Magnetic Resonance Imaging Findings of Musculoskeletal Brucellosis Zulkif Bozgeyik, Serpil Aglamis, Pinar Gundogan Bozdag, Affan Denk PII: DOI: Reference:

S0899-7071(14)00108-9 doi: 10.1016/j.clinimag.2014.04.007 JCT 7609

To appear in:

Journal of Clinical Imaging

Received date: Revised date: Accepted date:

13 December 2013 18 March 2014 14 April 2014

Please cite this article as: Bozgeyik Zulkif, Aglamis Serpil, Bozdag Pinar Gundogan, Denk Affan, Magnetic Resonance Imaging Findings of Musculoskeletal Brucellosis, Journal of Clinical Imaging (2014), doi: 10.1016/j.clinimag.2014.04.007

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ACCEPTED MANUSCRIPT MAGNETIC RESONANCE IMAGING FINDINGS OF MUSCULOSKELETAL

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BRUCELLOSIS

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Zulkif Bozgeyik, MD1 Serpil Aglamis, MD2 Pinar Gundogan Bozdag, MD3 Affan Denk, MD4 Department of Radiology, Faculty of Medicine, Firat University, 23119, Elazig, Turkey1 Department of Radiology, Van Government Hospital, 65300, Van, Turkey2 Department of Radiology, Elazig Government Hospital, 23200, Elazig, Turkey3 Department of Infection Disease, Faculty of Medicine, Firat University, 23119, Elazig, Turkey1

ABSTRACT

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Running Title: Musculoskeletal Brucellosis Corresponding Author: Zulkif Bozgeyik, MD Department of Radiology Faculty of Medicine Firat University 23119, Elazig, Turkey Tel:+90-424-233-35-55(ext.1396) Fax: +90-424-237-67-73 E-mail: [email protected]

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Objective: The aim of this retrospective study was to determine the magnetic resonance imaging (MRI) findings of patients with musculoskeletal brucellosis. Materials and Methods: Sixty-eight among 304 patients with musculoskeletal brucellosis, aged 12-82 years (average, 50.2 years), were included in the study. Patients were diagnosed based on clinical findings, Brucella agglutination tests, and MRI findings. MRI was performed to all of the patients with sacroiliitis, spondylitis-spondylodiscitis, and peripheral arthritis. Results: Brucella serum agglutination test was >1/160 in all cases and blood cultures were positive in twelve cases. The most commonly affected site was the spine (57.3%), wherein lumbar vertebrae were found to be most commonly affected. The second most common 1

ACCEPTED MANUSCRIPT affected site was sacroiliac joint (26.4%), whereas peripheral joints were affected in 11 cases (16.1%).

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Conclusion: Brucellosis may affect various sites in musculoskeletal system. The spine was

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the most frequently affected site in our study. Sacroiliac joints and the other peripheral joints were less commonly involved sites. Brucellosis should be included in the differential

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diagnosis of a patient with arthralgia or symptoms of musculoskeletal system disorders especially in endemic areas.

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Keywords; brucellosis; spondylodiscitis; sacroiliitis; peripheral arthritis; magnetic resonance imaging

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Introduction

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Human brucellosis, a chronic granulomatous zoonosis caused by facultative intracellular bacteria of the genus Brucella, involves many organs and tissues, [1]. The disease usually

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affects young and middle age adults. It is an endemic disease in the Mediterranean region

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including Turkey, Indian and Arabian Peninsula, parts of the Central and South America and Mexico [2]. The disease is transmitted to humans either by direct contact with the infected animals or by consumption of unpasteurized milk obtained from the infected animals or dairy products produced from such milk [3]. The disease mainly affects organs rich in reticuloendothelial cells, particularly the musculoskeletal system, which is the most frequent target site [4, 5]. The most common symptoms of brucellosis include fever, arthralgia, fatigue, sweating, inapetence, weight loss, chill, and myalgia. Incubation time of the disease is usually 1-5 weeks that may extend up to three months [6]. Diagnosis of musculoskeletal brucellosis may be difficult due to nonspecific clinical symptoms. Analysis of imaging of musculoskeletal brucellosis may be helpful in the diagnosis of the disease and in prevention

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ACCEPTED MANUSCRIPT of delayed manifestation of brucellosis with abscess which requires invasive treatment methods. The aim of this study was to present magnetic resonance imaging (MRI) findings of

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the musculoskeletal brucellosis.

