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Infectious Diseases in Clinical Practice:
doi: 10.1097/IPC.0b013e318168ffb3
Original Articles

Brucellar and Tuberculous Spondylitis in 87 Adult Patients: A Descriptive and Comparative Case Series

Kurtaran, Behice MD*; Sarpel, Tunay MD†; Tasova, Yesim MD*; Candevir, Aslihan MD*; Saltoglu, Nese MD*; Inal, Ayse Seza MD*; Aksu, Hasan Salih Zeki MD*

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Author Information

Departments of *Clinical Microbiology and Infectious Diseases and †Physical Medicine and Rehabilitation, Çukurova University Medical School, Adana, Turkey.

Address correspondence and reprint requests to Behice Kurtaran, MD, Department of Clinical Microbiology and Infectious Diseases, Çukurova University, 01330 Adana, Turkey. E-mail: behicekurtaran@gmail.com.

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Abstract

Our aim was to compare the clinical and evaluative features of a series of cases with spondylitis of the 2 most frequent etiologies, brucellosis and tuberculosis, in Turkey.

Of the 87 patients with spondylitis, 44 had brucellosis and 43 had tuberculosis. Patients with tuberculosis were more likely to have a history of pulmonary disease, longer time to diagnosis, and higher erythrocyte sedimentation rates and C-reactive protein levels. Fever, night sweating, and arthralgia were more frequent complaints in brucellosis, whereas weakness and neurological involvement were in tuberculous spondylitis. Vertebral destruction and compression, kyphosis, paraspinal masses, and cord compression were more frequent in tuberculosis. Sacroiliitis and discitis were significantly associated with brucellosis. Need for surgical treatment, unfavorable outcome, and death were more common in tuberculosis.

In countries with high prevalence of both diseases, documented history, clinical presentation, laboratory and histological examination, and radiographic imaging can be highly suggestive and sufficient for empirical treatment.

In many areas in the world, including Mediterranean countries, both brucellosis and tuberculosis still have a high incidence, and they are considered as a public health problem. Although the incidence of tuberculosis has declined in the 20th century, high population growth, uncontrolled migration, unemployment, and poor sanitation after the late 1960s resulted in a recent increase, and in 2002, the incidence was found to be 27 cases per 100,000 inhabitants in Turkey.1-3 Human-acquired brucellosis is still contracted by handling contaminated animal products or by consuming dairy products made of unpasteurized milk in Turkey.4 In 2004, 18,264 cases with brucellosis were notified to the Ministry of Health, with the incidence rate being 25 cases per 100,000.5

Spondylitis accounts for approximately 1% to 7% of all bone infections.6 It is the most prevalent and important clinical form of osteoarticular involvement in adults with infection due to both brucellosis and tuberculosis. Among the musculoskeletal involvement of these diseases, spondylitis is the most difficult one to diagnose early because it commonly starts insidiously and follows an indolent course. Because of their nonspecific presentation, both can easily be overlooked. Erroneous initial diagnoses are commonly made, delaying diagnosis for several weeks or months in both despite the availability of good diagnostic tools. An optimal outcome of these diseases requires heightened awareness, early diagnosis, prompt identification of pathogens, reversal of complications, and prolonged antimicrobial therapy.7-9

To our knowledge, there are few studies which compare tuberculosis and brucellar spondylitis.10,11 In addition, previous studies from Turkey about spondylitis has usually limited their scope to the description of cases or to a detailed analysis of particular etiologic categories.1,12-15 We aimed to describe the clinical and evaluative features of a series of cases with spondylitis, with particular attention to the differential aspects of the 2 most frequent etiologic groups in Turkey, to improve therapeutic management in the absence of a positive culture.

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PATIENTS AND METHODS

This study was carried out in the Department of Infectious Diseases and Clinical Microbiology of Çukurova University Medical School, Adana, Turkey. This is a tertiary referral hospital with 1050 beds providing care for approximately 10 million inhabitants from the Mediterranean and Southeast regions of Turkey. Records were reviewed for all adult patients with spondylitis who attended to our department between January 1997 and December 2004. Standardized patient forms were used for both tuberculous (TS) and brucellar spondylitis (BS) cases. These forms inquire about the patient's demographics, duration of symptoms, predisposing factors, clinical features at presentation, involved regions, laboratory tests, radiographic findings, microbiological study results, histopathologic findings, types and duration of therapy, and final outcomes for 87 patients.

