there was a history of eating raw-milk cheese few weeks before the onset of fever

49

Upload: nailah

Post on 24-Feb-2016

31 views

Category:

Documents


0 download

DESCRIPTION

Abdurrahman is a 16- year old schoolboy اول ثانوي from Ein Albasha who was presented to me on 13/11/2011 by his brother doctor who was completing the Internship in our hospital. Abdurrahman was C/O 6 months duration LBP with no history of trauma or any effort of lifting . - PowerPoint PPT Presentation

TRANSCRIPT

Page 1: There was a history of eating Raw-milk cheese few weeks before the onset of fever
Page 2: There was a history of eating Raw-milk cheese few weeks before the onset of fever

Abdurrahman is a 16- year old schoolboy اول from Ein Albasha who was presented to ثانويme on 13/11/2011 by his brother doctor who was completing the Internship in our hospital.Abdurrahman was C/O 6 months duration LBP with no history of trauma or any effort of lifting.His LBP had gradually developed for 6 months prior to the visit and was preceded by 38° - 39° fever and chills for one week .

Page 3: There was a history of eating Raw-milk cheese few weeks before the onset of fever

Also low grade fever and night sweats was almost present during the 6 months prior to consultation.There was neither associated radiation of the pain nor any sensory symptoms (numbness or paresthesias ).His symptoms worsened in the afternoon and was not relieved by bed rest.There was no impaired ability to control urine or stool.

Page 4: There was a history of eating Raw-milk cheese few weeks before the onset of fever

There was a history of eating Raw-milk cheese few weeks before the onset of fever.He had no medical history of diseases including tuberculosis . He also had no recent history of overseas travels or eating raw meat, and there was no evidence of specific family history including inflammatory joint disease.

Page 5: There was a history of eating Raw-milk cheese few weeks before the onset of fever

O/E

When I saw him he was enable to stand for longer than 10 minutes without increasing pain.The lumbar lordosis was preserved there was a painful limitation in the motion of the back in all directions: forward flexion, extension, left lateral flexion, right lateral flexion as well as mild to moderate tenderness on palpation and percussion over the lumbar region at the level of L2-L3.

Page 6: There was a history of eating Raw-milk cheese few weeks before the onset of fever

Neurologic examination was normal. – Power 5/5– Intact osteotendinous reflexes

HEART: Regular rate and rhythm without murmur. Examination of the chest reveals equal bilateral breath sounds. ABDOMEN: – soft ,lax – no hepato or splenomegaly

No cervical, axillary or inguinal lymphadenopathy,

Page 7: There was a history of eating Raw-milk cheese few weeks before the onset of fever

Laboratory evaluation

Showed hematocrit 0.40, white blood cells 7010/mm3 (neutrophils 61%, lymphocytes 35%, and monocytes 4%), platelets 223,000/mm3, erythrocyte sedimentation rate 19 mm/h, and CRP 16 mg/L. Urinalysis was normal. Standard agglutination testing for Brucella was negative twice.Enzyme -linked immunosorbent assay was not ordered also PCR (polymerase chain reaction)*A skin tuberculin test was negative.

Page 8: There was a history of eating Raw-milk cheese few weeks before the onset of fever

Blood cultures and cultures from bone marrow aspiration and biopsy specimens from bone lesions were not obtained. Blood cultures are expensive, a positive result may take many days, and the sensitivity is only about 70%

Bone marrow cultures are more sensitive (>90%) but are invasive and expensive. In addition, Brucella is a biohazard and cultures require biosafety level 3 precautions.

Page 9: There was a history of eating Raw-milk cheese few weeks before the onset of fever

Plain radiographs of the chest and sacroiliac joints were unremarkable. A magnetic resonance imaging of the lumbar spine was not performed

Page 10: There was a history of eating Raw-milk cheese few weeks before the onset of fever
Page 11: There was a history of eating Raw-milk cheese few weeks before the onset of fever

Diagnosis & differential

Page 12: There was a history of eating Raw-milk cheese few weeks before the onset of fever

Pott’s diseaseUnfortunately, adult diskitis has a slow, insidious onset, which can cause diagnosis to be delayed for months. Fever, chills, weight loss, and symptoms of systemic disease may be present but are not common.

Pyogenous

Page 13: There was a history of eating Raw-milk cheese few weeks before the onset of fever

Focal forms

Brucellosis often causes focal forms that have a more prolonged course and worse prognosis.

