B. BENJAMIN AND S. H. ANNOBIL
Childhood Brucellosis in Southwestern Saudi Arabia: a 5-year Experience by B. Benjamin, MD, MRCP and S. H. Annobil, MD, FRCP Department of Child Health, College of Medicine, King Saud University, PO Box 641, Abha, Saudi Arabia Summary
Introduction Brucellosis is a zoonosis of world-wide importance which is transmitted to man by contact with infected animals or the consumption of raw milk or other animal products. 1 Brucellosis has been reported to be endemic in the central and eastern desert regions of the kingdom of Saudi Arabia, 2 ' 3 and a recent report suggests that it is also common in the hilly Asir region of southwestern Saudi Arabia. 4 Though earlier reports gave the impression that brucellosis was uncommon in children,5 there is more recent evidence that it is an important childhood problem in the endemic areas of the Middle East. 6 " 9 We present our clinical experience with childhood brucellosis from Abha, the capital of Asir region of Saudi Arabia. Patients and Methods All children up to the age of 12 years admitted to Abha General and Asir Central hospitals at Abha over a 5-year period (August 1985 to July 1990) with proven brucellosis were studied prospectively. The diagnosis was based on the clinical presentation and confirmed by finding a significantly positive brucella antibody Journal of Tropical Pediatrics
Vol.38
August 1992
titre of 1:160 or above, 10 or the isolation of the organism from the blood. All patients had a complete history which included history of contact with animals and ingestion of raw milk or other animal products, and a complete physical examination. Serology was done using Rose Bengal plate and standard tube agglutination (STAT) tests. Brucella melitensis and abortus suspensions (Wellcome Diagnostics, England) and doubling dilutions from 1:80 to 1:1280 were used for the STAT. According to the availability of media, a single sample of blood was cultured in tryptic soy broth (Difco Laboratories, USA) in CO 2 under vacuum and subcultured weekly for 8 weeks. The strains were identified using thionin and basic fuchsin tests and slide agglutination with antisera (Difco Laboratories, USA). Other tests which were performed as indicated included complete blood counts, erythrocyte sedimentation rate, renal and hepatic profiles, urinalysis and routine urine culture, routine analysis and culture of the cerebrospinal fluid, and X-rays of the chest and skeleton. Other locally endemic diseases were excluded by appropriate tests. The patients were treated with oral co-trimoxazole, i Oxford University Press 1992
167
Downloaded from http://tropej.oxfordjournals.org/ at Carleton University on June 16, 2015
One-hundred-and-tifty-seven children admitted with brucellosis at Abha, Saudi Arabia, were studied prospectively. Ninety-two per cent gave a history of animal contact, usually with sheep or goats, or ingesting raw milk, milk products, or raw liver. Three-quarters of the patients had an acute or subacute presentation with diverse symptomatology: fever (100 per cent), malaise (91 per cent), anorexia (68 per cent), cough (20 per cent), abdominal symptoms (20 per cent), arthralgia (25 per cent). Hepatomegaly (31 per cent), splenomegaly (55 per cent), and lymphadenopathy (18 per cent) were common findings. Organ complications were rare except for arthritis (36 per cent) which usually presented as a peripheral oligoarthritis involving the hips and knees. All patients had significant agglutination titres; B. melitensis was grown from the blood in 7 of 16 (44 per cent) patients. Haematological variations were common, but non-specific: anaemia (64 per cent), thrombocytopenia (28 per cent), leucopenia (38 per cent), leucocytosis (12 per cent), and elevated erythrocyte sedimentation rate (81 per cent). Varying combinations of rifampicin, co-trimoxazole, tetracycline, and streptomycin resulted in a prompt pyrexial response (mean: 3.8 days), and a slower response in the arthropathy and hepatosplenomegaly. Relapses were related to poor compliance, use of a single drug or a shorter duration of chemotherapy. Brucellosis is a common childhood problem in southwestern Saudi Arabia as in other parts of the country and the Middle East. It should be considered in every child from an endemic area presenting with a febrile illness and a history of animal contact.
B. BENJAMIN AND S. H. ANNOBIL
50 40 30 24
I 20
-
,-, 15
'
18
18 !
