The patient was admitted to hospital with complaints of fatigue, fever, sweating and low back pain for 35 days. Six members of her family had a history of similar symptoms.
The patient was admitted to hospital with complaints of fatigue, fever, sweating and low back pain for 35 days. Six persons in her family had a history of similar symptoms. At physical examination, splenomegaly and susceptibility at her lower back were found. Erythrocyte sedimentation rate was 35 mm/1st 1h and C-reactive protein (CRP) was 40 mg/l. The hemogram was normal, except mild elevated levels of leukocytes. Lateral plain radiograph of the lumbar spine showed prominent sclerotic changes at the inferior end-plate of the L4 vertebra body and superior of the L5 vertebra body. Degenerative changes are mild at the other vertebras (Fig.1). Spin-echo T1-weighted sagital MR image showed decreased signal intensity at the L4 and L5 vertebral body and intervening disc (Fig 2a). Also there was a soft tissue component at the anterior paravertebral margin. Corresponding gradient-echo T2 weighted sagital MR images showed slightly increased signal intensities at vertebral bodies and prevertebral area (Fig.2b). Sagital MR sections taken after, intravenous bolus 10 cc contrast medium injection, revealed mild contrast enhancement both in vertebral bodies and anterior located soft tissue mass (Fig.2c). Serology test for brucella was found positive with an antibody titer of 1: 3720. Blood culteres also revealed Brucella mellitensis.
Brucellosis is a zoonosis endemic in the Mediterranean countries. The disease is transmitted to humans either through direct contact with infected animals or through ingestion of contaminated dairy products. Osteoartricular manifestations of brucellosis include: arthritis, sacroileitis, osteomyelitis, spondylitis, tenosynovitis and bursitis [1]. The sites of the spinal involvement are the lumbar, thoracic and cervical regions with decreasing order. Severe vascular and neurologic complications can be seen due to paraspinal abscess formations in brucellar spondylitis [2]. Initially, the mild degenerative changes that are detected on lateral radiographies can cause misdiagnosis [3]. Paravertebral and epidural masses can lead to serious neurological complications, so early diagnosis and treatment is very important in brucella [2]. Plain radiographs of the spine have a low sensitivity during the first weeks of the disease [4]; moreover, radiographic findings are similar to those of degenerative disease [3]. Infective spondylitis, the combined infection of the osseous vertebral structures and disc space, constitutes 2% to 4% of all cases of osteomyelitis, and is increasing in prevalence [5]. Differences in clinical and imaging presentation between children and adults are explained by developmental anatomic differences. Degenerative disc disease, seronegative spondyloarthropathies, and spondyloarthropathy associated with long-term hemodialysis may mimic the imaging abnormalities of infective spondylitis Degenerative diesase of the spine is an ongoing process. With aging, the degenerative changes occuring within the disc cause loss of the disc height and resultant bone marrow changes at the end-plates adjacent to disc. Type I end-plate changes with decreased signal on T1-WI and increased signal intensity on T2-WI can mimic the infective changes in Brucellosis. Discal vacuum phenomenom, well-defined sclerosis and erosions of vertebral endplates, high signal strip surrounding low signal of vertebral endplates on T1-weighted images are the most useful findings in differential diagnosis. The relative young age of the patient, a history of contamination with the infected animal can also provide differential diagnosis. Although a broad spectrum of a gram positive bacteria, mycobacteria and fungi have been reported to cause disc space infection and spondylitis. S. aureus is much more commonly found agent at disc space biopsies. The exact diagnosis is difficult only on the basis of imaging findings at infective spondylitis but laboratory findings, direct visualisation of the infective microorganism at the cultures, specific serologic tests can provide important diagnostic implications. Tuberculosis spondylitis with its characteristic findings relative to other microorganism can be differentiated by radiologic methods. It generally involves thorocalomber spine with or without concomitant lung involvement. The involvement of two adjacent vertebral bodies with usual large paravertebral abscesses and marked osteopenia are the important diagnostic clues . Marked kyphosis is seen at the end stage of the disease.
