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Clinical
study of childhood brucellosis in Jordan
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Sami M
Magableh MD
Hussein A Bataineh MD
From the pediatric department at Prince
Rashed Hospital (PRH) 2006.
Dr Hussein Bataineh
PO Box: 260, Aidoun 21166, Irbid,
Jordan
Tel: 00962777243881 Fax: 0096227100797
Email: 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.
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.
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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 |
Skin lesions 03 |
Carditis
02 |
Chorea
01 |
Meningitis
01 |
Peripheral neuritis 01 |
Total
08 |
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1.
Matyas Z, Fujikura T. Brucellosis as a world
problem. Dev Biol Stand 1984; 56:3-20.
2. Al-Eissa YA, Kambal AM, Al-Rabeeah AA,
Abdullah AM, Al-Jurayyan NA, Al- Jishi NM.
Osteoarticular brucellosis in children. Ann
Rheum Dis 1990; 49:896-900.
3. Corbel MJ. Brucellosis: an overview. Emerg
Infect Dis 1997; 3: 213-21.
4. Refai M. Incidence and control of brucellosis
in the Near East region. Vet Microbiol 2002;
90: 81-110.
5. Spink WW. The Nature of Brucellosis. Minnesota
University Press, Minnesota, 1956.
6. Foley BB, Clay MMO, Sullivan DJ.A study
of brucellosis epidemic. Irish J Med Sci 1970;
3: 457-59.
7. Glass WI. Brucellosis as an occupational
disease in New Zealand.NZ Med J 1964; 63:
301-3.
8. Williams E. Brucellosis and the British
public. Lancet 1970; i: 1220-24.
9. Cucullu LM, De Arambaru FG, Daro DA. Sobre
UN caso de brucellosis en la infan. Arch Argent
de Pedia 1949; 31: 191.
10. Annual Reports of the Ministry of Health
in Jordan, 1976-1987. Amman, Jordan, Ministry
of Health, 1976-1987.
11. Annual Reports of the Ministry of Health
in Jordan, 1988-1994. Amman Jordan, Ministry
of Health, 1988-1994.
12. Hall WH. Modern chemotherapy for brucellosis
in humans. Rev Infect Dis 1990; 12: 1060-99.
13. Brurgio R. Brucellosis. In: Ginebra JD
(ed.), Tratado de las Enfermeda des Infecciosas
en la Infancia, Barcelona Editorial CientficoMedico
1962; Vol. II: 873-900.
14. Sharda DC, Lubani MM. A study of brucellosis
in childhood. Clinical Pediatr 1986; 25: 492-95.
15. Lubani MM, Dudin KI, Sharda DC, et al.
A multicentre therapeutic study of 1100 children
with brucellosis. Pediatr Infect Dis J 1989;
8: 75-8.
16. Yinnon AM, Morali GA, Goren A, et al.
Effect of age and duration of disease on the
clinical manifestations of brucellosis-A study
of 73 consecutive patients in Israel.Isr J
Med Sci 1993; 1: 11-16.
17. Tohme A, Hammoud A, el Rassi B, Germanos-Haddad
M, Ghayad E. Human brucellosis Retrospective
studies of 63 cases in Lebanon. Presse Med
2001; 30: 1339-43.
18. Dalrymple-Champneys SW. Undulant fever-neglected
problem.Lancet 1950; i: 429.
19. 1st International Conference on Emerging
Zoonoses Jerusalem, Israel. Brucellosis: An
Overview. Emerging Infectious Diseases 1997;
3:213-221.
20. Cetinkaya Z, Aktepe OC, Ciftci IH, Demirel
R.Seroprevalence of Human Brucellosis in a
RuralArea of Western Anatolia, Turkey. J HEALTH
POPUL NUTR 2005; 23(2):137-141.
21. Al-Eissa YA, Kambal AM, al-Nasser MN,
et al. Childhood brucellosis - a study of
102 cases. Pediatr Infect Dis J 1990; 2: 74-9.
22. El-Amin EO, George L, Kutty NK, et al.
Brucellosis in children of Dhofar region,
Oman. Saudi Med J 2001; 22(7): 610-15.
23. Makarem Eh, Karjoo RK, Omidi A. Frequency
of Brucella melitensis in southern Iran. Trop
Pediatr 1982; 28: 97.
24. Colmenro JD, Valdivielso P, Camp MI, et
al. Brucellosis: estudio clinico epidemiologico
de 139 casos. Med Clin (Barc) 1983; 80:748-751
25. Gotuzzo E,Carillo C,Seas C,et al.Caracteristicas
epidemiologicasy clinicas de la brucellosis
en 39 groups familiares.Rev Esp Enterm Infecc
Microbiol Clin1987;7:519-23.
26. Black RA. Brucella-melitensis meningitis
in an infant. Arch Pediatr 1937; 54: 702.
27. Hill OW, Monger RH. Undulant fever in
a child under 7 months of age. JAMA 1931;
97: 176.
28. Kohlbry CO. Case of undulant fever in
an infant. Minnesota Med 1929; 12: 414.
29. Smits HL, Kadri SM. Brucellosis in India:
a deceptive infectious disease. Indian J Med
Res; 2005:122:375-384
30. Al-Shamahy HA, Wright SG. Astudy of 235
cases of human brucellosis in Sana'a, Republic
of Yemen. Eastern Mediterranean Health Journal
2001; 7: 238-246.
31.Sachdev A, Vohra R, Bijarnia S. Acute Brucellosis
of Childhood:Acase Report with Unusual Features.Indian
Pediatrics 2001; 38: 1421-1425
32. Ajlouni YM, Shaker K. The diagnostic value
of various laboratory tests in human Brucellosis.
Journal of the Royal Medical Services 1997;
4(2):9-12.
33. Giannakopoulos I, Nikolakopoulou NM, Eliopoulou
M, Ellina A, Kolonitsiou F, Papanastasiou
DA. Presentation of childhood brucellosis
in Western Greece.Jpn J Infect Dis. 2006;
59(3):160-3.
34. Gotuzzo E, Carillo C. Brucella arthritis.
In: Espinoza L, Goldberg D, Arnett F, Alarcon
G (eds), Infections in theRheumatic Disease.
Grune and Stratton, Orlando, 1988.
35. Center for Disease Control. Brucellosis
Surveillance Annual Summary, 1975. Center
for Disease Control, Atlanta 1976.
36. Simpson WM. The clinical picture of undulant
fever. Ohio State Med J 1931; 27:21-7
37. Degoy A, Montenegro C, Clinica y evolutividad
de la brucellosis infantil por melitensis
en medio endemico. Rev Assoc Med Argent 1951;
65: 568-73.
38. Feiz J, Sabbaghian LT, Miralai M. Brucellosis
due to B. melitensis in children. Clin Pediatr
1978; 17: 904-7.
39. Henk L, Kadri SM. Brucellosis. Indian
Journal for the Practising Doctor 2004; 1:11-12.
40. Issa H, Jamal M. Brucellosis in children
in south Jordan. Eastern Mediterranean Health
Journal1999; 5:895-902.
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