Mahmoud

El-Desouki,

MD

Skeletal Brucellosis: with Bone Scintigraphy’ To assess the usefulness of bone scmtigraphy in the detection of bone and joint abnormalities in brucellosis and show the pattern and frequency of such

abnormalities

at scintigraphy,

bone cellosis toms Bone of 319

scans in 214 patients and musculoskeletal were retrospectively scans were abnormal sites in 196 patients

with brusympanalyzed. at a total (91.6%);

the most

(142

patients

commonly [72.4%]);

affected bilateral

RUCELLOSIS

can

tious disease be transmitted

site in

is a worldwide of animals to humans

infecwhich

through infected infected

consumption of raw milk or milk products, contact with animals, or through the res-

piratory

tract,

losis

in-

volvement of these joints occurred 92 patients (46.9%). The sternoclavicular joints were affected in 32 patients (16.3%); costovertebral junctions, eight patients (4.1%); and

B

conjunctiva

102 patients (47.7%) had multiple skeletal abnormalities. Plain radiographs were abnormal in 52 of 214 patients (24.3%). The sacroiliac joints

were

Assessment

abraded

(1-3).

skin,

or the

In humans,

brucel-

is predominantly

due to three species of the genus Brucella: B melitensis, B abortus, and B suis. B abortus is most prevalent in North America and Europe, whereas B melitensis is the most common in many developing countries.

The clinical features of the disease are protean and difficult to diagnose (3,4). Bone and brucehlosis are ously reported ease is endemic,

joint involvement in not as rare as previ(5). Wherever the disas in Saudi Arabia

symphysis pubis, three patients (1.5%). It is concluded that scmntigraphy is sensitive in detection of skele-

and elsewhere in the Middle East, skeletal involvement is the most frequent complication (2,6,7).

tal brucellosis

This study demonstrates ness of bone scintigraphy tection of skeletal brucellosis as the pattern and frequency

formed

and

when

should

be perpatients with musculoskeletal

screening

brucellosis symptoms.

and

scintigraphic Brucellosis, 452.2029, 473.2029

Index

terms:

337.86,

ties, 337.202,

nuclide

Radiology

sity

Hospital,

of Medicine, King Khalid

P0 Box 7805, Riyadh

Division Univer-

11472, Saudi

Arabia. Received December 17, 1990; revision requested February 6, 1991; revision received May 29; accepted June 4. Address reprint re-

quests t

to the author.

RSNA,

1991

AND

of pain

low back pain

(113 patients

[52.8%]),

back pain associated with generalized joint and muscle pain (47 patients [22.0%]), and joint pain (54 patients [25.2%]).

The study

group

were

posterior views quantitation. Quantitation

obtained

in addition

of the sacroiliac was

to

joint

performed

by

for

means

of a microcomputer (Star; GE Medical Systems, Milwaukee), with which regions of interest were drawn over the sacroiliac joints, lumbar spine, and/or sacrum. The normal ratios of uptake of the sacroiliac joint to lumbar uptake and to sacral uptake had been previously established in a different age group of healthy Saudi subjects.

RESULTS Of the 214 patients examined, 196 (91.6%) had an abnormal bone scan in a total of 319 sites; 102 patients (47.7%) had multiple skeletal abnormalities.

The Table summarizes the scintigraphic findings in 196 patients (91.6%) with a positive bone scan. Plain radiographs were abnormal in 52 of 214 patients (24.3%) (26.5% of with

a positive

bone

scan).

METHODS

From March 1986 to July 1988, 214 patients with proved brucellosis and musculoskeletal symptoms were referred to King Khahid University Hospital in Riyadh, Saudi Arabia, for bone scan. During the same period, a total of 384 cases of brucellosis were recorded at the hospital. Diagnosis was confirmed by means of a high agglutination titer (> 1:320), positive blood culture, or both. The main skeletal symptoms at presentation

181:415-418

the Department Medicine (46),

as well of the

abnormalities.

