Arthroscopic synovectomy, an alternative in the treatment of brucellar arthritis of the knee with prolonged course. A report of two cases.

摘要

Brucellosis is a systemic infectious disease which shows a broad spectrum of clinical features. Among them, septic arthritis is one of the most frequent presentations.The authors present to cases of brucellar monoarthritis of the knee with a prolonged course in which arthroscopic synovectomy was performed.Although a combination therapy with two or more antibiotics is the treatment of election, in some cases the clinical course of the disease may be prolonged for a long time. In such cases, arthroscopic synovectomy and drainage of the joint should be considered as the next step to prevent further damage to the joint and bones when initial antibiotic treatment provides no improvement of the sympthoms after one week of treatment. Introduction Brucellosis is a systemic infectious disease caused by small, gram-negative nonsporulating coccobacilli, the Brucella. It is a zoonosis transmitted to humans from infected animals, mainly cattle (goats and sheep) and other domesticated animals such as camels. 1 Brucellae are shed in the feces, milk and urine of these animals and are transmitted to humans through direct contact, consumption of unpasteurized dairy products, or indirectly by environmental exposure to aerosolized infected fecal particles. Many Brucella species can produce human disease, including Brucella mellitensis, Brucella abortus, Brucella Suis and, rarely, Brucella canis. Among them, Brucella mellitensis is the most common source of human infection. It is still endemic in many parts of the world, specially in the Mediterranean countries and the Middle East. The most common clinical features of human brucellosis are undulant fever, sweats, arthromyalgias, lymphadenopathy and hepatosplenomegaly. 2 However, bone and joint infections are the most frequent localized sites, accounting for up to 85% of these cases. 34 In its acute form, peripheral poly- or mono-arthritis, specially of the larger joints, is a common clinical finding. A single swollen and painful joint is frequently observed as osteoarticular manifestation. The knee has in fact been found to be one of the most commonly affected joint in endemic areas in Greece, Kuwait , and Peru . 5 Brucellosis septic arthritis has become extremely rare in Western Europe and may be misdiagnosed because its variable clinical pictures and, in some chronic cases, microbiological and serological negativity . For this reason, suspicion of Brucella infection may sometimes be the key for correct diagnosis, specially in endemic regions.Although a combination therapy with two or more antibiotics is the treatment of election, in some cases it fails and the clinical course of the disease may be prolonged for a long time. In these cases, as proposed for other septic arthritis, an alteration in the microbial regimen with more definitive drainage should be considered in order to prevent complications such as osteomyelitis, and chondral damage. 6 The authors present two cases in which antibiotic therapy failed and arthroscopic synovectomy was performed. Arthroscopic synovectomy should be the treatment of choice when antibiotic therapy provides no improvement of the sympthoms after one week of treatment. Case Reports Case 1A 53-year-old cattleman was admitted to our department with a three-week history of pain and swelling of the right knee without any history of trauma. Clinical examination revealed a temperature of 37.5oC, a swollen and tender knee with effusion and limited motion. Haematological and biochemical tests were within the normal limits. Erythrocyte sedimentation rate (ESR) was 15 mm/h, C-reactive protein (CRP) showed an increase at 11 mg/l. Antistreptolisyn O and rheumathoid factor were normal.Plain radiographs revealed no pathological findings and magnetic resonance imaging showed an important hydrarthrosis and synovitis. A viscous white synovial fluid was obtained through aspiration under sterile technique. Cell count was 9000 cells/mm 3 with lymphocytic predominance (72% Lymphocyt