Pediatric Brucellosis Clinical Presentation
- Author: Nicholas John Bennett, MB, BCh, PhD; Chief Editor: Russell W Steele, MD more...
History
In children, brucellosis is frequently a mild self-limiting illness and is less chronic than in adults. A key element in the history is exposure to an infected animal or food. Symptoms are nonspecific, usually occurring within 2-4 weeks of inoculation.
- Symptoms include weakness, excessive sweating, lethargy, anorexia, weight loss, arthralgia, myalgia, abdominal pain, and headache.[5]
- Symptoms in young children include refusal to eat, lassitude, refusal to bear weight, and failure to thrive.
- Brucellosis can present as a fever of unknown origin,[6] and the fever may undulate, repeatedly coming and going (hence, the term "undulant fever").
- In the chronic form, with longer than 1 year of illness (undiagnosed and untreated brucellosis), an afebrile pattern is typical, with a history of myalgia, fatigue, depression, and arthralgias (chronic fatigue syndrome is the most important disease in the differential diagnosis). The chronic form is primarily caused by B melitensis and usually affects adults older than 30 years. The chronic form is rare in children.
- Brucellosis is apparently the most commonly reported laboratory-acquired bacterial infection, according to the CDC. A history of direct contact or exposure to aerosolized bacteria might be elicited from exposed workers. This is an unlikely reason for pediatric cases.
Physical
Physical abnormalities can be minimal. Fever and minimal lymphadenopathy are the most common physical findings. Occasionally, hepatosplenomegaly may be present. Disease is infrequently localized; physical findings are predominately related to a single organ.
- Physical examination reveals hot swollen tender joints, with limited movement in patients with arthritis (most commonly knees, ankles, and hips).
- A point of tenderness and limited movement is present in patients with osteomyelitis.
- Sacroiliitis is rare in children.
- Nuchal rigidity, Kerning sign, and Brudzinski sign are seen if meningitis is the focal point.
- Papilledema, cranial nerve palsy, and focal neurologic deficits may be present in patients with increased intracranial pressure or brain abscess.
- Generalized tenderness, rebound tenderness, and sluggish or absent bowel sounds can be expected in patients with peritonitis.
- A tender swollen scrotum with erythema is present in patients with epididymoorchitis.
- A new or changing murmur may be detected in patients with infective endocarditis.
- A pericardial rub is present in patients with pericarditis.
Causes
Brucella species are small, fastidious, non–spore-forming, gram-negative coccobacilli. They lack flagella, endospores, capsules, and naturally occurring plasmids. Their metabolism is oxidative, and all strains are aerobic, although some species require carbon dioxide for primary isolation.
Brucellae have catalase activity, but oxidase activity varies. Most strains reduce nitrate to nitrite. Hydrogen sulfide production and urase activity also vary. The bacteria can be grown on various laboratory media, including serum dextrose, blood, and chocolate agar. Four species are pathogenic to humans: B abortus, B melitensis, B suis, and Brucella canis.
Table 1. Animal Hosts for Brucella Species (Open Table in a new window)
| Nomina Species | Biovars | Preferred Host |
| B abortus | 1-6, 9 | Cattle |
| B melitensis | 1-3 | Goats, sheep |
| B suis | 1-3 | Swine |
| 4 | Reindeer | |
| 5 | Rodents | |
| B canis | None | Dogs[7] |
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| Nomina Species | Biovars | Preferred Host |
| B abortus | 1-6, 9 | Cattle |
| B melitensis | 1-3 | Goats, sheep |
| B suis | 1-3 | Swine |
| 4 | Reindeer | |
| 5 | Rodents | |
| B canis | None | Dogs[7] |
| Age | Antimicrobial Agents | Dose |
| Patients >8 y | Doxycycline plus streptomycin or doxycycline plus gentamicin | Doxycycline: 2-4 mg/kg/d PO qd or divided bid for 6 wk; not to exceed 200 mg/d Streptomycin: 1 g/d IM for 2 wk Gentamicin: 3-5 mg/kg/d IM/IV divided q8h for 1 wk |
| Alternative in patients >8 y | Doxycycline plus rifampin | Doxycycline: 2-4 mg/kg/d PO qd or divided bid for 6 wk; not to exceed 200 mg/d Rifampin: 15-20 mg/kg/d PO for 6 wk; not to exceed 600-900 mg/d |
| Patients < 8 y | Trimethoprim-sulfamethoxazole (TMP-SMZ) plus rifampin | TMP-SMZ: 8-10 mg (based on TMP component)/kg/d for 45 d; not to exceed 2 double-strength tab/d Rifampin: 15-20 mg/kg/d PO for 45 d; not to exceed 600-900 mg/d |
| Patients >8 y with meningitis,* endocarditis, or osteomyelitis | Doxycycline plus streptomycin or doxycycline plus gentamicin | Doxycycline: 2-4 mg/kg/d PO qd or divided bid for 4-6 mo; not to exceed 200 mg/d Streptomycin: 20 mg/kg/d IM for 1-2 wk; not to exceed 1 g/d Gentamicin: 3-5 mg/kg/d IM/IV divided q8h for 1-2 mo |
| Patients < 8 y with meningitis,* endocarditis, or osteomyelitis | TMP-SMZ plus rifampin | TMP-SMZ: 8-10 mg (based on TMP component)/kg/d PO divided bid for 4-6 mo Rifampin: 15-20 mg/kg/d PO for 4-6 mo; not to exceed 600-900 mg/d |
| *The use of corticosteroids as adjunctive therapy to antibiotics may be beneficial in culture-proven meningitis. | ||
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