The diagnosis of spondylitis was based on clinical symptoms (spinal pain unrelieved by rest, fever, and spinal pain on physical examination) confirmed by magnetic resonance imaging (MRI) findings.16,17 Plain radiographs consisted of at least an anteroposterior and lateral projection of the spine in the area of interest. Loss of intervertebral disk height together with irregularity of the end plates, adjacent vertebral bodies, and presence or absence of paravertebral soft-tissue mass were recorded. On MRI, a confluent decrease in signal intensity in the vertebral bodies and disks on T1-weighted images, increased signal in vertebral bodies on T2-weighted images and an increase in disk signal intensity on T2-weighted images, and loss of end-plate definition on T1-weighted images were considered evidence of vertebral osteomyelitis. The MRI signal-intensity changes and patterns of enhancement of the epidural and paraspinal soft tissue were also recorded.16,17.

Diagnosis of brucellosis was made by isolating Brucella species from blood or other body fluid or tissue specimens (Bactec 730 and 9000, Becton Dickson) and/or by standard tube agglutination testing, revealing a titer of antibodies to Brucella of 1/160 or greater and/or demonstration of at least 4-fold elevation of antibody titer in sera taken over 2 or 3 weeks in addition to compatible clinical findings.4

Diagnosis of tuberculosis was made by clinical and radiological findings compatible with TS and one of the following: (1) microbiological evidence for tuberculous infection from any samples (sputum, abscess, bone tissue) (Mycobacterium tuberculosis growth on Middlebrook H12 media, positive acid-fast bacilli (AFB) of Ziehl-Neelsen staining), or (2) histopathologic changes concordant with tuberculosis on pathological specimens. Histopathologic studies of biopsy samples particularly were performed to observe tuberculoid granulomas and caseation necrosis for TS.6,7

In TS, a 4-drug regimen was preferred for initial therapy, that is, the first 2 to 3 months: rifampicin (10 mg/kg per day orally, maximum of 600 mg) plus isoniazid (15 mg/kg per day orally, maximum of 300 mg) plus pyrazinamide (15-30 mg/kg per day orally) plus streptomycin (15 mg/kg per day intramuscularly, maximum of 1 g) or ethambutol (15-25 mg/kg per day orally). This regimen was continued with isoniazid and rifampicin for at least 9 months until erythrocyte sedimentation rate (ESR) and/or C-reactive protein (CRP) became normal and radiological stabilization was achieved. If resistance to any of the first-line drugs (excluding pyrazinamide) was detected during therapy, the treatment was adjusted according to the results of susceptibility. Second-line drugs, p-aminosalicylic acid (8-12 g/d orally), levofloxacin (500-1000 mg/d orally), and ciprofloxacin (1500 mg/d orally), were preferred to be used in this series.

In BS, patients were treated with several therapeutic schedules: (a) doxycycline (100 mg/12 hours orally) and rifampin (15 mg/kg per day orally) for at least 3 months ± aminoglycoside (gentamicin or netilmicin, 5 mg/kg per day intramuscularly) for 14 days for at least 3 months, or (b) ciprofloxacin (2 × 500-750 mg/d orally) plus rifampin ± aminoglycoside.

Indications for spinal surgery that included anterior decompression and bone grafting alone or plus abscess drainage were considered as large soft-tissue masses, spinal cord or root compression, spinal instability, or failure of medical treatment.

Once treatment was finished, patients were followed up monthly for at least 6 months, with careful attention for the detection of relapses.

Outcome was categorized as favorable (recovered with no or mild sequelae) or unfavorable (therapeutic failure, relapse, or moderate or severe sequelae or death).16 Recovery was defined as survival and disappearance of all signs and symptoms of active infection with no residual disability. Therapeutic failure was defined as persistent or worsening symptoms and signs of infection with a high CRP or ESR, or worsening imaging findings, or death attributable to infection. A relapse was defined as the reappearance of symptoms not to attributable to other causes, or new vertebral lesions or paraspinal abscess together with elevation in CRP and/or ESR after treatment.

The clinical sequelae were classified according to the patient's functional status at the end of follow-up as made in a previous study by Solero et al18: normal-no pain or neurological deficits remained; mild sequelae-no neurological deficits remained but pain with exercise that did not interfere with work was present; moderate sequelae-pain interfered with work or milder motor or sensorial deficits remained; and severe sequelae-permanent and excruciating pain (requiring rest and analgesics) or motor or sensorial deficits remained.

