Brucellosis Management

Introduction

Brucellosis is a zoonotic disease caused by bacteria of the genus Brucella, characterized by an acute or insidious febrile illness with systemic manifestations that can affect multiple organs and tissues, and is transmitted mainly by consuming unpasteurized dairy products or through direct contact with infected animals, with a period of incubation of 2-4 weeks, according to the World Health Organization (WHO) 1
The disease has a worldwide distribution, with 500,000 new cases reported annually, and areas of high endemicity in the Mediterranean, Middle East, Latin America, Western Asia, and parts of Africa, according to the World Health Organization (WHO) 1

In endemic areas, strongly positive Brucella serology (titers ≥1:160) may be sufficient for diagnosis without additional testing, according to the Infectious Diseases Society of America 2
In patients with suspected brucellar vertebral osteomyelitis, image-guided aspiration biopsy is not necessary if blood cultures are positive for Brucella or if serology is strongly positive in endemic areas, as recommended by the Infectious Diseases Society of America 2
In non-endemic areas, ELISA screening followed by confirmatory agglutination test is recommended for laboratory confirmation, as suggested by the Centers for Disease Control and Prevention 2 and the Clinical Infectious Diseases guideline 2
MRI of the spine is mandatory when spinal involvement is suspected, regardless of the spinal level affected, as recommended by the American College of Radiology 3
Brain MRI should include T1-weighted pre- and post-contrast sequences, T2-weighted and FLAIR sequences, diffusion-weighted imaging, and fat-suppressed post-contrast T1-weighted images for better visualization of leptomeningeal enhancement 4
Spine MRI should include sagittal T1-weighted pre- and post-contrast sequences, sagittal and axial T2-weighted sequences, fat-suppressed post-contrast T1-weighted images, and whole spine imaging when disseminated disease is suspected 5

Neurobrucellosis can be confused with multiple sclerosis, which presents with similar white matter lesions 6
Tuberculous meningitis and neurosarcoidosis can also be confused with neurobrucellosis due to similar basal meningeal enhancement and granulomatous lesions 6
Fungal infections can present with similar granulomatous lesions to neurobrucellosis 5

The Infectious Diseases Society of America (IDSA) recommends a combination antibiotic approach for Brucella osteomyelitis, with a first-line regimen consisting of doxycycline and streptomycin, or an alternative regimen of doxycycline and rifampicin 2
The American College of Physicians recommends treating neurobrucellosis with spinal involvement with a combination of doxycycline plus rifampicin for 3-6 months, with the addition of an aminoglycoside (preferably streptomycin) for the first 2-3 weeks, with a strength of evidence rated as high 2
Doxycycline-Streptomycin (DOX-STR) is considered the first-line regimen, with Doxycycline: 100 mg twice daily orally for 6 weeks and Streptomycin: 15 mg/kg daily intramuscularly for 2-3 weeks, and an evidence level of AI (highest recommendation) 3
The duration of treatment for uncomplicated neurobrucellosis should be at least 3 months, while complicated spinal brucellosis (with abscesses) requires 6 months or longer, as recommended by the World Health Organization 2

Surgical intervention should be considered in scenarios such as progressive neurologic deficits, spinal deformity, instability, or persistent infection, as recommended by the IDSA 2
Surgical intervention is indicated in cases of spinal cord compression, spinal instability, presence of abscesses requiring drainage, or failure of medical treatment, as recommended by the North American Spine Society 3 and the American Academy of Orthopaedic Surgeons (AAOS) 1
The spine (especially if there is cervical involvement) should be immobilized to avoid devastating neurological complications, with a strength of evidence rated as high 3

The Centers for Disease Control and Prevention recommends pasteurization of dairy products, vaccination of livestock, use of personal protective equipment when handling potentially infected animals, and public education about risks of consuming unpasteurized dairy products to prevent brucellosis, including neurobrucellosis 2
The prevention and control of brucellosis can be achieved through a combination of measures, including the pasteurization of dairy products, vaccination of livestock, use of personal protective equipment, and education of the public about the risks of consuming unpasteurized dairy products, as recommended by the Food and Agriculture Organization (FAO) of the United Nations 7

Regular clinical assessment, inflammatory markers, and imaging are essential to evaluate treatment response, and patients should be monitored for at least 12 months after treatment completion to detect relapses, as suggested by the IDSA 2
Surgery should not be performed solely based on worsening imaging findings at 4-6 weeks if clinical symptoms, physical examination, and inflammatory markers are improving, according to the IDSA 2
Treatment failure rates of approximately 20% have been reported in patients with brucellar vertebral osteomyelitis, regardless of regimen, highlighting the need for careful monitoring and prolonged treatment 2
The IDSA notes that 65.6% of patients with brucellar vertebral osteomyelitis were successfully treated with antimicrobial therapy alone, with the most common regimens being streptomycin plus doxycycline, or doxycycline plus rifampin, with treatment duration of at least 3 months 2