Spondylitis due to Brucella
1. From the provided lateral lumbar spine X-ray images, there are mild bony changes around the edges of the lumbar vertebral bodies, and some intervertebral spaces appear narrowed, especially at the lower lumbar segments (e.g., L3-L4 or L4-L5). The vertebral endplates show blurring or slight erosion, and local bone density is reduced.
2. MRI images demonstrate decreased T1-weighted signals and increased T2-weighted signals in the involved vertebral endplates, suggesting possible inflammatory or infectious lesions in the vertebral and intervertebral disc regions. Certain images also indicate paravertebral (or epidural) soft tissue swelling or abscess-like changes.
3. No obvious compressive fractures or significant vertebral collapse are observed, but abnormal signals within the vertebrae and paravertebral region suggest possible infection or other destructive processes.
4. Compared to common degenerative changes, the signal alterations between involved vertebrae and the intervertebral discs are more pronounced. On T1- and T2-weighted images, these changes are not entirely consistent with simple degenerative lesions, and further clinical correlation is necessary to determine the exact etiology.
Considering the patient's age (62 years) and the long duration (35 days) of systemic symptoms such as fever and night sweats, along with similar family history; the imaging evidence of combined vertebral and disc involvement; and possible paravertebral inflammation or abscess formation, Brucella infection is highly suspected based on local epidemiology and serological tests.
The most likely diagnosis: Brucellar spondylitis.
If further confirmation is needed, blood culture, bone marrow or lesion biopsy, and Brucella-related serological tests (Rose-Bengal, Brucella agglutination test, etc.) can be performed to identify the pathogen.
1. Pharmacotherapy:
- Treatment for Brucellar spondylitis typically involves combination antibiotics (e.g., doxycycline + streptomycin or fluoroquinolones) administered at adequate dosages and for adequate durations, usually from six weeks to three months or longer, depending on culture results and antibiotic sensitivity.
- Provide supportive and nutritional therapy, and regularly monitor liver and kidney function for potential drug-related adverse effects.
2. Conservative and Supportive Treatment:
- During the acute phase, appropriate bed rest and use of a brace or lumbar support may help reduce stress on the affected area.
- If paravertebral or epidural abscesses are severe, surgical intervention for drainage may be necessary. However, many experts advocate close monitoring with standardized antibiotic therapy first.
3. Rehabilitation and Exercise Prescription:
- Phase I (Acute Phase/Severe Pain): Protective movements are recommended. Perform mild bedside limb activities, such as ankle pumps or isometric quadriceps exercises, avoiding excessive lumbar loading. Do these exercises 2-3 times daily, 5-10 minutes per session.
- Phase II (Subacute Phase/Symptom Relief): Once antibiotic treatment has stabilized, introduce gentle back exercises (e.g., bridge exercises, low back stretches) along with simple core strengthening, done 3-4 times per week for about 15-20 minutes each session, ensuring no significant pain.
- Phase III (Recovery Phase): Gradually increase low-intensity aerobic exercises (such as brisk walking on flat ground, light swimming, or cycling) 3-5 times a week, about 30 minutes per session. Continue core and back muscle strengthening by progressively increasing sets and repetitions following the “FITT-VP” principle (Frequency, Intensity, Time, Type, Volume, Progression). Avoid excessive loads in a single session.
- Rehabilitation must be individualized. If the patient has osteoporosis or poor cardiopulmonary function, adjustments should be made to exercise intensity and safety measures.
This report provides a preliminary analysis based on the available imaging and medical history and is intended for clinical reference only. It does not replace a face-to-face medical diagnosis or professional medical opinion. In case of any concerns or changes in the patient’s condition, please seek prompt medical attention and consult with a specialist for subsequent treatment decisions.
Spondylitis due to Brucella