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PATIENTS AND METHODS

A retrospective analysis of 304 patients with brucellosis, presented to our hospital in last six

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years, was carried out. Sixty-eight patients with brucellosis involving musculoskeletal system were identified. Diagnosis of brucellosis was made by culturing the sera/body fluids

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employing standard BACTEC method [7] or testing the sera for Brucella agglutinins using the standard agglutination test. All positive agglutination tests were assumed to be secondary to brucellosis. Titers of 1:160 or more were considered as a significant parameter for diagnosis of brucellosis [8]. MRI was performed in all patients having pain and positive serological tests

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of brucellosis. Musculoskeletal system manifestations of brucellosis were diagnosed by

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appropriate laboratory findings and physical examination in conjunction with MRI findings. MRI was performed with 1.5-T MRI scanner (General Electric signa excite highspeed

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scanner, Milwaukee, USA) using appropriate coils. T1-weighted, T2-weighted, fat saturated

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T1- and T2-weighted images and STIR (short Tau Inversion Recovery) images were obtained on axial, coronal, and sagittal planes. T1-weighted contrast enhanced images were also obtained after administration of gadopentetat dimeglumin (Gd-DTPA). Vertebral bodies, endplates, intervertebral discs, paravertebral soft tissue, and epidural spaces were assessed for the diagnosis of spondylitis and spondylodiscitis. Presence of paraspinal involvement, diffuse or focal involvement, epidural extension, cord compression and multifocal involvement were evaluated in patients with spinal brucellosis. Typical MRI findings for

osteomyelitis or discitis were decreased signal intensity in the vertebral bodies on T1weighted image, increased signal intensity in the vertebral body on T2-weighted images, increased signal intensity in intervertebral discs on T2-weighted images, loss of endplate

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ACCEPTED MANUSCRIPT definition on T1-weighted images [9], increased enhancement of endplate, intervebral disc and paravertebral soft tissue after gadolinium injection [10].

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Bone marrow edema and intraarticular synovial fluids are important clues for early diagnosis

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of brucellar sacroiliitis. Sclerosis and ankylosis were observed in late phase of the disease. Unilateral or bilateral involvement, bone marrow edema, joint expansion or narrowing, joint

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fluid, joint derangement (irregularity of the joint surfaces), joint sclerosis, periarticular involvement, and contrast enhancement were assessed in sacroiliitis.

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Diagnosis of peripheral joint involvement was based on the visualization of increased synovial fluid and bone marrow edema on MRI. Evaluation of peripheral joint involvement included presence of bone marrow edema, joint derangement, enhancement of synovium and periarticular soft tissues after intravenous injection of gadolinium.

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RESULTS

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Twenty-seven (39.7%) male and 41 (60.2%) female patients with musculoskeletal brucellosis (mean age 50.2 years, range 12-82 years) were included in the study. Brucella serum

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agglutination test was >1/160 in all patients; and blood cultures were positive in 12 patients.

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The sensitivity of serum agglutination test and blood culture in the diagnosis of brucellosis in our patients were 100% and 17.6%, respectively. As well, bacteria from abscess formation were identified in three patients. The most commonly affected site was the spine (57.3%). Multilevel involvement was seen in eight patients (11.7%). Noncontiguous and contiguous multisegment involvements were seen in five (7.3%) and three patients (4.4%), respectively (Fig. 1). Lumbar vertebrae and disc spaces were most common affected sites of the spine (74.5%). Thoracic (17.6%) and cervical (7.8%) spine involvements were seen in nine and four patients, respectively. The most prominent involvement was L5-S1 in the lumbar spine (31.3%). Focal spinal involvement was seen in three patients (7.7%). Twenty-three patients (59%) had paravertebral soft tissue

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ACCEPTED MANUSCRIPT involvement and seven patients (17.9%) had abscess formation (Fig. 2). We also detected epidural extension in 22 patients (56.4%) and cord compression in four patients (10.2%)

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(Table 1).