,,1
1
16
12
11
10 _-
8
vmm
7 '
2
-1
-2
-3
-4
-5
Results A total of 157 children were identified with brucellosis over the 5-year period; 53 per cent of them were male. They constituted 2 per cent of all pediatric admissions. The age distribution (Fig. 1), showed the lowest incidence in the first year of life, the peak incidence in the second year and a lower frequency trend in older children over 7 years of age. Eighty-two per cent of the children were from the coastal Tihama plain, the remainder were from farms in the hills around Abha (elevation:7000 feet). One-hundred-and-forty-five patients (92 per cent) gave a history of direct contact with animals and 120 (76 per cent) gave a history of ingestion of raw milk or milk products such as soured mik or cheese, or of raw liver. Goats and sheep were the animals usually involved (n = 143); cattle (n = 2) or camels (n = 2) were only rarely so. Clinical features The main clinical features are summarized in Table 1. The presentation was acute (duration up to 7 days) in 16 per cent, subacute (8-30 days) in 60 per cent, and chronic (over 30 days) in the remaining 24 per cent of patients. A history of fever, often accompanied by chills or sweats, was invariably obtained. However, pyrexia was confirmed after admission in only 80 per cent. Other general symptoms such as anorexia, malaise, or weight loss were commonly noted as were various respiratory and abdominal symptoms. The liver and spleen were both enlarged in 44 cases; isolated splenomegaly was noted in a further 43
-9
-10
-11
-12
TABLE 1
Clinical features of childhood brucellosis Feature
Frequency
History of fever Documented pyrexia (>38°C) Malaise, fatigue Anorexia, weight loss Cough Abdominal symptoms (pain, vomiting, distension, constipation) Arthralgia Hepatomegaly (2-4 cm = 40, 5-6 cm = 9) Splenomegaly (1-3 cm = 53, 4-8 cm = 32, over 8 cm = 2) Lymphadenopathy (cervical = 20, axillary = 24, inguinal = 4)
157 (100%) 126 (80%) 143 (91%) 106 (68%) 32 (20%) 32 (20%) 40 (25%) 49 (31%) 87 (55%) 29 (18%)
patients and isolated hepatomegaly in only five children. Lymphnode enlargement usually involved the cervical and axillary groups, either alone or in combination. Complications The organ complications of brucellosis are summarized in Table 2. Arthropathy, the most frequent complication, usually involved the larger joints of the
TABLE 2
Organ involvement in childhood brucellosis Osteoarticular Genitourinary Pneumonitis Neurobrucellosis Hepatitis with jaundice
Journal of Tropical Pediatrics
57 (36%) 17(11%) 6 (4%) 2 (1.3%) 1 (0.6%)
Vol.38
August 1992
Downloaded from http://tropej.oxfordjournals.org/ at Carleton University on June 16, 2015
-6 -7 -8 Age (years) FIG. 1. Age distribution.
rifampicin or tetracycline, or parenteral streptomycin in various combinations for periods of 3-12 weeks and were followed up to check for clinical cure or relapses. The parents were instructed about the disease and its transmission, and advised against continued consumption of raw milk or its products.
168
9
B. BENJAMIN AND S. H. ANNOBIL
TABLE 3 Laboratory results in childhood brucellosis
Hb (g/D >110 90-109 70-89 10 5-10 400 15CMW0 100-149 50-99
Childhood Brucellosis in Southwestern Saudi Arabia: a 5-year Experience by B. Benjamin, MD, MRCP and S. H. Annobil, MD, FRCP Department of Child Health, College of Medicine, King Saud University, PO Box 641, Abha, Saudi Arabia Summary
Introduction Brucellosis is a zoonosis of world-wide importance which is transmitted to man by contact with infected animals or the consumption of raw milk or other animal products. 1 Brucellosis has been reported to be endemic in the central and eastern desert regions of the kingdom of Saudi Arabia, 2 ' 3 and a recent report suggests that it is also common in the hilly Asir region of southwestern Saudi Arabia. 4 Though earlier reports gave the impression that brucellosis was uncommon in children,5 there is more recent evidence that it is an important childhood problem in the endemic areas of the Middle East. 6 " 9 We present our clinical experience with childhood brucellosis from Abha, the capital of Asir region of Saudi Arabia. Patients and Methods All children up to the age of 12 years admitted to Abha General and Asir Central hospitals at Abha over a 5-year period (August 1985 to July 1990) with proven brucellosis were studied prospectively. The diagnosis was based on the clinical presentation and confirmed by finding a significantly positive brucella antibody Journal of Tropical Pediatrics
Vol.38
August 1992
titre of 1:160 or above, 10 or the isolation of the organism from the blood. All patients had a complete history which included history of contact with animals and ingestion of raw milk or other animal products, and a complete physical examination. Serology was done using Rose Bengal plate and standard tube agglutination (STAT) tests. Brucella melitensis and abortus suspensions (Wellcome Diagnostics, England) and doubling dilutions from 1:80 to 1:1280 were used for the STAT. According to the availability of media, a single sample of blood was cultured in tryptic soy broth (Difco Laboratories, USA) in CO 2 under vacuum and subcultured weekly for 8 weeks. The strains were identified using thionin and basic fuchsin tests and slide agglutination with antisera (Difco Laboratories, USA). Other tests which were performed as indicated included complete blood counts, erythrocyte sedimentation rate, renal and hepatic profiles, urinalysis and routine urine culture, routine analysis and culture of the cerebrospinal fluid, and X-rays of the chest and skeleton. Other locally endemic diseases were excluded by appropriate tests. The patients were treated with oral co-trimoxazole, i Oxford University Press 1992
