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Clinical Manifestations And Outcomes Of Treatment In 38 Cases Of Brucellar Spondylitis In Babol, Northern Iran

*M.R.Hasanjani Roushan,  #N Janmohammadi, жM. Ataie, **A. Bijani

*Department of Infectious Diseases, Yahyanejad Hospital, Babol Medical University, Babol, Iran.
#Department of Orthopedics, Babol Medical Univrsity, Babol, Iran.
жDepartment of Neurosurgery, Babol Medical University, Babol, Iran.
**Department of Research Center, Babol Medical University, Babol, Iran

Address for Correspondence

M.R.Hasanjani Roushan,
Department of Infectious Diseases,
Yahyanejad Hospital, Babol Medical University, Babol 4717641367, Iran.
Fax: +98 111 2224032, +98 111 2227667
Tel: +98 111 3234387


For assessing the clinical features and outcome of treatment in brucellar spondylitis, this study was conducted on 38 cases with brucellar spondylitis from April 1998 through December 2004. Twenty-five (65.8%) cases were males. The mean age of the patients was 45.9(±17) years. Back pain, sweating, fever and arthralgia, were the most common clinical manifestations. The disease was acute in 19 (50%), sub- acute in 16 (42.1%) and chronic in 3 (7.9 %) of the cases. Brucellar spondylitis was seen in 31 (81.6%) cases in lumbar and lumbo-sacral, in 2 (5.3%) cases in dorsal and in 3 (7.9%) cases in cervical regions. Twelve cases were treated with doxycycline plus Rifampicillin for 4 months. Relapse was seen in 2 (16.6%) cases. Relapse was seen in 1 (9.1%) of the eleven cases who were treated with cotrimoxasol plus Rifampicillin for 4 months. Relapse was not seen in fifteen cases treated with streptomycine for 14 days plus doxycycline and Rifampicillin for 4 months. Brucellar spondylitis may develop in any site of the spine mostly in lumbar region. Streptomycin for 14 days and doxycycline plus Rifampicillin for four months is a better regimen for therapy of brucellar spondylitis.

Keywords: Brucellar spondylitis, clinical manifestations, treatment

J.Orthopaedics 2006;3(1)e2


Brucellosis is still an important public health problem and is endemic in many countries throughout the world including Iran 1-3. Osteoarticular disease is the most common complication of brucellosis and has been described in 10-85% of patients 1,4. Spondylitis is the most prevalent and important clinical form of osteoarticular involvement in adults with infection due to brucella species 5-7

Brucellosis is a relative common cause of vertebral osteomyelitis in endemic areas 8-11. This complication was reported between 8-13.8% 5,7,12,13. Spondylitis may be complicated by potentially devastating neurological defects that must be considered in endemic areas 14,15.It may be difficult to diagnosis and can be complicated by potentially devastating neurological or vascular conditions 16,17. Treatment of brucellar spondylitis remains controversial regarding the selection of antibiotics, the duration of treatment and the role of surgery .It is often debilitating and difficult to treat and there is no consensus on the preferred combination of antibiotic 14. The purpose of this study was to assess the clinical manifestations and outcome of treatment in 38 cases of brucellar spondylitis in Babol, northern Iran.

Material and Methods :

From April 1998 through December 2004, thirty-eight cases of brucellar spondylitis were diagnosed and followed prospectively at the General Hospital of Yehyanejad, Babol, north of Iran. This hospital serves more than 500000 people living our region and department of infectious diseases serves more than two million people living in the west of the province Mazanderan, Iran. The diagnosis of brucellosis was established by standard tube agglutination test (STAT) with a titre ≥1: 320 and a titre in 2-mercaptoethanol (2-ME) ≥1: 160 for patients with clinical signs and symptoms compatible with brucellosis. For spondylitis, the radiographic findings were recorded by determining epiphysitis of the anterosuperior angle of the vertebra, narrowing of the disc space, erosion, sclerosis, vertebral collapse and osteomyelitis. Diagnosis of spondylitis was confirmed by magnetic resonance imaging (MRI). We also assessed CBC, hemoglobin, erythrocyte sedimentation rate and C-Reactive Protein (CRP) in all cases, and findings compared with the normal ranges in references 18. Clinical type (the onset of clinical symptoms and signs to diagnosis) was classified as acute (less than two months) and sub- acute (more than two months to on year) and chronic (more than one year). Three regimens of therapy were given to the patients as following: Doxycyclie plus Rifampicillin to all patient admitted from April 1998 to September 2000,Co-trimoxasol plus Rifampicillin to all patients from October 2000 to April 2001 and Streptomycin 1gr/day for two weeks plus doxycycline and Rifampicillin was given to all patients from May 2001 to December 2004. The dosage of doxycycline was 100 mg twice daily, and dosage of co- trimoxasol was 6 mg/kg/day of the trimethoprime component divided into 2 doses and the dosage of Rifampicillin was 15mg/kg once a day and streptomycin 1gr/IM/day. All of these combinations were given for four months.