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The second most common affected site was the sacroiliac joint (26.4%). Bilateral involvement of sacroiliac joints was detected in 11 patients, whereas unilateral joint involvement was seen

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in seven patients (Fig. 3). Bone marrow edema was seen in eleven patients. Sacroiliac joints were categorized as normal (not widened or narrowed) in ten patients (55.5%), widened in

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two patients (11.1%), and narrowed in six patients (33.3%). Intraarticular fluid was detected in six patients. Bone sclerosis and joint derangement were seen in 12 (66.7%) and 13 (72.2%) patients, respectively. Contrast enhancement of the joints was detected in 11 patients (61.1%); whereas, periarticular soft tissue involvement was seen in three patients (16.7%) (Table 2).

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Peripheral joints were affected in 11 patients (16.1%). Knee (27.3%) and ankle (27.3%) joints

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were most frequently affected sites. The other involved joints were sternocostal (18.2%) (Fig. 4), hip (9.1%), shoulder (9.1%) and elbow (9.1%). Increased fluid was observed in affected

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joints in all patients. Bursitis was seen in four patients (36.3%) and tendinitis was seen in five

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patients (45.5%). Contrast enhancement of the joint capsule and periarticular soft tissue was detected in six patients (54.5%) (Table 3). DISCUSSION

Brucellosis is one of the commonest anthropozoonotic infections with a pandemic distribution [11] and stays as an uncontrolled problem in regions of high endemicity. Although it has been manifested more commonly in developing countries, but the world is clearly becoming a “smaller” place due to increased travel rates; therefore understanding of these infectious processes from abroad is important. Brucellosis is an infectious process which may mimic other atypical infectious processes. Differential diagnosis of infectious musculoskeletal

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ACCEPTED MANUSCRIPT involvement should be considered along with patient history, findings of clinical and serological tests, and imaging outcomes.

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Human infection can occur through consumption of raw meat and unpasteurized dairy

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products that contain Brucella. Infection can also occur via inhalation of airborne animal manure and through skin abrasions [12]. Brucella affects all age groups, and our study

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showed a wide range of age distribution from 12-82 years similar to other studies [3, 13, 14]. A presumptive diagnosis can be made by demonstrating high or rising titers of specific

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antibodies in the serum. Mantecon et al. reported the sensitivity of standard agglutination test in brucellosis as 84.6% [8]. Isolation of the organism from the blood culture is the gold standard in the diagnosis of brucellosis, but it can be difficult to identify microorganism in

70% in chronic cases [6].

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blood culture. Sensitivity of blood culture in the diagnosis of brucellosis was reported as 30-

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Musculoskeletal involvement of the axial skeleton is the most common presentation of the Brucella infection, which is widely described in the literature [15]. The frequency of

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musculoskeletal involvement is high, and varies between 0-85% in the published reports [16-

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18]. The frequency of musculoskeletal brucellosis was 22.4% in our study, which is in concordance with the previous studies [6, 18]. The most common forms of musculoskeletal involvements are spondylitis/spondylodiscitis, arthritis, bursitis, tenosynovitis, and osteomyelitis. The type of skeletal involvement depends on the patient’s age. The sacroiliac joints and knee arthritis predominate in children and young adults, whereas the spine remains the most common site of involvement in elderly patients [19]. The most frequent site of musculoskeletal brucellosis is the spine [4, 20]. Two forms of spinal involvement, i.e., focal and diffuse, have been identified [5]. In the focal form, osteomyelitis is localized in the anterior superior endplate of a lumbar vertebra at the discovertebral