Page 14: There was a history of eating Raw-milk cheese few weeks before the onset of fever

20%–40% of cases involved 1 focal complication. Among the various focal forms, osteoarticular complications are, without doubt, the most common. In adults, these generally affect the axial skeleton, with vertebral osteomyelitis accounting for 35%–50% of all osteoarticular complications.The incidence of vertebral osteomyelitis is 6%–12%*

Page 15: There was a history of eating Raw-milk cheese few weeks before the onset of fever

The white blood cell count is often normal or low and the erythrocyte sedimentation rate is variableMR imaging shows decreased signal intensity in the intervertbral disc, whereas the adjacent vertebral bodies are hypointense on T1 weighted images and hyperintense on T2- weighted images

Page 16: There was a history of eating Raw-milk cheese few weeks before the onset of fever

Antibodies begin to form 2 weeks after the beginning of disease. Immunglobulin (Ig) M type antibodies appear in one week and reach a peak in three months. Ig G antibodies, on the other hand, appear in three weeks and reach a peak in six to eight weeks.

Page 17: There was a history of eating Raw-milk cheese few weeks before the onset of fever

Serum Agglutination Test (SAT)does not detect nonagglutinating antibodies; therefore false negatives can occurThe sensitivity of the IgM ELISA approaches 100% in acute sera. IgM may not be detectable in convalescent sera but can rarely remain positive for 19 months.

The IgG ELISA may be negative in sera collected very early in disease but approaches 100% in convalescent sera.

Page 18: There was a history of eating Raw-milk cheese few weeks before the onset of fever

Coombs test is needed to investigate blocking antibodies. Dilutions need to be performed in very high ratios in order to remove occurrence of prezone . In recent years, the immuncapture agglutination test, which is based on sandwich ELISA system, has been introduced. In this method, microwell is covered with Coombs antibodies against human origin Ig G, Ig M and Ig A antibodies. This method is brucella agglutination test that

occurs in microwell and performed with Coombs antiserum and determines the three antibodies that form against brucella.

Page 19: There was a history of eating Raw-milk cheese few weeks before the onset of fever
Page 20: There was a history of eating Raw-milk cheese few weeks before the onset of fever

RX

Several regimens have been used to treat brucellosis. None is 100 percent effective since about 10 percent of patients relapse after therapy.Most relapses occur within three months of stopping therapy and almost all within six months.

Page 21: There was a history of eating Raw-milk cheese few weeks before the onset of fever

— There are two major regimens for treatment of adult brucellosis:

Regimen A — Doxycycline 100 mg PO twice daily for six weeks plus streptomycin 1 gram IM daily for the first 14 to 21 days. It has been suggested that gentamicin can be substituted for streptomycin. A prospective, randomized study of doxycycline (100 mg PO twice daily for 45 days) in combination with either streptomycin (1 g IM daily for 14 days, DS regimen) or gentamicin (5 mg/kg per day IM for 7 days, DG regimen) in 191 patients found the two regimens to be equally efficacious (relapse rate 7.4 compared to 5.2 percent in the DS and DG regimens, respectively) – Gentamicin has been primarily evaluated in children in whom a short course (five

days at 5 mg/kg per day) has been used in combination with another drug. Regimen B — Doxycycline 100 mg PO twice daily plus rifampin 600 to 900 mg PO (15 mg/kg) once daily for six weeks.Therapeutic failure or relapse rate at 12 months (4.3 versus 4.9

percent) were similar in the two groups.

Page 22: There was a history of eating Raw-milk cheese few weeks before the onset of fever

RX

The World Health Organization (WHO) recommends a regimen B of doxycycline (200 mg/day) plus rifampin (600 to 900 mg/day) given for 6 weeks,

Recommendation(UTD) — The optimal regimen for treatment of brucellosis is not certain. Most favor regimen B, given the logistical convenience of oral therapy. – However, in the setting of spondylitis, regimen A should

be considered carefully, given its superiority for this form of disease, which is notoriously difficult to treat .

Page 23: There was a history of eating Raw-milk cheese few weeks before the onset of fever

Osteoarticular diseasePatients with focal disease (osteoarticular involvement being most common) have a less favorable prognosis than those without focal disease. The eradication of infection from the bone is difficult.This was illustrated in a study of 530 patients (including 170 patients with focal disease); those with focal disease had a greater likelihood of therapeutic failure, relapse, or death compared to those without focal disease (10.6 versus 3.6 percent). Surgical management was required in 15 percent of patients with focal disease.

Page 24: There was a history of eating Raw-milk cheese few weeks before the onset of fever

Therefore, long-term anti-brucellar antibiotic treatment should be prescribed .

Page 25: There was a history of eating Raw-milk cheese few weeks before the onset of fever

If relapse does occur, the patient should be carefully evaluated for the presence of focal disease that may need surgical therapy. If surgical therapy is not warranted, one may want to use an alternative regimen. However, development of in vitro resistance by Brucella is extremely rare, and a second course of treatment with the initial regimen may be effective.