Version 11.5 of SPSS software for windows was used for statistical analyses. Mann-Whitney U test was used for continuous variables, and Pearson χ2 test was used for categorical variables. A P < 0.05 was considered to indicate statistical significance.

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RESULTS

During the study period, 110 patients were diagnosed as spondylitis. Within these patients, 14 patients who were diagnosed of having pyogenic spondylitis and 9 patients in whom there was not enough information about follow-up period were excluded. Eighty-seven patients were included in this series: 44 had BS and 43 had TS. The percentage of male patients was 34.1% in BS versus 48.8% in TS (P = 0.195). The mean age of patients was 53.70 ± 14.63 years (range, 14-78 years) in BS and 47.42 ± 19.71 years (range, 14-80 years) in TS (P = 0.142). Percentage of patients who were 50 years or older was 70.5% (n = 31) in brucellosis and 46.5% (n = 20) in tuberculosis (P = 0.03). The general features of the patients are summarized in Table 1.

Table 1
Table 1
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Predisposing factors to spine infection included diabetes mellitus, immunosuppressive disease, steroid usage, history of hypertension and arteriosclerotic diseases, dialysis for chronic kidney failure, and previous surgery on spine. This group was 30.2% in BS versus 47.7% in TS (P = 0.125) in our series.

The medical history proved to be of great value in suggesting the etiologic diagnosis. Within patients with TS, 8 (18.6%) had a prior history of tuberculosis, 12 (27.9%) had a history of contact with an active pulmonary tuberculosis patients, and 15 (34. 9%) had an active or recently diagnosed pulmonary tuberculosis. Eight patients with brucellosis (18.2%) had a diagnosis of brucellosis during the previous year, and 10 (22.7%) had a family history of brucellosis.

Purified protein derivative of tuberculin (PPD) skin test results were recorded in 40 patients with tuberculosis and in 41 patients with brucellosis. Thirty-seven (86.0%) patients with tuberculosis had a positive reaction greater than 10 mm in diameter, whereas in BS, positive results were detected in 4 patients (9.8%) (range, 10-12 mm) who had at least 2 bacille Calmette-Guérin scars (P = 0.0001) and were with response to therapy for brucellosis.

Patients with TS have longer mean duration of symptoms before diagnosis (P = 0.0001). This duration ranged from 10 to 1085 days (median, 60 days) in BS and from 20 to 1460 days (median, 210 days) in TS.

Patients with tuberculosis have higher mean value of ESR and CRP (P = 0.020 and P = 0.000, respectively) than those of patients with BS. Erythrocyte sedimentation rates ranged from 2 to 130 mm/h in BS and 10 to 130 mm/h in TS. C-reactive protein levels ranged from 3 to 97 mg/L (median, 24 mg/L) in BS and 5 to 192 mg/L (median, 67 mg/L) in TS. Thirty-three patients (75%) of BS and 36 patients (83.7%) of TS had ESRs of 40 mm/h or greater (P = 0.429). Mean hemoglobin concentration was significantly lower in TS than in BS (P = 0.034). Mean value of aspartate aminotransferase was higher (mean, 40.18 ± 25.98 U/L) in those with BS than in those with TS (mean, 26.86 ± 16.51 U/L) (P = 0.033). Other parameters, such as white blood cell count, platelet count, alanine aminotransferase, alkaline phosphatase, and globulin, were not found to be helpful for diagnosis.

The symptoms and clinical findings are shown in Table 2. In both groups, back pain was the most common complaint (P = 0.434). Fever, night sweating, and arthralgia were significantly more frequent complaints in BS (P = 0.019, P = 0.030, and P = 0.000, respectively), whereas in TS, weakness or fatigue and cord and root compression were more frequent (P = 0.001, P = 0.007, and P = 0.007, respectively). Neurological involvement was evident in 25 cases (28.7%), significantly more frequent in TS (44.2%) than in BS (13.6%) (P = 0.002).

