eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Brucellosis: Differential Diagnoses & Workup

Author: Nicholas John Bennett, MBBCh, PhD, Staff Physician, Department of Pediatrics, State University of New York Upstate Medical University
Coauthor(s): Joseph Domachowske, MD, Associate Professor, Department of Pediatrics, Division of Infectious Diseases, State University of New York-Upstate Medical University; Walid Abuhammour, MD, FAAP, Associate Professor of Pediatrics, Michigan State University; Director of Pediatric Infectious Disease, Department of Pediatrics, Hurley Medical Center; Khaled Nashar, MD, Instructor of Clinical Internal Medicine, Section of Hospitalist Medicine, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh Medical Center
Contributor Information and Disclosures

Updated: Jan 25, 2008

Differential Diagnoses

Chronic Fatigue Syndrome
Influenza
Coccidioidomycosis
Mononucleosis and Epstein-Barr Virus Infection
Histiocytosis
Tuberculosis
Histoplasmosis
Tularemia

Other Problems to Be Considered

Acute brucellosis

Typhoid fever
Tularemia
Rickettsial diseases
Tuberculosis
Influenza
Infectious mononucleosis
Histoplasmosis
Coccidioidomycosis

Chronic brucellosis

Malignant histocytosis
Lymphoma
Fever of unknown origin

Workup

Laboratory Studies

  • Diagnosis is definitive when Brucella organisms are recovered from blood, bone marrow, or other tissue. Some Brucella species require 5-10% carbon dioxide for primary isolation. In vitro replication is fairly slow; therefore, alert laboratory personnel to maintain cultures for 4 weeks or longer. Blood culture results can be positive in 75% of patients with acute disease, while bone marrow culture allows isolation in 90% of patients.
  • The serum agglutination test (SAT) uses killed B abortus cells as antigen. SAT is the most commonly used serologic test and detects antibodies against B abortus, B suis, and B melitensis. B canis– specific antigen is used to detect its antibodies. SAT titers of 1:160 or higher indicate active infection. Repeat serologic tests are recommended if the initial titers are low.
  • The 2-mercaptoethanol test detects immunoglobulin G (IgG), and titers higher than 1:80 define active infection. A high IgG antibody titer or a titer that is higher after treatment suggests persistent infection or relapse. Prozone inhibition can cause false-negative results in the presence of sera with high titers, and dilution of sera is necessary to avoid this problem. Brucella antibodies can possibly cross-react with other organisms, such as Yersinia enterocolitica serotype O9, Francisella tularensis, and Vibrio cholera. Enzyme immunoassay (EIA) is the most sensitive method for detection of immunoglobulin M (IgM), immunoglobulin A (IgA), and IgG anti -Brucella antibodies.
  • Polymerase chain reaction (PCR) tests have been developed for the detection and rapid diagnosis of Brucella species in human blood specimens but are only available in specialist laboratories.7
  • WBC counts in patients with brucellosis are usually within reference range or lower. Anemia is reported in 75% of patients, thrombocytopenia is reported in 40%, and pancytopenia is reported in 6% of patients.
  • Elevated levels of liver enzymes may reflect the severity of hepatic involvement and correlate clinically with hepatomegaly.

Imaging Studies

  • Scanning techniques, including CT scanning and MRI, can be used for diagnosis of an occult focus of infection.

Other Tests

  • Bone marrow examination may reveal erythrophagocytosis. Microangiopathic hemolytic anemia, thrombocytopenic purpura,8 and Coombs-positive hemolytic anemia have been reported in brucellosis.
  • Neurobrucellosis: Cerebral spinal fluid (CSF) reveals pleocytosis, elevated protein levels, and hypoglycorrhea. CSF culture results are positive in fewer than 50% of patients. CSF antibodies are present in most patients.

Procedures

  • Bone marrow aspiration and lumbar puncture can be performed, if indicated.

Histologic Findings

  • Analysis of liver biopsy specimens may reveal granulomatous hepatitis and hepatic microabscesses. Specimens from bone marrow biopsy may test positive for granulomas, hemophagocytosis, or both.

More on Brucellosis

Overview: Brucellosis
Differential Diagnoses & Workup: Brucellosis
Treatment & Medication: Brucellosis
Follow-up: Brucellosis
References
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References

  1. Doyle TJ, Bryan RT. Infectious disease morbidity in the US region bordering Mexico, 1990-1998. J Infect Dis. Nov 2000;182(5):1503-10. [Medline].

  2. Pappas G, Papadimitriou P, Akritidis N, Christou L, Tsianos EV. The new global map of human brucellosis. Lancet Infect Dis. Feb 2006;6(2):91-9. [Medline]. [Full Text].

  3. Shakir RA. Neurobrucellosis. Postgrad Med J. Dec 1986;62(734):1077-9. [Medline].

  4. Tena D, Gonzalez-Praetorius A, Lopez-Alonso A, et al. Acute meningitis due to Brucella spp. Eur J Pediatr. May 12 2006;[Medline].

  5. al-Eissa YA, Kambal AM, al-Nasser MN, et al. Childhood brucellosis: a study of 102 cases. Pediatr Infect Dis J. Feb 1990;9(2):74-9. [Medline].

