eMedicine Specialties > Emergency Medicine > Warfare - Chemical, Biological, Radiological, Nuclear and Explosives

CBRNE - Brucellosis: Differential Diagnoses & Workup

Author: Gerald E Maloney Jr, DO, FAAEM, Senior Instructor, Department of Emergency Medicine, Case Western Reserve University School of Medicine; Director of Medical Toxicology, Department of Emergency Medicine; Associate Medical Director, MetroLifeFlight, MetroHealth Medical Center, Cleveland, OH
Contributor Information and Disclosures

Updated: Apr 29, 2009

Differential Diagnoses

Abortion, Septic
Osteomyelitis
Back Pain, Mechanical
Pneumonia, Bacterial
Brain Abscess
Pneumonia, Mycoplasma
Bronchitis
Pneumonia, Viral
CBRNE - Biological Warfare Agents
Spontaneous Bacterial Peritonitis
Depression and Suicide
Subarachnoid Hemorrhage
Endocarditis
Thrombocytopenic Purpura
Epididymitis
Tuberculosis
Gastroenteritis
Urinary Tract Infection, Female
Lumbar (Intervertebral) Disk Disorders
Urinary Tract Infection, Male
Meningitis

Other Problems to Be Considered

Typhus
Sacroiliitis
Erythema nodosum
Vasculitis

Workup

Laboratory Studies

  • Blood cultures
    • Blood cultures are positive in 10-90% of patients but are not particularly helpful in initial diagnosis of the disease.
    • Keep them for 2 months and reculture them onto solid media every week.
    • Because of the ease of aerosol transmission, handle any potential Brucella specimens under a biohazard hood.
  • Antibody testing
    • Antibody testing is the most reliable method for diagnosing brucellosis.
    • The best test is the tube agglutination method, which tests for anti-O-polysaccharide antibody. Titers of 1:160 or higher are diagnostic.
    • Enzyme-linked immunosorbent assay (ELISA) methods lack standardization.
  • Cerebrospinal fluid cultures
    • Obtain cerebrospinal fluid (CSF) cultures for suggested meningitis.
    • CSF demonstrates lymphocytic pleocytosis, elevated protein, and normal-to-low glucose.
    • CSF cultures are positive for brucellosis less than 50% of the time, but antibody testing of the fluid yields a diagnosis.
  • Complete blood count
    • CBC likely is ordered routinely as part of an evaluation for a patient with potential infectious disease.
    • Leukocytosis is rare, and a significant number of patients are neutropenic.
    • Anemia can be observed with chronic infection.
    • Thrombocytopenia may be observed secondary to hepatosplenomegaly or from immune thrombocytopenia.
  • Urinalysis and/or urine cultures
    • Urinalysis and/or culture and sensitivity may be sent in the presence of symptoms of urinary tract infection. It most likely demonstrates a sterile pyuria, similar to tuberculosis.
    • Send urine cultures, since the organism grows from the urine if the genitourinary tract is infected.
  • Arthrocentesis: Although significant joint effusion is uncommon, occasionally arthrocentesis may be needed to exclude septic arthritis. The joint aspirate demonstrates an exudative fluid with low cell counts and mononuclear predominance.

Imaging Studies

  • Chest radiography: Obtain a chest radiograph if respiratory symptoms are present or if a source of infection is not apparent. Chest radiographic findings in brucellosis are usually normal.
  • Cranial CT: Obtain a cranial CT scan for altered mental status or focal neurologic deficits. Although often normal, the CT scan may reveal evidence of acute or chronic brucella leptomeningitis, subarachnoid hemorrhage, or cerebral abscess.
  • Echocardiography
    • Echocardiography is used to evaluate for possible endocarditis. The primary site of vegetation is the aortic valve, with the sinus of Valsalva most commonly affected, followed by the mitral valve.
    • Mycotic aneurysms of the aorta or carotids may be observed on duplex arteriography.
  • Ultrasonography: Use of ultrasonography to diagnose testicular abscess from brucellosis has been reported; low-resistance flow appears to be characteristic for these tumors.2

Procedures

  • Arthrocentesis: Perform arthrocentesis for suggested septic arthritis. The joint aspirate demonstrates an exudative fluid with low cell counts and mononuclear predominance. Patients with brucellosis rarely present with acute monoarticular arthritis.
  • Bone marrow biopsy: Although not an emergency department (ED) procedure, bone marrow biopsy may be required to establish a diagnosis in certain patients.
  • Liver biopsy: While not an ED procedure, percutaneous biopsy may be needed in the patient with liver granulomas to obtain a specimen for diagnosis.

More on CBRNE - Brucellosis

Overview: CBRNE - Brucellosis
Differential Diagnoses & Workup: CBRNE - Brucellosis
Treatment & Medication: CBRNE - Brucellosis
Follow-up: CBRNE - Brucellosis
References
[ CLOSE WINDOW ]

References

  1. Celebi G, Kulah C, Kilic S, Ustundag G. Asymptomatic Brucella bacteraemia and isolation of Brucella melitensis biovar 3 from human breast milk. Scand J Infect Dis. 2007;39(3):205-8. [Medline].

