What are sign and symptoms of brucellosis
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Signs and Symptoms of Brucellosis
Source: Goldman-Cecil Medicine (International Edition) & Firestein & Kelley's Textbook of Rheumatology
Overview
Brucellosis (also historically called Malta fever, Mediterranean fever, or undulant fever) is a systemic zoonotic infection caused by Brucella species. It has protean (highly variable) manifestations, and virtually any organ system can be involved. The incubation period is typically 2-4 weeks from infection to bacteremia, though it can range from 1 week to several months.
Acute Brucellosis - General Symptoms
The onset can be abrupt or insidious. Classic features include:
| Symptom | Notes |
|---|---|
| Fever | The hallmark feature - often the distinctive "undulant" (wave-like) pattern in subacute/chronic disease. Can be continuous, remittent, or intermittent. |
| Profuse sweating | Especially nocturnal; classically described as having a "wet hay" or musty odor |
| Malaise & fatigue | Often profound and debilitating |
| Headache | Frequently reported, can be severe |
| Arthralgia / myalgia | Joint and muscle pain, very common |
| Back pain | Especially lumbar; may indicate spondylitis |
| Anorexia and weight loss | Common in prolonged illness |
| Depression | Psychiatric involvement is recognized |
| Chills | Accompany the febrile episodes |
Physical Examination Findings (Signs)
- Hepatomegaly - liver enlargement, found in up to 40-70% of patients
- Splenomegaly - enlarged spleen, very common (up to 20-30%)
- Lymphadenopathy - generalized or regional swelling of lymph nodes
- Hepatosplenomegaly - combined liver and spleen enlargement is a classic sign
- Tenderness over the spine - suggests vertebral osteomyelitis/spondylitis
- Joint swelling and tenderness - in cases with arthritis
- Skin rash - occurs in a minority (~5%) of cases; various forms described (maculopapular, purpuric, nodular, vasculitic)
Focal / Organ-Specific Manifestations
Focal disease occurs in approximately 30% of patients:
1. Osteoarticular (Most Common Focal Complication - ~60-70% of focal cases)
- Sacroiliitis - extremely painful; most common articular site in adults
- Spondylitis / vertebral osteomyelitis - most commonly lumbar spine; can cause epidural abscess
- Peripheral arthritis - monoarthritis or oligoarthritis; knee and hip most affected (especially in children)
- Bursitis and tenosynovitis - less common
2. Genitourinary
- Orchitis / epididymo-orchitis - swollen, tender testicle; occurs in ~2-20% of men with brucellosis; can mimic testicular torsion or tumor
- Pyelonephritis, glomerulonephritis - renal involvement
- Prostatitis
3. Neurological (Neurobrucellosis - ~1-5% of cases)
- Meningoencephalitis - headache, stiff neck, altered consciousness
- Radiculopathy / peripheral neuropathy
- Myelitis
- Cranial nerve palsies
- Psychiatric manifestations - depression, psychosis
- A 2024 systematic review and meta-analysis (PMID: 35930502) confirmed meningitis/meningoencephalitis as the dominant neurobrucellosis presentation
4. Cardiovascular (Rare but Serious)
- Endocarditis - most feared complication; accounts for most brucellosis-related deaths; typically affects the aortic valve
- Myocarditis, pericarditis
- Arterial aneurysms
5. Pulmonary
- Pneumonia, pleuritis, pleural effusion, lung abscess - less common
- Inhalation is an important occupational route of infection (lab workers, slaughterhouse workers)
6. Hepatic
- Granulomatous hepatitis - liver granulomas are common pathological findings
- Jaundice - in cases with significant liver involvement
- Liver abscess - rare
7. Ocular
- Uveitis (anterior or posterior), optic neuritis, and keratitis (noted in Kanski's Clinical Ophthalmology)
8. Hematological
- Thrombocytopenia - low platelet count, can cause bleeding
- Leukopenia - low white cell count
- Anemia
- Hemophagocytic lymphohistiocytosis (HLH) - a rare but serious complication (reported in 2024, PMID: 38663334)
Disease Phases
| Phase | Duration | Key Features |
|---|---|---|
| Acute | < 2 months | Fever, sweats, malaise, hepatosplenomegaly |
| Subacute | 2-12 months | Undulant fever, focal complications begin |
| Chronic | > 12 months | Fatigue, depression, focal disease (endocarditis, spondylitis, neurobrucellosis); can be difficult to treat |
Key Clinical Pearls
- The undulant fever pattern (fever waxing and waning over weeks) is classic but not always present
- Night sweats with a characteristic musty odor are a distinguishing feature
- Brucellosis should be suspected in anyone with prolonged fever + osteoarticular pain + exposure history (livestock, unpasteurized dairy, travel to endemic regions)
- Orchitis in a young man from an endemic area should raise suspicion
- Laboratory findings often show leukopenia, mild anemia, and elevated ESR/CRP; liver enzymes are often mildly elevated
Sources:
- Goldman-Cecil Medicine, International Edition (9780323930345), pp. 2421 onwards
- Firestein & Kelley's Textbook of Rheumatology, p. 1696
- Neurobrucellosis: Tajerian et al., 2024 Systematic Review
- HLH with brucellosis: Guo et al., 2024
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