Patients were assessed every 20 days during therapy and reassessed every three months interval after completion of therapy as well as whenever clinical symptoms reappeared. Duration of follow - up for all cases was one year.

Relapse was said to occur when the indicative clinical picture reappeared and reduced titer of STAT or 2 ME after treatment, increased again. Symptoms or signs of the disease that persisted at the end of treatment defined therapeutic failure. X2- test and Fisher’s exact tests (when appropriate) were used for categorical variables and Student’s t-test was used to compare mean values. Differences with a P value of < 0.05 were considered significant.

Results :

Sixteen patients underwent the procedure in the last 2 years. All of them were referred from the orthopedics department. All were done electively. Seven patients underwent the procedure for defects in the region of the Achilles tendon – either immediately for inadequate soft tissue cover, or for later skin necrosis post repair. Nine patients underwent the procedure for exposed tibia in the lower third of the leg.

Table 1: Clinical manifestation and laboratory test results in 38 cases of brucellar spondylitis











Type of disease:








    Sub acute





Back pain                                     



















Normal Hb

17 (68)











Predisp factor




Normal ESR




CRP; C- Reactive Protein, ESR; Erythrocyte Sedimentation Rate, Hb; Hemoglobin. There were not any differences in clinical manifestations and test results between sexes (P>0.05%)

Out of the 16 patients, 2 were females and the rest, males. The ages ranged from 14 years to 65 years, the average being 36.8. Two people were diabetics and 2 had peripheral vascular disease as demonstrated by color Doppler.

Table 2: Spinal involvement in 38 cases of brucellar spondylitis

Vertebral level                                               




     L1, L2


     L2, L3


     L3, L4


     L4, L5




     L1, L2, L3


     Facet Joint arthritis of L4 and L5


     L3, L4, T1


     L1, L2, L3, T9-T12









The sizes of the flaps ranged from 4 X 3 cm to 12 X 10 cm. Three of the flaps underwent complete necrosis. One flap had minimal rim necrosis. All the rest survived totally and provided satisfactory cover. One patient complained of excessive bulk and underwent flap thinning twice. There were no cases of florid infection, hematoma or total graft loss at the donor site.

Four of the cases were done under spinal anesthesia and 1 under general anesthesia. Ten cases were done under combined sciatic and femoral nerve block, which made the prone positioning and the position changes needed during graft harvest and inset of the flap, very simple.

Discussion :

During the study 823 cases of brucellosis were admitted in our department and among them, 38 (4.6%) cases had brucellar spondylitis. Twenty-five (65.8%) cases were males and 13 (34.2%) were females. Mean age of the male patients was 42.7±16 years and for females was 51.5±18 years (P=0.716). The total mean age of the patients was 45.9±17 years ranged 7 to 77 years. Twenty -eight cases (73.7%) were from rural areas. Eleven (28.9%) cases had a history of consumed unpasturised cheese, 10 cases were husbandry and the remainders of 17 cases (44.7%) had no predisposing factor for brucellosis. The mean days from the onset of disease to diagnosis was 100±106 days ranged 7 days to 410 days. The disease was acute in 19 (50%) and sub- acute in 16 (42.1%) and chronic in 3 (7.9 %) of the cases. Risk factor for brucellosis were reported from 43.3% of the patients. The most common clinical symptoms and signs were back pain, sweating, fever and arthralgia and were found in 38 (100%), 31 (81.6%), 28 (73.7%) and 13 (34.2%) of the cases, respectively. Lecucytosis and normal sedimentation rate were seen in 9 (23.7%) and 30 (78.9%) cases, respectively. The distribution of the clinical symptoms and signs of the patients between sexes are shown in table 1.Single focal involvement of two vertebrae was seen in twenty-eight cases (figure 1), single focal involvement of one vertebra in 6 cases and single focal involvement of more than two adjacent or non-continuous vertebrae in three cases (figure 2). One case had left facet Joint arthritis of L4 and L5. Spondylitis was seen in 31 (81.6%) cases in lumbar and lumbodorsal, in 2 (5.3%) cases in dorsal and in 3 (7.9%) cases in cervical regions (table 2). Among twelve cases who were treated with doxycycline plus Rifampicillin, relapse was seen in 2 (16.6%) cases. Relapse was seen in 1 (9.1%)case of the eleven cases who were treated with cotrimoxasol plus Rifampicillin.