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ACCEPTED MANUSCRIPT junction [21]. This area is morphologically rich in blood supply. Osseous endplate erosions, defined as brucellar epiphysitis and anterior osteophyte formation (parrot’s beak), constitute

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other findings of spinal brucellosis. Presence of intradiscal gas, a unique finding in

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brucellosis, may help to differentiate it from other forms of infection and degenerative disc diseases [5]. In the diffuse form, osteomyelitis affects the entire vertebral endplate or the

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whole vertebral body. The infection spreads via vascular communication and ligaments to approach adjacent discs, vertebral bodies, epidural space, and paraspinal soft tissues [21].

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Differentiation of spinal brucellosis from other spinal pathologies such as tuberculous and pyogenic spondylitis, metastasis and postoperative changes is important. In case of metastatic lesions of the spine, vertebral discs are not involved [22]. Predilection for the lumbar region, moderate epidural extension, association with intradiscal gas, invariable presence of bone

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sclerosis and gibbus deformity, and subligamentous spread findings are indicative of

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tuberculosis rather than brucellosis. In spinal brucellosis, vertebral body morphologies are almost always preserved. The size of paraspinal mass in tuberculosis is usually larger than

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that in brucellosis. Thick and irregular enhancement of the abscess wall and ill-defined

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paraspinal abnormal signal suggest pyogenic spondylitis [21, 23]. Differential diagnosis of spinal involvement should be based on patient history, symptoms, results of clinical and serological tests, and imaging findings. Brucellar spondylitis represents 6-58% of musculoskeletal localizations [24], which is found to be 57.2% in this study. Similar to this, Al-Shahed et al. reported the spinal involvement in 52.7% cases [5]. The most common affected site, as reported in earlier study, was lumbar spine (60%) followed by thoracic spine (19%) and cervical spine (12%). Multilevel involvement was seen in 3-14% of the patients in other studies [19, 24, 25]. In our study, involvement rates of the lumbar, thoracic, cervical, and multilevel were 74.5%, 17.6%, 7.8% and 11.7%, respectively. The most frequently involved site in our study was L5-S1 level,

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ACCEPTED MANUSCRIPT which had also been reported to be affected more commonly in comparison to other lumbar vertebra levels [14]. Paravertebral abscesses are typically characterized by well defined

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margins and had been reported to occur with a frequency of 30% and 13.6% in two different

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studies [22, 26]. Paravertebral abscess was found in 17.9% of our patients.

MRI is the imaging modality of choice for the diagnosis of brucellar spondylodiscitis,

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abscesses, and cord or root compression, especially in the early phase of the disease [4, 20]. Fat-suppressed T2-weighted and fluid-sensitive sequences must be added to conventional

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MRI sequences in order to identify the lesions. The intravenous gadolinium administration allows better definition of the spinal lesions [10, 24].

Brucellar sacroiliitis had been reported in 0-72% of the patients with musculoskeletal brucellosis [27]. In our study, the sacroiliac joints were involved in 26.4% of patients and

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bilateral sacroiliitis was observed in 61.1% cases. Some investigators believe that sacroiliitis

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occurs mainly unilateral in patients with musculoskeletal brucellosis [27]. However, Tasova et al. (47%), Turan et al. (82.4%), and Corderea-Sanchez et al. (60%) showed that the patients

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with musculoskeletal brucellosis had bilateral sacroiliitis, similar to our findings [13, 14, 28].

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Sacroiliac involvement may occur together with spondylitis. We had a patient with musculoskeletal brucellosis together with sacroiliac involvement and lumbar spondylodiscitis. MRI should be a preferred modality for the diagnosis of intraarticular fluid, bone marrow edema, and periarticular involvement, especially during the early phase of the disease. Subchondral sclerosis, erosions and ankylosis of joint may be seen in chronic phases of the disease [10]. Peripheral arthritis, usually involving large joints, especially hip, knee, and ankle [3, 7], occurs more frequently in children and young adults, and it is presented as monoarthritis [3]. The frequency of peripheral joint involvement in brucellosis was reported as 14-19.5% in different studies [13, 6, 29]. In this study, peripheral joint involvement was observed in 16.1%

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ACCEPTED MANUSCRIPT of the patients. Knee and ankle joints were most commonly affected sites in our study. MRI can reveal synovial fluid, bone marrow edema, and involvement of periarticular soft tissue.

