Bone and joint complications are the most common manifestation of chronic and relapsing brucellosis, occurring in 10-80% of cases in various studies (Mousa et al. 1987; Tasova et al. 1999; Zaks et al. 1995). Arthritis is usually peripheral and monoarticular and often involves the knee or hip; however, some patients develop polyarthritis (Geyik et al. 2002; Gotuzzo et al. 1982; Gotuzzo et al. 1987; Hasanjani Roushan et al. 2004). Peripheral arthritis may be infectious (in which case it is usually monoarticular, and the organism may be recovered from the joint) or reactive (in which case involvement is often polyarticular or pauciarticular, and the organism will not be recovered from the joint) (Bravo et al. 2003). Sacroiliitis is the second-most frequent articular lesion (Alarcon et al. 1981; Ariza et al. 1993; Khateeb et al. 1990); it is usually unilateral. Spondylitis may affect 5-10% of patients with Brucella arthritis (Ariza et al. 1985; Gotuzzo et al. 1982; Namiduru et al. 2004; Solera et al. 1999). Radiographic features may include the presence of lytic and blastic lesions, erosion of the anterior superior part of the vertebral body (a “parrot peak” sign) (Ibero et al. 1997), and spondylodiscitis. Postinfection spondyloarthritis, bursitis, tenosynovitis, and infection of joint prostheses have also been reported (Weil et al. 2003). Although any joint might be involved during brucellosis, arthritis of the hips and knees is most common during acute disease and is usually manifested within 12 months of infection; involvement of the axial skeletal system and spondylitis are most common during chronic disease; and sacroiliitis might occur during either acute disease or chronic disease (Akritidis and Pappas 2001; Ariza et al. 1985; Colmenero et al. 1996; Doganay et al. 1993; Gotuzzo et al. 1987; Mousa et al. 1987; Namiduru et al. 2004; Norton 1984).

The committee concludes that there is sufficient evidence of an association between brucellosis and arthritis and spondylitis. Arthritis is usually manifested within 12 months of the acute illness; spondylitis might be manifested later.

Hepatic Involvement

Human brucellosis is often associated with changes in liver function and has been associated with granulomatous hepatitis (Harrington et al. 1982; Lulu et al. 1988; Williams and Crossley 1982). Hepatomegaly may be present (Lulu et al. 1988), but cirrhosis has not been reported. Chronic abscesses of the liver and spleen may occur (Ariza et al. 2001; Colmenero et al. 2002; Vallejo et al. 1996).

The committee concludes that there is sufficient evidence of an association between brucellosis and hepatic abnormalities, including granulomatous hepatitis.

Neurologic Involvement

Neurobrucellosis has been reported in 1-5% of adults who have Brucella infections (al Deeb et al. 1989; Bashir et al. 1985; Bouza et al. 1987; Young 1983). It usually involves meningitis or meningoencephalitis that is often chronic (al Deeb et al. 1989; Bashir et al. 1985; Bodur et al. 2003; Bouza et al. 1987; McLean et al. 1992; Mousa et al. 1986; Pascual et al. 1988). Fever, headache, nuchal rigidity, and altered consciousness may occur (Bodur et al. 2003; Gokul et al. 2000). Evaluation of cerebrospinal fluid usually reveals lymphocytic pleocytosis, increased protein concentration, and normal or moderately decreased glucose (Pascual et al. 1988). Microbiologic cultures of cerebrospinal fluid are positive for brucellae in 10-20% of cases. Rare brain or epidural abscesses, myelitis-radiculoneuritis, demyelinating meningovascular syndromes, deafness, sensorineural hearing loss, and GBS have been reported (Dalrymple-Champneys 1950; Kochar et al. 2000a; Lubani et al. 1989a; McLean et al. 1992;

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