This is a 17‐year old Kuwaiti man without significant medical history, who presented to the emergency department (ED) of a tertiary‐care medical center in the United States after 1 week of fevers and diaphoresis, then acute onset of left knee pain on the morning of admission. He endorsed the ingestion of unpasteurized camel's milk on a regular basis at home in Kuwait, but had not encountered problems with this in the past. Physical examination was significant for a fever to 38.3°C, a 2 × 2 cm effusion over the superoanteromedial tibia with associated tenderness to palpation. In the ED, he underwent aspiration of the left prepatellar bursa as well as the left knee. Pertinent laboratory findings included a peripheral white blood cell count of 6.3 × 1000/mm3, a C‐reactive protein level of 2.9 mg/L, and the presence of 4150 WBC/mm3 in the synovial fluid, with no crystals and negative gram stain. He was initially started on intravenous vancomycin and tazobactam/piperacillin, However, cultures of blood and bursal fluid subsequently grew Brucella melitensis, and the antibody titer to brucella was positive at 1:2560. Cultures of the joint fluid from the knee showed no growth. Multiple subsequent blood cultures showed growth of Brucella melitensis. Antibiotics were changed to doxycycline 100 mg by mouth twice daily and gentamicin 5 mg/kg intravenously daily for 5 days in hospital. He was transitioned to oral medications earlier than advised by the Infectious Diseases service due to patient preference. He was discharged on doxycycline and rifampin 900 mg by mouth daily to complete a 6‐week course, with follow‐up to be arranged in Kuwait. Before discharge, echocardiography and MRI of the lumbosacral spine showed no evidence of abnormality.
Although rare in the United States, brucellosis is a relatively common zoonosis in the developing world. Typically, humans acquire this infection through ingestion of unpasteurized dairy products from infected animals, or through direct contact. The presentation of brucellosis usually begins as a nonspecific febrile illness, sometimes associated with hepatosplenomegaly and lymphadenopathy. Localized musculoskeletal manifestations can occur subsequently. Due to the prolonged incubation period (1–4 weeks), individuals can make their initial presentation to medical attention outside of the endemic area. After a review of literature, it appears that this is the first reported case of prepatellar bursitis caused by Brucella melitensis in the United States.
Brucella melitensis, although not a common infection in the United States, can be found in travelers from endemic areas. Physicians treating individuals with acute febrile illnesses from endemic areas should be vigilant about brucellosis if their presentation is consistent. Follow‐up can be difficult to arrange in the patient's home country.
Summary of Microbiologic Results
|Date/Time of Culture||8/14 1732||8/14 2208||8/15 1550||8/15 1640||8/16 1400||8/18 0035||8/20 0530||8/20 2200|
|Bursa||Positive (anaerobic + aerobic)||Synovial fluid taken from left knee; bursal fluid taken from left prepatellar bursa. All positive cultures grew Brucella melitensis,|
To cite this abstract:Chang W. Prepatellar Bursitis Due to Brucella Melitensis. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 410. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/prepatellar-bursitis-due-to-brucella-melitensis/. Accessed September 22, 2019.