167
Downloaded from http://tropej.oxfordjournals.org/ at Carleton University on June 16, 2015
One-hundred-and-tifty-seven children admitted with brucellosis at Abha, Saudi Arabia, were studied prospectively. Ninety-two per cent gave a history of animal contact, usually with sheep or goats, or ingesting raw milk, milk products, or raw liver. Three-quarters of the patients had an acute or subacute presentation with diverse symptomatology: fever (100 per cent), malaise (91 per cent), anorexia (68 per cent), cough (20 per cent), abdominal symptoms (20 per cent), arthralgia (25 per cent). Hepatomegaly (31 per cent), splenomegaly (55 per cent), and lymphadenopathy (18 per cent) were common findings. Organ complications were rare except for arthritis (36 per cent) which usually presented as a peripheral oligoarthritis involving the hips and knees. All patients had significant agglutination titres; B. melitensis was grown from the blood in 7 of 16 (44 per cent) patients. Haematological variations were common, but non-specific: anaemia (64 per cent), thrombocytopenia (28 per cent), leucopenia (38 per cent), leucocytosis (12 per cent), and elevated erythrocyte sedimentation rate (81 per cent). Varying combinations of rifampicin, co-trimoxazole, tetracycline, and streptomycin resulted in a prompt pyrexial response (mean: 3.8 days), and a slower response in the arthropathy and hepatosplenomegaly. Relapses were related to poor compliance, use of a single drug or a shorter duration of chemotherapy. Brucellosis is a common childhood problem in southwestern Saudi Arabia as in other parts of the country and the Middle East. It should be considered in every child from an endemic area presenting with a febrile illness and a history of animal contact.
B. BENJAMIN AND S. H. ANNOBIL
50 40 30 24
I 20
-
,-, 15
'
18
18 !
,,1
1
16
12
11
10 _-
8
vmm
7 '
2
-1
-2
-3
-4
-5
Results A total of 157 children were identified with brucellosis over the 5-year period; 53 per cent of them were male. They constituted 2 per cent of all pediatric admissions. The age distribution (Fig. 1), showed the lowest incidence in the first year of life, the peak incidence in the second year and a lower frequency trend in older children over 7 years of age. Eighty-two per cent of the children were from the coastal Tihama plain, the remainder were from farms in the hills around Abha (elevation:7000 feet). One-hundred-and-forty-five patients (92 per cent) gave a history of direct contact with animals and 120 (76 per cent) gave a history of ingestion of raw milk or milk products such as soured mik or cheese, or of raw liver. Goats and sheep were the animals usually involved (n = 143); cattle (n = 2) or camels (n = 2) were only rarely so. Clinical features The main clinical features are summarized in Table 1. The presentation was acute (duration up to 7 days) in 16 per cent, subacute (8-30 days) in 60 per cent, and chronic (over 30 days) in the remaining 24 per cent of patients. A history of fever, often accompanied by chills or sweats, was invariably obtained. However, pyrexia was confirmed after admission in only 80 per cent. Other general symptoms such as anorexia, malaise, or weight loss were commonly noted as were various respiratory and abdominal symptoms. The liver and spleen were both enlarged in 44 cases; isolated splenomegaly was noted in a further 43
-9
-10
-11
-12
TABLE 1
Clinical features of childhood brucellosis Feature
Frequency
History of fever Documented pyrexia (>38°C) Malaise, fatigue Anorexia, weight loss Cough Abdominal symptoms (pain, vomiting, distension, constipation) Arthralgia Hepatomegaly (2-4 cm = 40, 5-6 cm = 9) Splenomegaly (1-3 cm = 53, 4-8 cm = 32, over 8 cm = 2) Lymphadenopathy (cervical = 20, axillary = 24, inguinal = 4)
157 (100%) 126 (80%) 143 (91%) 106 (68%) 32 (20%) 32 (20%) 40 (25%) 49 (31%) 87 (55%) 29 (18%)
patients and isolated hepatomegaly in only five children. Lymphnode enlargement usually involved the cervical and axillary groups, either alone or in combination. Complications The organ complications of brucellosis are summarized in Table 2. Arthropathy, the most frequent complication, usually involved the larger joints of the
TABLE 2
Organ involvement in childhood brucellosis Osteoarticular Genitourinary Pneumonitis Neurobrucellosis Hepatitis with jaundice
Journal of Tropical Pediatrics
57 (36%) 17(11%) 6 (4%) 2 (1.3%) 1 (0.6%)
Vol.38
August 1992
Downloaded from http://tropej.oxfordjournals.org/ at Carleton University on June 16, 2015
-6 -7 -8 Age (years) FIG. 1. Age distribution.
rifampicin or tetracycline, or parenteral streptomycin in various combinations for periods of 3-12 weeks and were followed up to check for clinical cure or relapses. The parents were instructed about the disease and its transmission, and advised against continued consumption of raw milk or its products.
168
9
B. BENJAMIN AND S. H. ANNOBIL
TABLE 3 Laboratory results in childhood brucellosis
Hb (g/D >110 90-109 70-89 10 5-10 400 15CMW0 100-149 50-99