PATIENTS

were

I From of Nuclear

de-

site

those

#{149} Joints, abnormali473.2029 #{149} Joints, radio337.1299, 452.1299 #{149} Spine, ab-

452.2029,

1991;

useful-

31.86, 32.86, 33.86,

studies, 31.202, 32.202, 33.202

normalities,

the

in the

Radionuclide bone scans were acquired 3-4 hours after an intravenous injection of technetium-99m methylene diphosphonate. Anterior and posterior total body scanning was performed in all patients at a speed of 1 m/6 mm. Spot views to the

consisted

Brucella The

Sacroiliitis sacroiliac

most tients

joint

occurred

in 50 patients

was easily detected cially in the anterior young patients with tis, visual interpretation

cient, more with

was

commonly affected [72.4% ]). Unilateral

by far the site

(142

pa-

sacroiliitis (25.5%) and

visually, espeview (Fig 1). In bilateral sacroihiiwas insuffi-

and quantitative method was sensitive (Fig 2). All the patients scintigraphic evidence of sacro-

iliitis

presented

with

or without

with

low

back

pain

tenderness.

of 202 adults

and

12 children: 117 male and 97 female patients, with an average age of 37 years (range, 11-76 years). Ninety percent of the patients were Saudi Arabian.

Abbreviation:

SCJ

= sternoclavicular

joint.

415

Spinal

Ganado

Brucellosis

The lumbar spine was the most commonly affected spinal site. Brucellosis of the lumbar spine occurred in 48 patients (24.5%); of the thoracic spine, 14 patients (7.1%); and of the cervical spine, only two patients (1.0%). Lower lumbar vertebrae were mainly involved, particularly the L-3 to L-4 vertebrae (Fig 3). Increased up-

take

was

noted

adjacent

in one

vertebra

or two

vertebrae.

(10).

affected of 11.1%.

previously might be scanning

joints,

oc-

the

most

commonly affected large joints, in 44 patients (22.4%); in the hips, 14 patients (7.1%); the ankles, eight patients (4.1%); and shoulders, four patients (2.0%). Three-phase bone scintigraphy was helpful in the detec-

tion

of arthritis

and

assessment

tive inflammation increased vascularity

by

in the

and

mildly

early

phase

increased

in the

pool

normal

or

periarticular

delayed

image

Smalljoints.-Other by Brucella arthritis

uhar joints

of ac-

demonstrating and blood

uptake

(Fig 4).

(SCJs)

(32 patients

[16.3%];

symphysis pubis (three patients [1.5%]), and costerovertebral junctions (eight patients [4.1%]).

Involvement

of the SCJ may

be uni-

lateral or bilateral (Fig 5). The ity of the patients either were tomatic or had symptoms that

have pain

been from

majorasympmight

masked by more severe other sites. Increased activ-

ity at the costerovertebral junction was usually bilateral, involving upper dorsal spine (Fig 6). The patients with increased activity symphysis pubis were two men

one woman other parts

the three in the and

and had involvement of the skeleton as well

of (Fig

7).

DISCUSSION Brucellosis

with

is an

worldwide

estimated still contract

that the

In humans, clinical

index

distribution half a million disease each

brucellosis

has

manifestations,

of suspicion

and

Bone

of symptoms

male

female

patients

in the

were

patients

(54.7%

Only

scintigraphy

12 pa-

than 15 that the in chil(4).

has been

sensitive

detection

than

shown

of skeletal

et al found

that

pain with or without the sacroiliac joints, joint pain. The second most fected

site

was

Other

recent

lumbar

spine

involved

tenderness or even with commonly

the

lumbar

reports

416

by

brucellosis

#{149} Radiology

was

reported

ment,

which and

pubis

Inis in-

af-

showed

that

most

frequently

(7,11,12).

The

tion

usually

was begins

and

dense

by

and

sclerosis

of the

result

“parrot-beak” The knee monly

pro-

is characterized

aspect may

interver-

to the adjavertebral osteothe common of adjacent

of destruction the

visuinfec-

inflammatory

in brucellosis

anterior

to of joint in involve-

both

in the

The

(5).

for

due

Spinal

tebral disk and spreads cent bone to produce myelitis; this explains finding of involvement

the

cause

assessed

quantitatively.

end

characteristic

osteophytes joint was the large

re-

of the

vertebral

in the

involved

of arthritis,

three-phase by

was normal.

symphysis

spine.