Table 2
Table 2
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The mean number of involved vertebra was not different in BS and TS (3.16 ± 2.27 and 3.67 ± 3.85, respectively). In both groups, lumbar segment was the most frequently affected level; 79.5% in BS and 72.1% in TS; however, thoracic involvement was significantly more frequent in TS (P = 0.030). The involvement of multilevel and more than 2 vertebrae was more frequent in patients of TS than in those of BS, but it was not statistically significant. The involvement of sacroiliac joints was present in 11.6% of TS and 29.5% of BS. Kyphosis was more common in patients with TS (11.6%) than in those with BS (2.3%) (P = 0.011) (Table 1).

All patients had a plain radiography of spine done. The plain radiography was normal on admission only in 7 patients with brucellosis. Spinal MRI was performed in all patients. Destruction and compression of vertebral body were significantly more frequent in patients with tuberculosis than those with brucellosis (P = 0.005 and P = 0.0004, respectively). Diskitis was significantly more frequent in BS (P = 0.001). Paraspinal masses were detected in 43 patients (40.5%), significantly higher in TS (67.4%) than in BS (31.8%) (P = 0.001). Table 3 shows our MRI findings (Figs. 1-4). Psoas abscesses were detected in 2 (4.4%) of the BS and 10 (23.2%) of the TS cases. Difference was statistically significant (P = 0.011)

Table 3
Table 3
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Figure 1
Figure 1
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Figure 2
Figure 2
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Figure 3
Figure 3
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Figure 4
Figure 4
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Only eight patients (18.2%) with BS underwent surgery. Culturing was found to be unnecessary because of the positive results of standard tube agglutination test. In 31 patients (72.1%) with TS, the spinal specimens were obtained by open surgery. Although all biopsy specimens of patients with TS were examined histologically, only 19 were sent for culturing. In the remaining 12 patients with tuberculosis, surgeons had assumed that the macroscopic appearance of the involved tissues was analogous to the tissue with tuberculosis, and such specimens were found unnecessary to be sent for culturing. The overall results of the spinal biopsies in TS were as follows: positive histopathologic findings in 77.4% (24/31 patients), positive AFB culture in 57.9% (11/19 patients), and positive AFB smear on Ziehl-Neelsen staining in 47.4% (9/19 patients). Tuberculous spondylitis was diagnosed based on imaging study evidence of a spinal tuberculous focus in conjunction with positive bacteriologic and/or histological findings from a specimen taken at an extraspinal skeletal site in 12 patients who did not undergo surgery. In 3 patients having fistula over the affected vertebrae and right iliac region, specimen of discharge grew M. tuberculosis. Two patients also had a meningeal involvement; one of them had a positive cerebrospinal fluid culture, and the other patient had positive CSF smears for AFB. Of the remaining 7 patients, 2 had a positive sputum culture for M. tuberculosis, and 5 had only positive smears for AFB. Resistance to antituberculous drugs was detected in 23.5% ofthe patients.

Standard tube agglutination testing was positive for antibodies to Brucella (≥1/160) in all patients with brucellosis. This serological test was negative in cases with TS. Blood culture was taken in only 10 patients with BS, and 3 (30%) of them were positive.

All patients received medical treatment with a combination of agents. Although the treatment was medical alone in 36 patients (81.8%) with BS and 12 (27.9%) with TS, 31 patients with TS and 8 patients with BS had an additional surgery (P = 0.0001). The mean duration of medical treatment was significantly longer in TS (12.30 ± 5.40 months; range, 1-28 months) than in BS (4.75 ± 2.33 months; range, 2-11 months) (P = 0.0001). There was no severe adverse event needing cessation of therapy in TS patients, whereas in BS patients, 3 of the treatments were revised. Streptomycin and anti-inflammatory drugs were stopped in one of the patient who developed acute renal failure, and rifampicin was changed to ciprofloxacin in 2 patients with hepatotoxicity.

Five patients with tuberculosis died, whereas in the BS group, no mortality was seen. Only 1 patient with BS had a relapse. Sequelae were mild or moderate in 19 patients (43.2%) in BS and 17 (39.5%) in TS. Unfavorable outcome was in only 3 patients (6.8%) with BS versus in 11 (25.6%) with TS (P = 0.021).