  2. Koc Z, Turunc T, Boga C. Gonadal brucellar abscess: imaging and clinical findings in 3 cases and review of the literature. J Clin Ultrasound. Sep 2007;35(7):395-400. [Medline].

  3. Hegazy YM, Ridler AL, Guitian FJ. Assessment and simulation of the implementation of brucellosis control programme in an endemic area of the Middle East. Epidemiol Infect. Mar 17 2009;1-13. [Medline].

  4. Brouillard JE, Terriff CM, Tofan A, Garrison MW. Antibiotic selection and resistance issues with fluoroquinolones and doxycycline against bioterrorism agents. Pharmacotherapy. Jan 2006;26(1):3-14. [Medline].

  5. CDC. From the Centers for Disease Control and Prevention. Suspected brucellosis case prompts investigation of possible bioterrorism-related activity--New Hampshire and Massachusetts, 1999. JAMA. Jul 19 2000;284(3):300-2. [Medline].

  6. Dimitrov Ts, Panigrahi D, Emara M, et al. Seroepidemiological and microbiological study of brucellosis in Kuwait. Med Princ Pract. Jul-Aug 2004;13(4):215-9. [Medline].

  7. Franz DR, Jahrling PB, Friedlander AM, et al. Clinical recognition and management of patients exposed to biological warfare agents. JAMA. Aug 6 1997;278(5):399-411. [Medline].

  8. Hasanjani Roushan MR, Mohraz M, Hajiahmadi M, et al. Efficacy of gentamicin plus doxycycline versus streptomycin plus doxycycline in the treatment of brucellosis in humans. Clin Infect Dis. Apr 15 2006;42(8):1075-80. [Medline].

  9. Henry NK, Wilson WR, Hendley JO. Infections caused by Brucella, Francisella Tularensis, Pasteurella, Yersinia species, and Bordetella pertussis. In: Stein, ed. Internal Medicine. 5th ed. 1998:1604-1607.

  10. Hoover DL, Friedlander AM. Brucellosis. In: Textbook of Military Medicine: Medical Aspects of Chemical and Biological Warfare. 1997:513-521.

  11. Kocak I, Dundar M, Culhaci N, Unsal A. Relapse of brucellosis simulating testis tumor. Int J Urol. Aug 2004;11(8):683-5. [Medline].

  12. Mantur BG, Akki AS, Mangalgi SS, et al. Childhood brucellosis--a microbiological, epidemiological and clinical study. J Trop Pediatr. Jun 2004;50(3):153-7. [Medline].

  13. Med Lett Drugs Ther. Drugs and vaccines against biological weapons. Med Lett Drugs Ther. Feb 12 1999;41(1046):15-6. [Medline].

  14. Pappas G, Papadimitriou P, Akritidis N, et al. The new global map of human brucellosis. Lancet Infect Dis. Feb 2006;6(2):91-9. [Medline].

  15. Taliani G, Bartoloni A, Tozzi A, et al. Lumbar pain in a married couple who likes cheese: brucella strikes again!. Clin Exp Rheumatol. Jul-Aug 2004;22(4):477-80. [Medline].

  16. Tohme A, Zein E, El Rassi B, et al. [Human brucellosis in Lebanon. Clinical features and therapeutic responses in 88 patients]. J Med Liban. Jul-Sep 2004;52(3):149-55. [Medline].

  17. Tur BS, Suldur N, Ataman S, et al. Brucellar spondylitis: a rare cause of spinal cord compression. Spinal Cord. May 2004;42(5):321-4. [Medline].

  18. Ustun I, Ozcakar L, Arda N, et al. Brucella glomerulonephritis: case report and review of the literature. South Med J. Dec 2005;98(12):1216-7. [Medline].

  19. White SR, Eitzen EM. Hazardous materials exposure. In: Emergency Medicine: A Comprehensive Study Guide. 5th ed. 2000:1201-14.

  20. Young EJ. Brucella species. In: Principles and Practices of Infectious Diseases. 3rd ed. 1995:2053-2057.

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

Malta fever, Crimean fever, undulant fever, Brucella, zoonotic infection, brucellosis infection, brucellae, Brucella suis, Brucella melitensis, Brucella abortus, Brucella canis, Brucella species

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Gerald E Maloney Jr, DO, FAAEM, Senior Instructor, Department of Emergency Medicine, Case Western Reserve University School of Medicine; Director of Medical Toxicology, Department of Emergency Medicine; Associate Medical Director, MetroLifeFlight, MetroHealth Medical Center, Cleveland, OH
Gerald E Maloney Jr, DO, FAAEM is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, American College of Osteopathic Emergency Physicians, American Osteopathic Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Jerry L Mothershead, MD, Medical Readiness Consultant, Medical Readiness and Response Group, Battelle Memorial Institute; Advisor, Technical Advisory Committee, Emergency Management Strategic Healthcare Group, Veteran's Health Administration; Adjunct Associate Professor, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences
Jerry L Mothershead, MD is a member of the following medical societies: American College of Emergency Physicians and National Association of EMS Physicians
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Robert G Darling, MD, FACEP, Clinical Assistant Professor of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine; Associate Director, Center for Disaster and Humanitarian Assistance Medicine
Robert G Darling, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, and Association of Military Surgeons of the US
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.