(Fig 8). most com-

joint.

Peripheral

tion

fected

in the

of hip

the

was

site

ally

plate

af-

radiograph

uptake seen.

sacroihiitis

this disagreement is probably the high frequency of detection abnormalities of the sacroiliac our study, especially bilateral

pair,

of patients

The plain

was the most common complication (6). Patients with sacroiliitis may present with low back pain, localized

(2,6,7).

study

iliitis. creased cidentally

brucellosis,

joint arthritis is usually benign and responds well to antibiotic therapy (7). Bone scanning was more sensitive than radiography in the early detec-

largest

right

1. Anterior spot view of the pelvis markedly increased uptake in the sacroiliac joint because of Brucella sacro-

radiography

early detection (3,4,9). Fever, back and joint pain, and excessive sweating are the most common presenting symptoms. The most common complications are bone and joint involvement

The

Figure shows

particularly in acute sacroihiitis and other abnormalities in which joints are affected (11,12). The sacroiliac joint was by far the most commonly involved site. In a study of more than 300 cases in Peru,

people year

for its

onset

respectively).

to be more

a combination

a high

skeletal

(5.6%) were younger a fact which suggests is rather uncommon as previously reported

(8). It is

is necessary

the

45.3%,

tients years, disease dren,

cess

diverse

a preva-

study,

frequencies, to the use of bone the earliest radio-

more

than

disease

(1).

or joints

of spinal brucellosis and may appear

after

Slightly

vertebrae

infectious

In our

reported attributed because

Gotuzzo

joints affected were sternoclavic-

Malta

bones

in 698 patients,

graphic findings are nonspecific

and arthritis

from

cases,

involvement occurred in at least 56% of the patients with proved brucehlosis; this frequency, much higher than

affected

Large joints.-Brucella curred in the knee

(1958)

6,301

hence

months

Arthritis

Craig

the

were

(11). Brucella

and Of

in assessment

and bone

performance

scanning

of disease

could

activity.

of help

Figure

2.

Quantitation increased

markedly joints

in

Right

sacroiliac

204.31,

ratio

a patient left

=

uptake

with

method shows in both sacroiliac

bilateral

joint/lumbar

sacroiliac

joint/lumbar

sacroiliitis.

spine

ratio

=

spine

193.13.

November

1991

Arthritis uncommon

is usually an of brucellosis (12). In their review of more than 500 cases of brucehlosis, Mousa et al (13) found only four patients (0.8%) with arthritis of the SCJ (13). The onset of septic arthritis in the SCJ, unlike that in other joints, may be insidious (14). Abnormalities on bone scans may appear as early as 1 day after the onset of symptoms (15). In this study, all patients had other skeletal involvement except one who presented only with

The for

of the SCJ complication

5,120),

and

itive.

Needle

formed,

the

but

dramatic

blood

culture

biopsy the

was

patient

was

not

pos-

per-

showed

response

to anti-B rucella treatment. In one patient both the and symphysis pubis were affected besides

the

spine

(Fig

9). The

of the symphysis pubis has previously reported, to our knowledge, and it was associated

arthritis of the right SCJ (Fig 5). Brucella titer was extremely high both B melitensis and B abortus (1:

patients

explain

the

with

symptoms

generalized

back pain. The “caries sign,” described by Bahar et al (16,17), was not observed in our patients and might be related to chronicity of the disease.

not

CONCLUSION Brucellosis

skeletal abnormalities. The of the costovertebral uncommon, as previously (16,17), and was associated

with sacroiliitis, resulting and scintigraphic features mimic those of ankylosing

might

involve-

ment been

with other involvement joints was described

SCJ

tis. This

of those

in clinical that can spondyli-

with

is an

worldwide

loskeletal common brucellosis

infectious

disease

distribution.

Muscu-

involvement is the most complication. Therefore, must be considered in the

differential diagnosis matologic syndromes tient is from an area ease is endemic.

of many rheuwhen the pawhere the dis-

a

Figure

R t,

,

.

scintigram

skeleton

*

1

from

‘I

--

3* ;4

*1

Figure

4.

shows ticular

increased uptake

Three-phase

181

flow (arrow).