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Joint space narrowing and destruction, which are rarely reported, are usually observable only

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at late phase of the disease [5]. Periarticular bursitis and tendinitis can be present alone or may be accompanied with arthritis [3, 27]. Mousa and colleagues reported bursitis and tendinitis

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in 1.2% of 169 brucellosis patients [30], which, in this study, were found in 1.6% patients. Muscle abscess occurs most commonly in the psoas and paraspinal muscles in patients with

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musculoskeletal brucellosis [31]. We observed abscess of psoas muscle in seven patients, which were treated with percutaneous drainage in three patients. Treatment of brucellosis with musculoskeletal involvement include double or triple antibiotic combination for a minimum of three months depending on the clinical signs and

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complications. Relapse has been noticed in 3.6-4.5% of the patients with uncomplicated

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brucellosis and in 11% of patients with osteoarticular or focal involvement [6, 32]. This study had some limitations. Firstly, joint fluid aspiration from the cases of peripheral

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arthritis was not performed for the diagnosis of brucellosis. The confirmative diagnosis of

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brucellosis commonly includes isolation of Brucella from blood, bone marrow or other tissues; which is, however, difficult as it is an invasive method, not practical for clinical purposes. Disco-vertebral specimens are usually obtained by imaging-guided needle biopsy. Although it is not specific, but still the histological appearance of brucellosis can be taken as a positive diagnosis. Lesions in the spine may resemble low-grade suppurative osteomyelitis [33]. Therefore, we did not perform the biopsy from the intervertebral disk spaces. Diagnosis of tendinitis and bursitis was based on MRI findings and Brucella agglutination test, which was another limitation of the study. In conclusion

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ACCEPTED MANUSCRIPT Brucellosis is an endemic disease in the Mediterranean and Indian regions, and some parts of the Central and South America and Mexico. The spine is the most frequently affected site;

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whereas, sacroiliac joints and the other peripheral joints are less commonly involved sites.

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Spondylodiscitis is important complication of brucellosis which can cause persistent neurologic deficits. Brucellosis should be included in the differential diagnosis of a patient

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with arthralgia or symptoms of musculoskeletal system disorders especially in endemic areas. MRI should be a preferred modality for diagnosis and assessment of complications of the

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patients, especially in the early phase of the disease.

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ACCEPTED MANUSCRIPT REFERENCES 1. Wyatt HV. Brucella melitensis can be transmitted sexually. Lancet 1996;348: 615.

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2. Luk S, To WK. Diagnostic challenges of human brucellosis in Hong Kong: a case

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series in two regional hospitals. Hong Kong Med J 2010;16:299-303. 3. Geyik MF, Gür A, Nas K, Cevik R, Sarac J, Dikici B, Ayaz C. Musculoskeletal

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involvement of brucellosis in different age groups: a study of 195 cases. Swiss Med Wkly 2002;132:98-105.

MA NU

4. Salata RA, Ravdin JI. Brucella species (brucellosis). In: Mandell GL, Douglas RG, Bennet JE, editors. Principle and practice of infectious disease. New York, NY: Wiley; 1985. pp. 1283-90.

5. Al-Shahed MS, Sharif HS, Haddad MC, Aabed MY, Sammak BM, Mutairi MA.

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Imaging features of musculoskeletal brucellosis. Radiographics 1994;14:333-348.

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6. Colmenero JD, Reguera JM, Martos F, Sanchez-De-Mora D, Delgado M, Causse M, Martín-Farfán A, Juárez C. Complications associated with Brucella melitensis

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infection: a study of 530 cases. Medicine (Baltimore) 1996;75:195-211.