  6. Sharda DC, Lubani M. A study of brucellosis in childhood. Clin Pediatr (Phila). Oct 1986;25(10):492-5. [Medline].

  7. Mitka S, Anetakis C, Souliou E, Diza E, Kansouzidou A. Evaluation of different PCR assays for early detection of acute and relapsing brucellosis in humans in comparison with conventional methods. J Clin Microbiol. Apr 2007;45(4):1211-8. [Medline].

  8. Young EJ, Tarry A, Genta RM, et al. Thrombocytopenic purpura associated with brucellosis: report of 2 cases and literature review. Clin Infect Dis. Oct 2000;31(4):904-9. [Medline].

  9. Lubani MM, Dudin KI, Sharda DC, et al. A multicenter therapeutic study of 1100 children with brucellosis. Pediatr Infect Dis J. Feb 1989;8(2):75-8. [Medline].

  10. Roushan MR, Mohraz M, Janmohammadi N, Hajiahmadi M. Efficacy of cotrimoxazole and rifampin for 6 or 8 weeks of therapy in childhood brucellosis. Pediatr Infect Dis J. Jun 2006;25(6):544-5. [Medline].

  11. Corbel MJ. Vaccines against bacterial zoonoses. J Med Microbiol. Apr 1997;46(4):267-9. [Medline].

  12. Lubani M, Sharda D, Helin I. Brucella arthritis in children. Infection. Sep-Oct 1986;14(5):233-6. [Medline].

  13. al-Eissa YA, al-Mofada SM. Congenital brucellosis. Pediatr Infect Dis J. Aug 1992;11(8):667-71. [Medline].

  14. Committee on Infectious Diseases. Brucellosis. In: Red Book. 27th Ed. 2006:235-237.

  15. Schultze GE, Jacobs RF. Brucella. In: Behrman RE, Kliegman R, Jenson HB, eds. Nelson Textbook of Pediatrics. 16th ed. Philadelphia, Pa: WB Saunders; 2000:868-9.

  16. Trifiletti RR, Restivo DA, Pavone P, et al. Diabetes insipidus in neurobrucellosis. Clin Neurol Neurosurg. Sep 2000;102(3):163-5. [Medline].

  17. Young EJ. An overview of human brucellosis. Clin Infect Dis. Aug 1995;21(2):283-9; quiz 290. [Medline].

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Further Reading

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Keywords

brucellosis, Brucella abortus, Brucella melitensis, Brucella suis, Brucella canis, Brucella infection, zoonosis, Mediterranean fever, Malta fever, gastric remittent fever, undulant fever, sarcoidosis, endocarditis, sacroiliitis, epididymoorchitis, meningitis, papilledema, optic neuropathy, radiculopathy, stroke, intracranial hemorrhage, neurobrucellosis, hepatic abscess, splenic abscess, thyroid abscess, epidural abscess, pneumonitis, pleural empyema, uveitis, peritonitis, food-borne brucellosis, failure to thrive, chronic fatigue syndrome, hepatosplenomegaly, lymphadenopathy, arthritis, osteomyelitis

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Contributor Information and Disclosures

Author

Nicholas John Bennett, MBBCh, PhD, Staff Physician, Department of Pediatrics, State University of New York Upstate Medical University
Nicholas John Bennett, MBBCh, PhD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Coauthor(s)

Joseph Domachowske, MD, Associate Professor, Department of Pediatrics, Division of Infectious Diseases, State University of New York-Upstate Medical University
Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Walid Abuhammour, MD, FAAP, Associate Professor of Pediatrics, Michigan State University; Director of Pediatric Infectious Disease, Department of Pediatrics, Hurley Medical Center
Walid Abuhammour, MD, FAAP is a member of the following medical societies: American Medical Association and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

Khaled Nashar, MD, Instructor of Clinical Internal Medicine, Section of Hospitalist Medicine, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh Medical Center
Khaled Nashar, MD is a member of the following medical societies: American College of Physicians, American Medical Association, and American Society of Hypertension
Disclosure: Nothing to disclose.

Medical Editor

Itzhak Brook, MD, MSc, Professor, Department of Pediatrics, Georgetown University School of Medicine
Itzhak Brook, MD, MSc is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians-American Society of Internal Medicine, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, Armed Forces Infectious Diseases Society, Association of Military Surgeons of the US, Infectious Diseases Society of America, International Immunocompromised Host Society, International Society for Infectious Diseases, Medical Society of the District of Columbia, New York Academy of Sciences, Pediatric Infectious Diseases Society, Society for Ear, Nose and Throat Advances in Children, Society for Experimental Biology and Medicine, Society for Pediatric Research, Southern Medical Association, and Surgical Infection Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Mark R Schleiss, MD, American Legion Chair of Pediatrics, Professor of Pediatrics, Division Director, Division of Infectious Diseases and Immunology, Department of Pediatrics, University of Minnesota School of Medicine
Mark R Schleiss, MD is a member of the following medical societies: American Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Society for Pediatric Research
Disclosure: Nothing to disclose.

CME Editor

Robert W Tolan Jr, MD, Chief of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Consulting; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching; sanofi pasteur Grant/research funds Unrestricted research grant; sanofi pasteur  Consulting; sanofi pasteur Honoraria Speaking and teaching; Tap Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD, Professor and Vice Chairman, Department of Pediatrics, Head, Division of Infectious Diseases, Louisiana State University Health Sciences Center
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

 
 
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