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DISCUSSION

Brucellosis and tuberculosis are both relatively common causes of vertebral osteomyelitis in many endemic areas of the world such as the Mediterranean basin.1-5,18 The frequency of spondylitis in brucellosis ranges from 2% to 58%.1,19-23 Spondylitis is the most common site of skeletal involvement of tuberculosis, comprising in most series approximately 50% of cases.24,25 Recently, an incidence of 51% has been reported from Turkey.26

Tuberculous spondylitis usually affects adults in the fourth decade, and BS affects those older than 50 years. In both forms, men are predominantly affected.10,11,14,18,27-29 On the contrary, in our series, in concordance with other reports from Turkey, the majority of our cases were females.13,22

In vertebral osteomyelitis, early diagnosis is essential because it can be complicated by potentially devastating neurological conditions.7,11,29,30 Unfortunately, diagnosis is easily missed despite the availability of good diagnostic tools, and treatment is often unnecessarily delayed. Cordero and Sanchez10 and Solera et al18 reported that the mean time to diagnosis in BS was 72 and 100 days, respectively. In TS, it was found to vary across studies, from 120 to 231 days.10,11,27-29 In our series, the mean diagnostic delay was significantly shorter in BS (118 days) than in TS (355 days). This fact could be explained by the availability of serological test for brucellosis in Turkey.

A high degree of clinical suspicion of TS allows early diagnosis and treatment. Medical history such as a previous history of tuberculosis or brucellosis or contact with tuberculosis-infected patients or family history for both diseases is valuable clues for the diagnosis.18,26,28,29 The frequency of these clues about medical history has been found to vary across studies, from 8% to 42% of patients with tuberculosis26,27 and 23% in BS,11 which was similar (46.5%) to that reported in our series.

The PPD skin test remains an important diagnostic tool,but several reports notice variable percentages of PPD-negative patients.11,25,27,28 Our data support the fact that a negative tuberculin test does not rule out TS.

Routine laboratory data reported in most studies have been of little diagnostic value.11,27,29 However, in this series, some findings were found to be useful in distinguishing the 2 etiologies. In this respect, high values of ESR and CRP levels and low hemoglobin concentration should point to tuberculosis with compatible clinical and imaging findings for TS.30 Erythrocyte sedimentation rate and CRP levels, although nonspecific, may be useful in evaluating response to treatment and disease activity for both diseases.7,9,30

Vertebral osteomyelitis encompasses a range of clinicalmanifestations. Both infections typically manifest with nonspecific symptoms of discomfort with a slow or insidious onset that may be difficult to distinguish from neck or back pain due to other causes. Patients present with a combination of systemic manifestations such as weight loss, low-grade fever, sweating, malaise, and fatigue, as well as localized back pain.30-32 Fever was more common in BS (range, 60%-85%) than in tuberculosis (range, 32%-58%), which was similar to the reported 63.7% to 37.2% rates in our series, respectively.10,27-29 Localized back pain which is the earliest sign of spondylitis is present in nearly all cases with both diseases,31,32 as seen in this series. In addition to localized back pain and fever, arthralgia and night sweating were more important clinical findings in our cases with brucellosis.

Spondylitis may be complicated by potentially devastating neurological defects that must be considered carefully in endemic areas.31,32 In reported previous series, this rate ranges from 23% to 76% in TS and 10% to 43% in brucellosis.11,18,19,27,28 The larger diagnostic delay partially explains this fact. As expected, neurological involvement was significantly more frequent in TS in our series (44.2% in TS vs 13.6% in BS) similar with the reported studies.

Tuberculous spondylitis most commonly affects the lower thoracic and upper lumbar regions of the spine, both of which comprise 80% to 90%.11,27-29 In some previous reports, the thoracic and lumbar segments were nearly equally affected.1,12,28,33-35 In our case series, the lumbar spine was the most commonly involved region, accounting for 72.1%, followed by the thoracic spine (53.5%), which was similar to the reported 66% and 47% by Pertuiset et al,28 respectively. However, thoracic involvement was more frequent in TS than in BS in our case series (P = 0.030). As for BS, the lumbar spine is frequently reported as the most common site of involvement, followed by thoracic and cervical locations. Lumbar involvement was detected in 79.5% of our patients, which was similar to the reported 45% to 83% rates.10,11,18,19,22,27 Multilevel involvement is more frequent in patients of TS in some of the previously reported studies.11,28,30 However, it has been reported to account for 1% to 24% in cases of tuberculosis28,33,36 and 5%to 21% in cases of brucellosis.11,20,27,28 Similarly, we found a slightly increased number of multilevel involvement in TS group, although it is not statistically significant.

