A 4-year-old male came to a hospital with complaints of undulating fever, femurs pain, impaired motor function in the lower limbs. For two years, the complaints increased and the patient was referred to our hospital with lower limb deformities and with a suspicion of a fracture of the right femoral neck.
A plain X-ray of the pelvis and knee joints was performed. It showed shortening of the diaphysis of the right femur, calcification of the soft tissues of the femur on both sides, in the proximal left tibia. Such extensive calcification might be due to the often long, chronic, subclinical course of the disease. The x-ray showed that the iliosacral joints were intact, without any pathological changes. (Fig.1a). It also showed erosion of the condyle of the left femur, preservation of a fairly uniform non-narrowed joint space, and no changes in the condyles of the tibia and patella (Fig.1b).
Pelvic computed tomography showed a comminuted fracture of the right femoral neck with a significant periosteal reaction, nonunion of bone fragments, pseudarthrosis of the right femoral neck (Fig.2).
A biopsy of the right femur was performed, a culture of Brucella melitensis was isolated. Antibodies to Brucella melitensis were also detected in blood samples. The patient was diagnosed with chronic brucellosis infection. The management of the patient included surgical treatment: detorsional supracondylar osteotomy of the left femur with plastic defect correction at the level of the distal metaepiphysis, followed by fixation with a cellacast spica cast, and antibiotics in combination therapy.
Brucellosis is a particularly dangerous and socially significant zoonotic infection caused by aerobic Gram-negative bacillus of the genus Brucella. Brucella melitensis is considered the most pathogenic species for humans [1]. Endemic areas for brucellosis include countries of the Mediterranean Basin, the Middle East, Asia, the Indian subcontinent, Africa
[2,3]. Brucellosis can affect various organs and tissues: most often it is the osteoarticular system (30-85%) with arthritis, bursitis, sacroiliitis (up to 54%), spondylitis (2-50%), osteomyelitis [4,5,6]. Osteomyelitis is an extremely rare complication of brucellosis, usually affecting long tubular and flat bones. The clinical picture is non-specific - fever, bone pain, signs of local inflammation, limitation of range of motion. X-ray shows destructive changes in bones or cavities of destruction, surrounded by a zone of sclerosis, compaction of paraosseous soft tissues. Against the background of the underlying disease, pathological bone fractures can form [7, 8]. Brucellosis osteomyelitis is characterized by a periosteal reaction, calcification of soft tissues. First of all, there should be a differential diagnosis between brucellosis osteomyelitis and nonspecific osteomyelitis for which, as a rule, are not characterized by such an extensive periosteal reaction of the bone tissue. The final diagnosis is based on laboratory studies: serological methods, allergic skin testing, culture selection, or identification of the pathogen by polymerase chain reaction performed on peripheral blood / other biological fluids and tissues [9]. General principles of brucellosis treatment include the use of antibiotics in combination therapy and prolonged duration of treatment [10].
For radiologists, information about the anamnesis of the disease and clinical symptoms is the main key in making a correct preliminary diagnosis, which allows clinicians to determine the further tactics of introducing and treating a patient.
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Brucella osteomyelitis
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From the patient’s lower extremities and pelvis X-ray and CT images, the following characteristics can be observed:
Based on the imaging findings and the child’s persistent or periodic fever (“undulant fever”) and lower limb pain, the following potential diagnoses should be considered:
Considering the child’s age, prolonged clinical symptoms (undulant fever, bone pain, gait disturbances), characteristic imaging features (extensive bone destruction, periosteal reaction, potential pathological fracture), and pathogen screening results, the most likely diagnosis is: Brucella Osteomyelitis.
For further confirmation, serological tests (e.g., Brucella agglutination test, ELISA), culture, and PCR can be used to comprehensively evaluate the diagnosis. If necessary, a biopsy of the bone lesion may be performed to exclude other infections or neoplastic processes.
Treatment Plan:
Rehabilitation Training and Exercise Prescription (FITT-VP Principle):
Throughout rehabilitation, special attention should be paid to the child’s fragile bones. High-force or high-impact movements should be avoided. Monitor the child’s temperature, pain, and local signs before and after training sessions. If discomfort occurs, adjust the plan accordingly.
This report is provided solely as a reference for the patient’s condition and does not replace in-person consultation or professional medical advice. Detailed diagnosis and treatment should be determined based on the patient’s actual condition and clinical assessments by specialized physicians and a multidisciplinary team.
Brucella osteomyelitis