AC

7. Franco MP, Mulder M, Gilman RH, Smits HL. Human brucellosis. Lancet Infect Dis 2007;7:775-786. 8. Mantecón MA, Gutiérrez P, del Pilar Zarzosa M, Duenas Al, Solera J, FernandezLago L, Vizcaíno N, Almaraz A, Bratos MA, Rodríguez Torres A, Orduña-Domingo A. Utility of an immunocapture-agglutination test and an enzyme-linked immunosorbent assay test against cytosolic proteins from Brucella melitensis B115 in the diagnosis and follow-up of human acute brucellosis. Diagn Microbiol Infect Dis 2006;55:27-35. 9. Dagirmanjian A, Schils J, McHenry M, Modic MT. MR imaging of vertebral osteomyelitis revisited. AJR Am J Roentgenol 1996;167:1539-1543.

11

ACCEPTED MANUSCRIPT 10. Arkun R, Mete BD. Musculoskeletal brucellosis. Semin Musculoskelet Radiol 2011;15:470-479.

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of human brucellosis. Lancet Infect Dis 2006;6:91-99.

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11. Pappas G, Papadimitriou P, Akritidis N, Christou L, Tsianos EV. The new global map

12. Sathyanarayanan V, Razak A, Saravu K, Ananthakrishna SB, Mukhyprana Prabhu M,

India. Asian Pac J Trop Med 201;4:397-400.

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Vandana KE. Clinical profile of brucellosis from a tertiary care center in southern

MA NU

13. Taşova Y, Saltoğlu N, Sahin G, Aksu HS. Osteoarthricular involvement of brucellosis in Turkey. Clin Rheumatol 1999;18:214-219.

14. Turan H, Serefhanoglu K, Karadeli E, Togan T, Arslan H. Osteoarticular involvement

Med 2011;50:421-428.

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among 202 brucellosis cases identified in Central Anatolia region of Turkey. Intern

PT

15. Priest JR, Low D, Wang C, Bush T. Brucellosis and sacroiliitis: a common presentation of an uncommon pathogen. J Am Board Fam Med 2008;21:158-161.

CE

16. Madkour MM, Sharif HS, Abed MY, Al-Fayez MA. Osteoarticular brucellosis: results

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of bone scintigraphy in 140 patients. AJR Am J Roentgenol 1988;150:1101-1105. 17. Pourbagher A, Pourbagher MA, Savas L, Turunc T, Demiroglu YZ, Erol I, Yalcintas D. Epidemiologic, clinical, and imaging findings in brucellosis patients with osteoarticular involvement. AJR Am J Roentgenol 2006;187:873-880. 18. Hashemi SH, Keramat F, Ranjbar M, Mamani M, Farzam A, Jamal-Omidi S. Osteoarticular complications of brucellosis in Hamedan, an endemic area in the west of Iran. Int J Infect Dis 2007;11:496-500. 19. Raptopoulou A, Karantanas AH, Poumboulidis K, Grollios G, Raptopoulou-Gigi M, Garyfallos A. Brucellar spondylodiscitis: noncontiguous multifocal involvement of the cervical, thoracic, and lumbar spine. Clin Imaging 2006;30:214-217.

12

ACCEPTED MANUSCRIPT 20. Shivaram U, Wollschlager C, Khan F, Khan A. Spinal tuberculosis revisited. South Med J 1985;78:681-684.

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21. Sharif HS, Aideyan OA, Clark DC, Madkour MM, Aabed MY, Mattsson TA, al-Deeb

RI P

SM, Moutaery KR. Brucellar and tuberculous spondylitis: comparative imaging features. Radiology 1989;171:419-425.

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22. Bozgeyik Z, Ozdemir H, Demirdag K, Ozden M, Sonmezgoz F, Ozgocmen S. Clinical and MRI findings of brucellar spondylodiscitis. Eur J Radiol 2008;67:153-158.

