Brucellosis is a Gram-negative, aerobic zoonotic infection acquired by Brucella species and transmitted from animals to humansthrough the ingestion of infected food products, direct contact with an infected animal, or inhalation of aerosols. Usually, thedisease remains undiagnosed due to lack of awareness and inadequate reporting and is a challenging health problem in tropicalcountries. We report a case of 16-year-old male presenting to us with chronic inflammatory symmetric polyarthritis misdiagnosedas juvenile idiopathic arthritis but later found to be suffering from brucellosis on reevaluation. Through this case report, we wouldlike to highlight the possibility and advantage of the high degree of suspicion for an infectious etiology responsible for arthritis inthe background of autoimmunity and would also like to emphasize on the possibility of Brucella inducing a false-positive responsefor young patients presenting with arthritis

Anand, Rohit

Gupta, Kamlesh K

Mishra, Arvind K

Saini, Rohin

English

Atharva Scientific Publications (E-Jounals)

Vol 4 | Issue 3 | May - Jun 2018 Indian J Case Reports 206
Case Report
Brucellosis - A major differential for juvenile idiopathic arthritis
Arvind K Mishra1, Rohit Anand2, Kamlesh K Gupta3, Rohin Saini4
From 1Professor, 2Senior Resident, 3Assistant Professor, 4Resident, Department of Internal Medicine, King George Medical University, Lucknow, 
Uttar Pradesh, India
Correspondence to: Arvind K Mishra, 1/94, Viram Khand, Gomti Nagar, Lucknow, Uttar Pradesh, India. 
E-mail: anuarvindmisra@yahoo.com
Received – 26 March 2018 Initial Review – 22 April 2018 Published Online – 28 June 2018
Brucellosis is a zoonotic illness caused by genus Brucella and the species that cause human infection are Brucella suis, Brucella canis, Brucella melitensis, and 
Brucella abortus [1]. It commonly presents as pyrexia of unknown 
origin and can involve multiple systems, musculoskeletal 
being one of them, where it commonly presents as arthritis. It 
is transmitted from animals to humans through the ingestion of 
infected food products, direct contact with an infected animal, or 
inhalation of aerosols.
Brucellosis is reported as the world’s most common bacterial 
zoonosis, with an incidence of over half a million cases annually. 
The prevalence rate in some countries exceeds ten cases per 
100,000 population [2-4] and is higher in people working in 
organized farms. Despite being endemic in many developing 
countries, brucellosis is underdiagnosed and underreported in 
our country, which is mainly due to the ambiguous nature of the 
disease. The clinical presentation of brucellosis may resemble with 
various conditions, a major differential being juvenile idiopathic 
arthritis. Juvenile idiopathic arthritis, a clinically heterogeneous 
disorder with an unknown cause, is an enigma to the clinicians 
characterized by inflammatory changes within the joint in 
patients younger than the age of 16 years. It is responsible for 
acute and chronic disabilities in young children. It is considered 
as a diagnosis of exclusion and a common cause of arthritis in 
young patients [4].
Here, we report a case of a 16-year-old male presenting to us 
with chronic inflammatory symmetric polyarthritis misdiagnosed 
as juvenile idiopathic arthritis but later found to be suffering from 
brucellosis on reevaluation.
CASE REPORT
A 16-year-old male presented to our outpatient department with 
a complaint of the pain of right ankle and ball of the right foot 
for 4 months. The pain was of dull aching nature, gradual onset, 
non-radiating, and non-traumatic. Slowly, the pain progressed to 
the right knee and then the right shoulder and did not get relieved 
with ibuprofen medication. 2 months later, he developed pain in 
left shoulder and left ankle with eventual involvement of bilateral 
hip and sacroiliac joint and restriction of movements due to pain. 
There was no history of redness of eyes, burning micturition, and 
diarrhea.
Clinical examination of the joint showed no external signs 
of inflammation and swelling. His small joints, cervical spine, 
and temporomandibular joints were unaffected. His nails were 
normal, and no evidence of infection or pitting was present. Signs 
of skin scaling were absent.
X-rays of all joints did not reveal erosive changes. Laboratory 
investigations revealed normal total leukocytes with normal 
renal and liver profile, an erythrocyte sedimentation rate (ESR) 
of 6 mm/h, and c-reactive protein of 40 mg/L. Antistreptolysin 
O titers were negative with non-reactive enzyme-linked 
immunosorbent assay for immunoglobulin M (IgM), Epstein–
Barr, rubella, and coxsackie virus. His urine was negative for 
casts and pus cells along with negative for human leukocyte 
antigen b27 marker. He was also negative for rheumatoid factor 
and anti-citrullinated cyclic polypeptide. An antinuclear antibody 
(ANA) profile done was 2+ with a negative extractable nuclear 
antigen profile and negative anti ds-DNA. He was treated as a 
ABSTRACT
Brucellosis is a Gram-negative, aerobic zoonotic infection acquired by Brucella species and transmitted from animals to humans 
