4). Successful
isolation of B. melitensis was possible in knee
joint synovial fluid of three out of five patients
attempted. Two joints were affected in four patients
and three patients showed involvement of three
joints.
Eight
patients presented with complications that included
papular skin lesions (3), carditis (2), chorea
(1), meningitis (1), and peripheral neuritis (1)
(Table 5).
The prevalence of brucellosis in the present study
was 1.6 per cent (93 children), which is much
higher than the reports of Spink5 and Cucullu.9
Pediatric
brucellosis is uncommon where B. abortus is endemic.12
However, in areas where B. melitensis is endemic,
pediatric cases are seen14-17 in endemic B. melitensis
areas, children represent 20-25 per cent of the
cases.13
In
the present study, 93 (19.1 per cent) children
out of 485 cases were diagnosed as having brucellosis
during a period from 1996 to 2006. This finding
is similar to the data obtained from the Middle
East countries, 14-17 although lower figures have
been quoted by Dalrymple-Champney 18 from England.
The high prevalence of childhood brucellosis in
the present series can be attributed to the endemicity
of this area for B. melitensis. The isolation
of only B. melitensis species supported this fact.
All the 73 patients, including 32 children with
brucellosis, were due to B. melitensis in Israel16
and B. melitensis remains the principal cause
of human brucellosis 19
The
vehicle of transmission in most of the cases in
the present study was the consumption of raw milk.
Like that based on the findings of our study,
we conclude that the main risk factor for brucellosis
is consumption of fresh, unpasteurized dairy produce.20
The
studies from Saudi Arabia, 21, 22 Iran, 23 and
Spain 24 report that raw milk ingestion is an
important factor in disease transmission. This
finding may also be the reason for our cases showing
predominance in school-aged children. These children
may consume raw milk while tending the flock in
their spare time. Children younger than 5 years
had the least infection, and this has also been
reported in literature.25-28
Human brucellosis usually manifests as an acute
or sub acute febrile illness, which may persist,
and progress to a chronically incapacitating disease
with severe complications.29 In the present study;
only 15 cases (16.13 per cent) were suspected
of having brucellosis, showing that the disease
awareness in an endemic area is important to arrive
at a clinical diagnosis like Al-Shamahy et al
in which: "If clinicians are made more aware
of the presenting features of brucellosis and
that it should come into the differential diagnosis
of fever associated with enlarged liver, spleen
and lymph nodes, it will lead to an increasing
index of suspicion for this infection".30
In the present series, 78 cases (83.87 per cent)
on admission were classified as enteric fever,
malaria, pyrexia of unknown origin, and rheumatoid
arthritis, showing the protean manifestations
of brucellosis and necessitating collaboration
between clinician and microbiologist even in endemic
areas for the diagnosis of brucellosis. So: Brucellosis
should be suspected and investigated for, in any
case of pyrexia of unknown origin.31
The
main clinical presentation of brucellosis in children
is fever, but the skeletal manifestations of the
disease are also significant.23 Fever was the
commonest complaint in the present study and it
is worth mentioning the joint pain, which was
the only complaint in 19 patients. Fever and pityriasis
Alba were a common association in the present
series as ; In a prospective study in Jordan,
fever (88%) was the most common clinical feature
encountered, followed by sweating, arthralgia
and general weakness. 32 and as that in Japan
in which: Fever, arthritis or arthralgia, hepatomegaly
and splenomegaly were the main findings.33
Monoarticular
arthritis of the knee is the most frequent reported
form, 14, 15, 34 which was observed in 19 patients
in the present series.
Skin
lesions are an uncommon feature of brucellosis.5,
35-38 All three patients with skin lesions in
the present series had papules. To our knowledge,
ours is the fourth report of bacteriologically
confirmed skin lesions in brucellosis in the world.
The skin lesions disappeared within 8-10 days
of the start of antibiotic therapy. Neurological
manifestations of brucellar origin although reported,
have not documented chorea as a symptom in the
world literature. One patient had brucellar chorea
that was successfully treated. Brucellar meningitis
reported in the present series received successful
treatment. Relapse was not recorded in any of
the cases. In our experience combination therapy
with a minimum of two drugs and extending treatment
for at least 6 weeks with two drugs seems warranted
to improve outcome and prevent relapses like in
Henk et al: The standard treatment of uncomplicated
cases in adults and children 8 years of age and
older is 100 mg doxycycline twice a day for 6
weeks plus 1 g. streptomycin daily for 2 to 3
weeks. Instead of streptomycin, rifampicin may
be given in combination with doxycycline (200
mg/day orally for 6 weeks) at a dose of 600-900
mg for 6 weeks.39 In our series, pediatric brucellosis
is quite common since this area is endemic to
B. melitensis where a strong clinical suspicion
or laboratory routine screening has to be done
to diagnose and institute specific therapy. Similar
to Issa H et al 1n 1999 in south of Jordan "Brucella
agglutination test and titer in association with
a suggestive clinical picture was more sensitive
than blood culture in the diagnosis of brucellosis".40
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Table 1. Antibody
profile and culture status
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Titre Number
positive Number culture done
Culture positive
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160
37
24 15
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320
23 19
08
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640
10
10 07
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1280
15
15 09
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2560
04 02
02
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5120
04
02 02
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Total
93
72 43
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Table
2. Age and sex distribution
of 93 patients
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Age
(years) Male
Female Total
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0–5
02 01
03
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6–10
24 08
32
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11–14
47 11
58
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Total
73 (78.49%) 20 (21.5%) 93
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Table
3. Clinical profile of 93
patients
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Clinical
presentation No.
of patients
% of patients
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Fever
49
52.68
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Joint
pain
19 20.43
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Fever,
joint pain & low backache
03 3.2
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Fever
and joint pain 14
15.05
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Fever
and low backache
06
06.43
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Jerky
movements of limbs 01
01.07
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Burning
feet
01
01.07
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Splenomegaly
09
09.67
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Hepatomegaly
05
05.37
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Hepatosplenomegaly 48
51.61
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Table
4. Involvement of joints
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Joint(s)
No. of patients %
of patients
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Knee 19
52.77
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Hip 07
19.4
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Shoulder 01
02.7
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Ankle 02
05.5
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Knee
and elbow 01
02.7
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Knee
and hip 03
8.3
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More
than 2 03
8.3
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Table
5. Complications of brucellosis
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| Complication
No. of patients |
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Skin lesions 03 |
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Carditis
02 |
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Chorea
01 |
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Meningitis
01 |
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Peripheral neuritis 01 |
| Total
08 |
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