MA NU

23. Jung NY, Jee WH, Ha KY, Park CK, Byun JY. Discrimination of tuberculous spondylitis from pyogenic spondylitis on MRI. AJR Am J Roentgenol 2004;182:14051410.

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24. Chelli Bouaziz M, Ladeb MF, Chakroun M, Chaabane S. Spinal brucellosis: a review. Skeletal Radiol 2008;37:785-790.

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25. Zormpala A, Skopelitis E, Thanos L, Artinopoulos C, Kordossis T, Sipsas NV. An unusual case of brucellar spondylitis involving both the cervical and lumbar spine.

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Clin Imaging 2000;24:273-275.

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26. Harman M, Unal O, Onbaşi KT, Kiymaz N, Arslan H. Brucellar spondylodiscitis: MRI diagnosis. Clin Imaging 2001;25:421-427. 27. Bosilkovski M, Krteva L, Caparoska S, Dimzova M. Osteoarticular involvement in brucellosis: study of 196 cases in the Republic of Macedonia. Croat Med J 2004;45: 727-733. 28. Cordero-Sánchez M, Alvarez-Ruiz S, López-Ochoa J, Garcia-Talavera JR. Scintigraphic evaluation of lumbosacral pain in brucellosis. Arthritis Rheum 1990;33:1052-1055.

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ACCEPTED MANUSCRIPT 29. Ariza J, Pujol M, Valverde J, Nolla JM, Rufí G, Viladrich PF, Gudiol F. Brucellar sacroiliitis: findings in 63 episodes and current relevance. Clin Infect Dis

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1993;16:761-765.

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30. Mousa AR, Muhtaseb SA, Almudallal DS, Khodeir SM, Marafie AA. Osteoarticular complications of brucellosis: a study of 169 cases. Rev Infect Dis 1987;9:531-543.

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31. Gundes SG, Gunde H, Sarlak A, Willke A. Primary brucellar psoas abscess: presentation of a rare case of psoas abscess caused by Brucella melitensis without any

MA NU

osteoarticular involvement. Int J Clin Pract Suppl 2005;147:67-68. 32. Solera J, Lozano E, Martínez-Alfaro E, Espinosa A, Castillejos ML, Abad L. Brucellar spondylitis: review of 35 cases and literature survey. Clin Infect Dis 1999;29:14401449.

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33. Ghozlan R, Boissy M, Caruel N. Lumbar epiduritis disclosing brucellar

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spondylodiskitis. Rev Rhum Mal Osteoartic. 1981;48:60-63.

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ACCEPTED MANUSCRIPT Table 1. MRI findings of 39 patients with brucellar spondylitis and spondylodiscitis

+ + + + + +

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+ + +

+ +

+ + +

+

+

+

+ +

+

+ + + + + + + + + + + + + +

EE + + + + + + + + + + + + + + + + + + + + + + -

CC + + + + -

MI + + + + + + + + -

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+ + + +

Abscess + + + + + + + -

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FI

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DI +

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PI + + + + + + + + + + + + + + + + + + + + + + + -

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VL L4-5 L5-S1 L3-5, T7-8 L2-3 L5-S1 L5-S1 T12-L1, T8-9 L4-5 L1-2 L3-4 L5-S1 T11-12, L1-3 L4-5 L5-S1 L5-S1 L5 L3-5 L2-3, L5-S1 C1-2, C5-6 L5-S1 T9-10 L5-S1 L3-4 L3-4, L5 C3-4 L3-4 L5-S1 L1-2 L5-S1 T12-L3 L2-3 C2-3 T6-7, T9-10 L5-S1 L5-S1 L5-S1 L3-L4 L1 L5-S1

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Sex M M M M M F F F F M F F F F M M F M M F F F F F F F F F F M F M M F F M F F F

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Age 48 54 79 76 34 37 70 33 70 43 50 78 42 48 56 56 56 76 72 44 52 58 65 40 70 54 62 51 49 59 66 56 80 28 37 56 66 82 72