#{149} Number

a patient

was affected.

,

1;

Volume

Bone

4*L,

:

I

4 #{182}

5.

with Brucella arthritis of the right sternoclavicular joint shows markedly increased uptake in the right joint. No other part of the

Figure 3. Posterior spot view of the lumbar spine shows increased uptake in two adjacent vertebrae, possibly as the result of initial involvement of the L3-4 disk space.

bone

and

blood

2

scan

from

pool

t a child to the

right

with

Brucella

knee.

Delayed

arthritis view

of the right shows

knee

increased

(R) penar-

6. Posterior view of the spine increased uptake in the costovertebral tions as well as in the sacroiliac joints. Figure

Radiology

shows junc-

#{149} 417

b.

a. Figure with view

Spot brucellosis (a) shows

views of the lumbosacral area in a male patient and a painful right sacroiliac joint. The posterior increased uptake in the right sacroiliac joint, while

7.

the anterior physis

view

(b) shows

Bone scintigraphy is more sensitive than plain radiography in the detection of bone and joint abnormalities and should be used as a screening procedure in patients with brucellosis and musculoskeletal symptoms. The main presenting symptoms are fever, low back pain, and joint pain; the

5.

most commonly involved sites are the sacroiliac joints, lumbar spine, and knee joints. Early detection and treat-

8.

ment is important the complications

to avoid many of the disease.

6.

to Minnie

lent secretarial medicine

Amores

assistance,

technologists

for her

7.

technical

of

2. 3.

BM.

assis-

distribution

Madkour

Mlvi,

Brucellosis

J 1985;

Rahman

A, Mohamed

in Saudi

Arabia.

Saudi

E, Alarcon involvement

9.

11.

a retrospective

analysis

of

Figure

1983;

Dis

GS, Bocanegra in human

8.

Parrot-beak

osteophytes

characteristic radiographic spinal brucellosis.

feature

are a of chronic

TS, et al. brucello-

of 304 cases.

Dis

43:347-353.

Maryas

Z, Fujikura problem.

T.

Dev

Brucellosis

Biol

Stand

as a 1984;

56:43-

Siddiqui HS. Brucellosis in the Middle East. Postgraduate Doctor (Middle East) 1985; 8:485-492. Ganado W, Craig AJ. Brucellosis myopathy. J Bone Joint Surg (Am) 1958; 40:1380-

67:345-351. Rajapakse

13.

et al. Spinal brucellosis. 26:28-31. Mousa AM, Muhtaseb

CNA,

Al-Aska

AK,

14.

15.

Al Orainey

AA, Habib

FM.

clavicular

arthritis,

the

Brucellar forgotten

DS,

sternocomplica-

1988; 82:275-

Yood RA, Goldenberg DL. Sternoclavicular joint arthritis. Arthritis Rheum 1980;

a.

23:232-239.

Figure

Magd

M,

Frankel

in skeletal

RS.

RH, Al-Suhaili

MK, Kaddah

Bahar

et al.

appearance

Clin

Nucl

RH,

Med

Al-Suhaii

Scintigraphic

chronic brucellosis Nucl Med 1990;

and

9. body bone brucellosis abnormalities

imagischemic

AIR 1976; 126:832-841.

in children.

Bahar Brucellosis:

Radionuclide

inflammatory

disease

Nawaz

17.

I,

1987;

SA, Al-Mudallal

Marafie

ing

16.

SJ. Spi(Br) 1985;

Br J Rheum

tion. Ann Trop Med Parasitol 281.

Med

6:324-332.

Lifeso RM, Harder E, McCorkell nal brucellosis. J Bone Joint Surg

12.

E, et

Al-Freihi H, Al-Mohaya SA, Al-Mohsen MF, et al. Brucellosis in Saudi Arabia: diverse manifestation of an important cause of pyrexial illness. Ann Saudi Med 1986; 6:9599.

#{149} Radiology

review

Infect

Semin Arthritis Rheum 1982; 12:245-255. Norton WL. Brucellosis and rheumatic syndrome in Saudi Arabia. Ann Rheum

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4.

Brucellosis:

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