through the ingestion of infected food products, direct contact with an infected animal, or inhalation of aerosols. Usually, the 
disease remains undiagnosed due to lack of awareness and inadequate reporting and is a challenging health problem in tropical 
countries. We report a case of 16-year-old male presenting to us with chronic inflammatory symmetric polyarthritis misdiagnosed 
as juvenile idiopathic arthritis but later found to be suffering from brucellosis on reevaluation. Through this case report, we would 
like to highlight the possibility and advantage of the high degree of suspicion for an infectious etiology responsible for arthritis in 
the background of autoimmunity and would also like to emphasize on the possibility of Brucella inducing a false-positive response 
for young patients presenting with arthritis.
Key words: Arthritis, Brucella, Hip, Knee involvement
Mishra et al. Brucellosis as a differential for juvenile idiopathic arthritis
Vol 4 | Issue 3 | May - Jun 2018 Indian J Case Reports 207
case of idiopathic juvenile inflammatory arthritis and was started 
on steroids with which his pain and fever flared up.
Further investigation for infectious disease panel revealed 
IgM dengue negative and IgM Chikungunya negative. The sera 
was tested for Brucellosis using standard agglutination test, and a 
positive titer for IgM Brucella more than 1:40 (positive at >1:160) 
was observed in the patient. He was started on rifampicin 
600 mg/day and doxycycline 100 mg twice a day and continued 
for 6 weeks. The patient improved and made full recovery in due 
course of therapy.
DISCUSSION
Brucella infection associated with arthritis is seen in 10.25% 
of patients. The most commonly affected joints are the 
sacroiliac joint (26%), knee (25%), followed by hips (18%) 
and spine (8%) [5]. The disease frequently presents with non-
specific clinical manifestations such as fever, profuse sweating, 
polyarthralgia, and weight loss [6]. Systemic involvement of the 
disease often indicates brucellosis, and diagnosis can be made 
based on blood testing for brucellosis. In the localized form of the 
disease, systemic symptoms may be absent [5].
Brucellosis is a systemic infection which presents with wide 
clinical spectrum, ranging from an asymptomatic form of the 
disease to severe form causing death [7]. Arthritis may usually 
present in association with acute or undulant systemic disease. 
A polyarticular joint involvement, as seen in our patient with 
hip arthritis and without constitutional symptoms, is an unusual 
condition in brucellosis. Due to indolent presentation and moderate 
local signs of inflammation, the diagnosis of localized Brucella 
arthritis is difficult. The joint fluid examination is helpful in the 
diagnosis of Brucella arthritis, but the isolation of Brucella from 
synovial fluid is difficult due to the relative paucity of organisms 
present in specimens [8]. The standard agglutination test is the 
most widely used serological procedure, with a titer of >1/160. 
We have done standard agglutination test for Brucella which was 
found to be positive. There were a variety of serological tests, but 
at least two serological tests have to be combined to avoid false-
negative results. Usually, the serum agglutination test is used for 
the first screening, and Coombs test confirms its results [9]. In the 
present case, articular manifestations were the only symptoms of 
brucellosis, and systemic symptoms did not develop during the 
follow-up period.
Clinicians should not overlook the possibility of Brucella 
infection in children with arthritis. The diagnostic delay of 
Brucella arthritis can cause several complications such as 
dislocation and avascular necrosis of the hip [1,10,11]. Brucellosis 
should be considered in the differential diagnosis of arthritis in 
children, especially who comes from an area endemic for the 
disease. A detailed history of animal contact or the ingestion of 
unpasteurized milk or other products is required, and appropriate 
serological tests should be done.
CONCLUSION
After excluding most possible causes of inflammatory joint 
arthritis, we postulated that ANA-positive patients should be 
worked up for infective causes of arthritis even if there is an absence 
of fever. In tropical countries, this can aid in earlier detection of 
treatable causes of idiopathic arthritis of inflammatory origin 
along with special emphasis on Brucellosis which is frequently 
misdiagnosed and should always be considered as a differential 
when patients do not respond to standard therapy.
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Funding: None; Conflict of Interest: None Stated.
How to cite this article: Mishra AK, Anand R, Gupta KK, Saini R. 
Brucellosis - A major differential for juvenile idiopathic arthritis. Indian J 
Case Reports. 2018;4(3):206-207.


Brucellosis - A major differential for juvenile idiopathic arthritis

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Brucellosis - A major differential for juvenile idiopathic arthritis

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