Page 26: There was a history of eating Raw-milk cheese few weeks before the onset of fever

utd

Patients with brucella spondylitis appear to respond better to doxycycline-streptomycin or a three-drug regimen (doxycycline-streptomycin-rifampin) than to doxycycline-rifampin .

Page 27: There was a history of eating Raw-milk cheese few weeks before the onset of fever

In the setting of adverse drug reactions, ciprofloxacin-rifampin may be an alternative regimen to doxycycline-streptomycin; this was illustrated in a nonrandomized study of 31 patients in which the observed clinical response was similar among the patients receiving the two regimens .

Patients with osteoarticular disease likely benefit from an extended course of antimicrobial therapy. In a prospective study of 90 patients with osteoarticular brucellosis, patients treated for more than five months had a lower relapse rate than those treated with six weeks of therapy . Other investigators favor a minimum duration of three months.

Page 28: There was a history of eating Raw-milk cheese few weeks before the onset of fever

Human osteoarticular Brucellosis: Do We Need to Revise Our

Therapeutic Policy?YASSER M. EL MIEDANY, MAHA EL GAAFARY, MANAL BADDOUR, and IHAB AHMEDhttp://www.jrheum.org/content/30/12/2666J Rheumatol Conclusion. Extending treatment for longer than previously recommended (6 weeks) resulted in an incidence of relapse significantly lower than for shorter courses of treatment. IgG antibody in addition to seroagglutinating antibody titers are useful for serological followup of patients with brucellosis.

Page 29: There was a history of eating Raw-milk cheese few weeks before the onset of fever
Page 30: There was a history of eating Raw-milk cheese few weeks before the onset of fever

Thank you

Page 31: There was a history of eating Raw-milk cheese few weeks before the onset of fever

Chronic brucellosis is usually caused by persistent foci of infection in tissues, such asbone, spleen, liver, and other organs.In chronic brucellosis, symptoms can recur over long periods and are associated with objective signs, such as fever. An important laboratory finding is the persistence of high titers of IgG antibodies

Page 32: There was a history of eating Raw-milk cheese few weeks before the onset of fever

Which ab in ig m or ig g recurrences

Page 33: There was a history of eating Raw-milk cheese few weeks before the onset of fever

Although associated mortality is low, vertebral osteomyelitis is, evertheless, a serious complication of brucellosis, because it requires lengthy antibiotic treatment, often requires spinal surgery (with consequent long hospital stays), and, quite often, results in functional sequelae, all of which lead to greatly increased health care costs.Little information is available about brucellar vertebral osteomyelitis (BVO). Most studies have examined small series of cases managed very heterogeneously,resulting in considerable confusion about the most suitable treatment and the prognosis of this common complication of brucellosis [9–11].

Page 34: There was a history of eating Raw-milk cheese few weeks before the onset of fever

Brucellosis is a systemic, infectious disease caused by the bacterial genus Brucella and a common zoonosis that still remains a major health problem in certain parts of the world such as the Mediterranean region, the Middle East, and Latin America. It may involve multiple organs and tissues. Osteoarticular involvement is the most frequent complication of brucellosis,

Page 35: There was a history of eating Raw-milk cheese few weeks before the onset of fever

Osteoarticular complications are the most common focal complications of brucellosis. Although vertebral osteomyelitis is the most frequent location in adults >30 years of age, little information is available about this serious complication of brucellosis, and great confusion surrounds its prognosis and the most appropriate treatment.

Clinical Infectious Diseases2008:46 (1 February) • Colmenero et al.

Page 36: There was a history of eating Raw-milk cheese few weeks before the onset of fever

Les localisations ostéo-articulairesElles sont secondaires à une disséminationdes bactéries par voie hématogène et peuventêtre présentes à tous les stades de la maladie.Elles sont plus fréquentes au cours de laphase post bactériémique, réalisant devéritables métastases septiques. Ellesreprésentent 69 à 75% des brucellosesfocalisées et peuvent être révélatrices de lamaladie .

Page 37: There was a history of eating Raw-milk cheese few weeks before the onset of fever

La fréquence des manifestations ostéo-articulaires est plus élevée dans les pays en voie de développement . L’atteinte initiale est habituellement osseuse, l’extension articulaire survient par contiguïté . Les localisations ostéo-articulaires au cours de la brucellose sont très variées : on distingue les arthrites aiguës périphériques uniques ou pluri focales, les sacro-iliites, les ostéites et les spondylodiscites.

Page 38: There was a history of eating Raw-milk cheese few weeks before the onset of fever

Cont….