OE + + + + + + + + + + + + + + + + + + -

Ankylosis + + + + -

VL: Vertebra Level; PI: Paraspinal Involvement; DI: Diffuse Involvement; FI: Focal Involvement EE: Epidural Extension; CC: Cord Compression; MI: Multifocal Involvement; OE: Osseous erosion

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ACCEPTED MANUSCRIPT Table 2: MRI findings of 18 patients with sacroiliitis

+ + + + + + + + + + + + + + +

JE + + -

JN + + + + + +

JF + + + + + +

JD + + + + + + + + + + + + +

JS + + + + + + + + + + + + -

PI + + +

CE + + + + + + + + + + +

OE Ankylosis + + + + + + +

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+ +

BME + + + + + + + + + + +

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BI +

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UI

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Sex M F F F F F F M F F M M F F F M M M

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Age 31 70 55 50 71 24 42 24 20 37 26 58 22 41 60 25 25 26

UI: Unilateral Involvement; BI: Bilateral Involvement; BME: Bone Marrow Edema; JE: Joint Expansion

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JN: Joint Narrowing; JF: Joint Fluid; JD: Joint Derangement (irregularity of the joint surfaces); JS: Joint

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Sclerosis; PI: Periarticular Involvement; CE: Contrast Enhancement; OE:Osseous erosions

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ACCEPTED MANUSCRIPT Table 3: MRI findings of 11 patients with peripheral arthritis Bursitis + + + + -

Tendinitis + + + + +

BME + + + + -

JD -

CE + + + + + +

PI OE Ankylosis + + + + + + + + -

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Fluid + + + + + + + + + + +

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Sites SCJ Elbow Hip Knee Shoulder Knee Knee Foot Foot SCJ Foot

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Sex F F M M M M F F F M M

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Age 55 53 28 34 60 68 37 71 54 15 12

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CE

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BME: Bone Marrow Edema; JD: Joint Derangement; CE: Contrast Enhancement; PI: Periarticular Involvement ; SCJ: Sternocostal Joint; OE: Osseous erosions

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Figure 1. Brucellar spondylodiscitis. A. Sagittal STIR image shows hyperintense lesions

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contiguous spinal involvement. B. Sagittal T1-weighted image shows hypointense signal in the vertebral bodies and endplates. C. Contrast enhanced T1-weighted sagittal image shows

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formation of spondylitis and involvement of intervertebral disc space between T10-S1 vertebral levels. D. Contrast enhanced T1-weighted axial image shows enhancement in

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affected vertebra and paravertebral soft tissue.

Figure 2. Brucellar spondylodiscitis and abscess formation. A. STIR image shows increased signal intensity on L3 and L4 vertebral bodies, epidural space and paravertebral area. B. Contrast enhanced T1-weighted sagittal image shows enhancement in L3-L5 vertebral bodies,

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intervertebral disc space, epidural space representing brucellar involvement. A focal abscess

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in epidural space is visualized as accompanying finding. C. Contrast enhanced T1-weighted sagittal image shows enhancement in affected vertebra body, disc and paravertebral soft tissue

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with a peripherally enhanced right psoas abscess.

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Figure 3. Brucellar sacroiliitis and osteomyelitis. A. Semicoronal T1-weighted image shows low signal intensity at the sacral and iliac sides of the right sacroiliac joint. B. Semicoronal STIR image shows high signal intensity at the right sacral and iliac bones and sacroiliac joint representing edema. C. Semicoronal contrast enhanced T1-weighted image shows prominent enhancement at the involved areas. Figure 4. Brucellar sternocostal arthritis. A. Axial fat-saturated T2-weighted image shows bilateral lower sternocostal joints with high signal intensity. B. Coronal fat-saturated T2weighted image shows increased fluid at the sternocostal joints.

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Magnetic resonance imaging findings of musculoskeletal brucellosis.

The aim of this retrospective study was to determine the magnetic resonance imaging (MRI) findings of patients with musculoskeletal brucellosis...
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