Avicenna Journal of Clinical Medicine

Volume 31, Issue 3

Original Article

Bone and Joint Complications in Hospitalized Brucellosis Patients: A 10-Year Study in Hamadan, Iran

Peyman Eini1 , Narmin Karimian2, Azar Pirdehghan3, Pooya Eini4,*

1 Infectious Disease Research Center, Hamadan University of Medical Sciences, Hamadan, Iran

2 School of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran

3 Department of Community Medicine, Hamadan University of Medical Sciences, Hamadan, Iran

4 Toxicological Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran

*Corresponding author: Pooya Eini, Toxicological Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Email: pooyaeini.pe@sbmu.ac.ir

EXTENDED ABSTRACT

Background

Brucellosis is an important zoonotic infection and remains a public-health challenge in endemic areas of Africa, Central and South America, Asia, and the Mediterranean region [1, 2]. Iran and neighboring Middle Eastern countries remain among the areas where human brucellosis is regularly encountered, and national and regional studies cited in the original article have documented continuing disease occurrence [3, 4]. Brucella species are small, nonmotile, Gram-negative intracellular coccobacilli capable of infecting humans and several domestic animals [5]. Although isolation of Brucella by culture from blood or other body fluids is the definitive laboratory approach, culture and molecular methods are not always readily available because of time and resource limitations; consequently, serologic methods such as Rose Bengal, Wright agglutination, Coombs Wright, 2-mercaptoethanol, and ELISA are commonly used in clinical practice [4–6]. Osteoarticular involvement is among the most frequent focal manifestations of brucellosis, with reported frequencies varying widely across populations [6–9]. Sacroiliitis is frequently described in younger adults, whereas lumbar spondylitis is more prominent in older patients [6–9]. Back and spinal pain may be the presenting complaint and can mimic intervertebral-disc disease or sciatica, sometimes causing diagnostic delay or inappropriate intervention [10]. Brucellar spondylodiscitis may involve one or multiple spinal levels and, in complicated disease, can be associated with epidural or paravertebral extension and neurologic deficits [11–16]. Peripheral involvement can include arthralgia, arthritis, osteomyelitis, bursitis, tendinitis, and tenosynovitis, particularly in weight-bearing joints such as the hip and knee [17, 18]. Because musculoskeletal manifestations are common, nonspecific, and potentially disabling, defining their clinical pattern in endemic settings is important. The present study therefore evaluated bone and joint manifestations and complications among patients hospitalized with confirmed brucellosis at Sina Hospital in Hamadan over a 10-year period.

Methods

This retrospective descriptive study reviewed the medical records of 782 patients hospitalized with brucellosis at Sina Hospital in Hamadan, Iran, from 2011 through 2020. The study used an anonymous data-collection form, and information was extracted without personal identifiers. Definite brucellosis required compatible clinical findings together with confirmatory serology. Patients were excluded if they were younger than 14 years, had clinical findings without serologic confirmation, had a Wright agglutination titer below 1:160 or a 2-mercaptoethanol titer below 1:80, or had incomplete or insufficient medical records. Extracted variables included age, sex, educational status, season of infection, place of residence, exposure to livestock, consumption of unpasteurized dairy products, clinical manifestations, laboratory results, and recorded imaging findings and disease complications. The source article reports assessment of complications using imaging records, including MRI and other scan findings, and separately reports MRI and bone-scan results in the Results section. Data were entered into the designed form and analyzed using SPSS version 16. Descriptive analyses were used to summarize demographic characteristics, exposure history, clinical symptoms, musculoskeletal complaints, and disease complications. The study was approved by the Ethics Committee of Hamadan University of Medical Sciences (IR.UMSHA.REC.1399.623), and patient information was collected anonymously in accordance with the approved ethical procedures.

Results

Among the 782 hospitalized patients, 438 (56.1%) were men and 344 (43.9%) were women. Rural residents constituted 47.7% of the sample and urban residents 52.2%. The largest proportion of cases occurred in summer (32.8%), followed by spring (29.4%), autumn (19.0%), and winter (18.8%). Exposure histories were strongly suggestive of recognized transmission routes: 87.6% of patients reported consumption of unpasteurized dairy products and 57.2% reported livestock contact during the preceding year. Fever was the most frequent recorded clinical sign, occurring in 572 patients (73.1%). Weakness and fatigue were reported in 522 patients (66.7%), joint pain in 490 (62.7%), sweating in 459 (58.7%), headache in 167 (21.4%), and weight loss in 268 (34.3%). Musculoskeletal symptoms were prominent. Back pain was reported in 514 patients (65.7%), knee pain in 378 (48.3%), hip pain in 315 (40.3%), ankle pain in 234 (29.9%), wrist pain in 105 (13.4%), elbow pain in 93 (11.9%), and shoulder pain in 85 (10.9%). These findings identify axial and weight-bearing-joint pain as dominant components of the musculoskeletal presentation.

Table 3. Frequency of osteoarticular and musculoskeletal symptoms among hospitalized patients with brucellosis (n=782).

The principal osteoarticular complications were arthritis, spondylitis, and sacroiliitis. Arthritis was documented in 191 patients (24.4%), spondylitis in 120 (15.4%), and sacroiliitis in 105 (13.4%). Other reported disease complications included orchitis in 93 patients (11.9%), epididymo-orchitis in 58 (7.4%), meningitis in 8 (1.0%), and endocarditis in 4 (0.5%). Imaging findings also demonstrated a substantial burden of focal disease: complications were reported in 155 patients (19.9%) on MRI and in 144 patients (18.4%) on bone scan. In the discussion, the authors report a mean patient age of 44.2 years and note that the predominance of male patients was consistent with several previous regional and international studies, potentially reflecting greater occupational or animal exposure in men. The study also observed that cases were concentrated in spring and summer, consistent with seasonal patterns associated with livestock reproduction, milk production, and consumption of unpasteurized dairy products. Overall, the clinical data show that common systemic manifestations such as fever, weakness, fatigue, sweating, and arthralgia frequently coexist with substantial musculoskeletal involvement. The frequencies of arthritis, spondylitis, and sacroiliitis in this hospitalized cohort also fall within the broad ranges reported in the comparative literature discussed by the authors [19–30].

Table 4. Frequency of disease complications among hospitalized patients with brucellosis (n=782).

Conclusion

The clinical spectrum of hospitalized brucellosis in Hamadan was characterized by frequent fever, weakness and fatigue, joint pain, and substantial musculoskeletal involvement. Back pain and knee pain were especially common, while arthritis, spondylitis, and sacroiliitis were the leading bone and joint complications. MRI and bone-scan findings indicated that approximately one fifth of hospitalized patients had imaging-detected osteoarticular complications. These results support careful assessment of musculoskeletal complaints in patients with brucellosis, particularly in endemic settings where spinal or joint involvement can resemble other orthopedic or neurologic disorders and contribute to delayed diagnosis. Greater clinical awareness and appropriate imaging when indicated may help recognize focal complications and support timely management.

Keywords: Brucellosis, Bone Complications, Diagnosis

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