No relapse was seen among fifteen cases who were treated with streptomycine, doxycycline and Rifampicillin.


Brucellosis is still endemic in Iran and consumption of unsafe dairy product as well as occupational exposure are the mean route of transmission of brucellosis both in rural and urban residents like the reports of other researchers in endemic regions 6,7,19,20. Osteoarticular involvement is the commonest complication of brucellosis with varying degrees of frequency 5-8,19.Brucellar spondylitis is one of the most frequent complications of Brucellosis and frequently seen in geographic areas of the world which brucella melitensis is endemic 9-11,16, 21,22. The frequency of spondylitis in brucellosis ranges from 2% to 53% in different studies 5,8,19,23,24.Brucellar spondylitis occurs most commonly in adults aged between 50 and 60 years. The mean age of our series of patients was much lower than the results of other studies 13,25. Because of the demographic features of human brucellosis in Iran most patients in this study were males, and had occupational risk factors, like the results of other studies in endemic areas 6-7,12,13. Whereas in the study from Portugal and Israel, the disease predominated in females and was mainly caused by ingestion of unpasturized dairy product 26-28. The most common clinical symptoms and signs in these series of patients were back pain, sweating, fever and arthralgia and were similar to the report of other researchers in endemic areas 10-13,23-25. In the present study, spondylitis occurred most frequently in the lumbar region, followed by cervical and thoracic locations. The pattern of the involvement of the spine in our study was similar to the results of other researchers 13,15,20,25,28. But unlike the results of these studies, paravertebral soft tissue swelling, epidural and paravertebral abscess were not seen in our series of patients. Lack of these complications in our patients may be due to early identification of the patients and administration of appropriate treatment. Involvement of the spine may be either focal or diffuse, with a predilection to the lumbar region 28. Spondylitis with neurobrucellosis was seen in one of our cases. Lopes et al reported two cases of spondylitis with neurobrucellosis among 17 patients with brucellar spondilitis in Portugal 26.Arevalo Lorido et al reported a case of brucellar spondylitis with meningoencephalitis 29.In our series of cases, both lumbar and dorsal and lumbar and cervical spondylitis were seen in 2 cases and 1 case respectively. Other researchers also reported more than two anatomic sites of the spine for involvement 13,30.Management of brucellar spondylitis remains controversial regarding the selection of antibiotics, the duration of treatment and the role of surgery. In our study, with streptomycin 1 gr/day for 14 days plus doxycycline and Rifampicillin for four months we have not seen any relapse. Relapse was seen in two cases treated by doxycycline plus Rifampicillin and in one case treated with cotrimoxasol plus Rifampicillin for four months. A study from Turkey showed that with regimens such as doxycycline plus Rifampicillin, ofloxacine plus Rifampicillin for 45 days the relapse rates were 15% and 26%, respectively. They also treated 22 patients with streptomycin 1 g/day i.m for 15 days and doxycycline 100 mg every 12 h orally for 45 days plus rifampicin 15 mg/kg per day in a single morning dose orally for 45 days (SDR). They had no relapse with this regimen 31. Some recommended the use of a combination of doxycycline and ciprofloxacin for a period of 3 months. Successful use of this combination in five patients with spondylitis also was reported 14. In Summary, brucellar spondylitis may occur in any site of the spine mostly in lumbar region. Streptomycin for 14 days and doxycycline plus Rifampicillin for 4 months is a better regimen for treatment of   brucellar Spondylitis.   

Acknowledgement: The authors express their appreciation to Mohammad Jafar Soleimani Amiri.Ph.D, for performing the laboratory tests.                                                                                                                  

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This is a peer reviewed paper 

Please cite as : M.R.Hasanjani Roushan: Clinical Manifestations And Outcomes Of Treatment In 38 Cases Of Brucellar Spondylitis In Babol, Northern Iran

J.Orthopaedics 2006;3(1)e2





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