I could smell there was something wrong with him: Clinical case of a decade of chronic undiagnosed brucellosis

Background

Brucellosis is a zoonotic infection, typically transmitted by ingestion of unpasteurised dairy products or direct contact with infected animals. It is associated with specific occupations, and travel to endemic countries. There are numerous reports of delayed diagnosis, particularly in non-endemic areas because diagnosis requires a high level of clinical suspicion. However, chronic brucellosis of 10-year duration is rare.

Case report

A 43-year-old previously well sportsman presented to primary care with acute flu-like symptoms and large joint arthralgia following travel to Southern France with his young family. The initial symptoms resolved, but recurred every few months over the subsequent decade with fever, depression, joint pain and malodorous perspiration. Approximately one year into the infection, a diagnosis of inflammatory polyarthritis was made, which was treated with oral corticosteroidssteroids.

However, this treatment was ineffective, and over the next nine years the patient experienced recurrent episodes of acute inflammation associated with extensive synovitis and severe erosive disease involving the left ankle and both knees, which eventually required joint replacement surgery.

Only following further microbiology testing Only during the work up for joint replacement surgery was the diagnosis of septic arthritis established when a small sinus track was identified discharging small amounts of serous fluid. Brucella melitensis was cultured from the ankle and knee joints and confirmed through serology. Following antibiotic treatment joint replacement was undertaken and the patient made an excellent recovery.

Conclusion

Although this patient had clinical features compatible with brucellosis, and relevant travel history, this diagnosis (nor any infective cause) was not considered for nearly a decade. Indeed, the initial steroid treatment could have exacerbated the infection.

We emphasise the importance of considering brucellosis in individuals who present with atypical osteoarticular inflammation, where there is a compatible travel history and for whom conventional microbiology has been negative.