Paravertebral masses, epidural masses, and psoas abscesses were detected in 45.8%, 27.1%, anSixty-three patients (65.6%) received medication only (treated for 3 months*), and 33 (34.4%) required surgical therapy??? in addition to medication. Twenty percent of patients experienced therapeutic failure??. Attributable mortality was 2.1%, and severe functional sequelae were apparent in 6.2% of the patients.

Clinical Infectious Diseases2008:46 (1 February) • Colmenero et al.

RX

Page 39: There was a history of eating Raw-milk cheese few weeks before the onset of fever

Relapse was defined as either the existence of a new positive blood culture result once antibiotic treatment was concluded or the reappearance of compatible symptoms or new vertebral lesions, together with an increased C-reactive protein level or erythrocyte sedimentation rate after the end of the treatment and persistence of or a new increase in the previous serological titers.

Page 40: There was a history of eating Raw-milk cheese few weeks before the onset of fever

Functional sequelae were considered to be severe if disability prevented the patients from performing their usual occupation or daily activities.

there do not seem to be any apparent differences between the regimens of doxycycline administered for 3 months plus streptomycinadministered for 3 weeks and doxycycline plus rifampicin administered together for 3 months. It is possible that, as happens with uncomplicated brucellosis, the duration of streptomycin therapy can be

shortenedto 2 weeks and that streptomycin can be replaced bygentamicin with a similar efficacy.

Page 41: There was a history of eating Raw-milk cheese few weeks before the onset of fever

Fever,chills, arthralgia, backache, high levels of C-reactive protein, positive rheumatoid factor, and splenomegaly were more frequent in osteoarticular brucellosis than in nonosteoarticular disease.

Page 42: There was a history of eating Raw-milk cheese few weeks before the onset of fever

http://cid.oxfordjournals.org/content/9/3/531.short

Osteoarticular Complications of Brucellosis: A Study of 169 Cases

Arthritis occurred in the hip joint in 90 cases (53%), knees in 61(36%), sacroiliacs in 33 (20%), ankles in 25 (15%), elbows in nine (5.3%), shoulders in eight (5%), wrists in six (3.5%), and sternoclavicular arthritis occurred in three cases (1.8%). Spondylitis occurred in 10 cases (6%), osteomyelitis in four (2.4%), and tendinitis or bursitis in two (1.2%). Treatment with tetracycline or trimethoprim-sulfamethoxazole (TMP-SMZ) alone (four to eight weeks) or in combination with streptomycin (two to four weeks) resulted in a relapse rate of 16.6%.

Page 43: There was a history of eating Raw-milk cheese few weeks before the onset of fever

a 2ME

2 mercapto-ethanol testThe basic agglutination test detects both IgM and IgG antibodies. The addition of 2-mercaptoethanol destroys the binding ability of only the IgM antibody so this test detects the presence only of Brucella specific IgG.????

Page 44: There was a history of eating Raw-milk cheese few weeks before the onset of fever

Sacro-illitis is the most common articular manifestation in sub-acute brucellosis although it is usually unilateral (80% of the time). Brucellosis should always be a consideration in a febrile patient with fairly new onset of severe back pain with inability to bear weight. Epididymitis occurs in 3-10% of young male patients so it should be thought of along with STDs and viral diseases.

Page 45: There was a history of eating Raw-milk cheese few weeks before the onset of fever

oral doxycycline and rifampin, which in our hands has a success rate in preventing relapse of 90% in uncomplicated disease. With complicated disease we recommended treatment for 3 full months with oral doxycycline and rifampin,

Page 46: There was a history of eating Raw-milk cheese few weeks before the onset of fever

With successful treatment IgG antibody does not often persist at any positive level (≥1/80) for more than a year and should start diminishing very soon after treatment. When a patient presents the second time (months later) with a 2ME titre that was higher than it was initially, this was a presumptive indicator of still active infection.

Page 47: There was a history of eating Raw-milk cheese few weeks before the onset of fever

Incubation 15 days is usually between 5 and 21 days. Occasionally, the interval between infection and first worrisome symptoms, including fever, may be as long as 7 months , or perhaps longer.

Page 48: There was a history of eating Raw-milk cheese few weeks before the onset of fever

The severity of the illness ranges from mild to seriously ill. Mild cases may last for just a few days, while the acute phase of severe cases may persist for weeks to many months. In some cases this lingering illness consists of fever and malaise, which occur in most cases. In some cases, severe debilitation may occur.The fever of acute brucellosis caused by B melitensis usually lasts for 10-30 days, undulates irregularly, and is not associated with rash.

Page 49: There was a history of eating Raw-milk cheese few weeks before the onset of fever

III- PATHOGENIE