Sacroiliitis, together with spondylitis, is the most frequent osteoarticular involvement in adult patients with brucellosis,18,20,33,37 accounting for 29.5% of our series. Sacroiliac tuberculosis is often associated with tuberculous lesions elsewhere, such as psoas abscess and TS. Approximately 10% of skeletal tuberculosis occurs in sacroiliac joint as seen in our study.38 In our series, sacroiliac joint involvement was not statistically significantly different in both groups (P = 0.062).

The radiological diagnoses of BS and TS are based on the findings of MRI and CT, although radiographs of the spine and bone scan also provide some information. Plain radiographic films do not detect vertebral involvement until at least 50% of a vertebra is destroyed. The bone scan is very sensitive in early stage, but it is scarcely specific.33-35 Therefore, CT and MRI yielding positive findings in the early stage have become the radiological modalities of choice in the diagnosis of both diseases.34,39 It was not the purposes of our study to analyze the yield of the different imaging techniques in both groups. However, we detected that some findings may be helpful in distinguishing the 2 etiologic groups. In this respect, destruction and compression of vertebral body (30.2% and 34.9%, respectively), paraspinal abscesses (67.4%), root and cord compression (20.9% each one), and kyphosis (11.6%) should point to tuberculosis, as described by other authors.1,11,28,29 However, characteristic MRI findings of BS include primarily intact vertebral architecture despite the evidence of diffuse vertebral osteomyelitis, disk space involvement, diskitis, minimal associated paraspinal soft-tissue involvement, and the absence of kyphosis.10,11,18 In our series, 79.5% of the cases with brucellosis showed disk involvement, which is similar to the reported 66% to 78% rates by previous studies Cordero and Sanchez10 and Colmenero et al.11 A kyphotic deformity, frequently described as a feature of TS, may be evident due to collapse and anterior wedging of vertebral bodies.29,40 In our series, it was significantly more frequent in the TS group (P = 0.011).

Bacteriological diagnosis is considered to be a gold standard in BS and TS. Confirmation by culture is highly desirable and leaves no doubt about diagnosis.4,6,11 Collection of a spinal or paraspinal specimens is not absolutely necessary in TS if an extraspinal skeletal focus such as pulmonary, lymph node, and discharge of fistula can be sampled.7,28,31 In some cases, the organism will not be seen on smear or culture, but caseating granuloma, which is a sufficient evidence to begin therapy, will be demonstrated on histological examination,28,30,41 as seen in the present case series. Histological studies of spinal biopsies provided proof of tuberculosis in 77.4% of our patients and in 59% to76% of cases in previous reports.28,29,42 In several studies, the frequency of bacteriologic proof in patients with TS was reported as 47% to 84%,11,28-30 whereas in our series, spinal and extraspinal specimens had a yield of 39.5% and 48.8% for acid-fast smear and culture, respectively. Some surgeons assume that histopathologic examination for TS is sufficient and does not routinely send for M. tuberculosis culturing,1,12,35 as seen in our study. This inappropriate clinical practice could be a major factor threatening the success of tuberculosis control programs in developing countries where antituberculous drug resistance is prevalent. The rate of antituberculous drug resistance in Turkey has been reported as 29.9% to 55.3%.43,44 Our resistance rate was 23.5%; therefore, clinicians and surgeons should be aware of the patterns of antituberculous drug resistance in their geographic area.

Brucella can be cultured from blood during a bacteremic episode, from involved lymph nodes, or from granuloma later in the course of the disease. The presumptive diagnosis of BS can be made serologically.4,18 Brucella agglutination test is quite reliable: 97% of infected persons become positive within 3 weeks of exposures.4 In our study, a spinal biopsy was obtained from only 8 patients with brucellosis because all of the cases had positive results of standard tube agglutination testing.

The management decision should be based on the goals of treatment for each individual case, depending on the stage of the vertebral osteomyelitis.6,7,42,45 Although the rational modality for treatment is combination of both surgical and medical treatments in TS,1,11,12,27,28 antibiotics are the mainstay of the treatment of brucellosis. Antibiotic combination is the norm in both tuberculosis and brucellosis.4,13,18 Although there is no preferred combination for the treatment of spinal brucellosis, the most widely used antibiotic combination for therapy is doxycycline and rifampicin or aminoglycoside. In addition, the problem lies in deciding on the appropriate duration of chemotherapy in both groups.45 This is an area where there is no consensus in tuberculosis. The American Thoracic Society and the Centers for Diseases Control and Prevention clearly indicated that bone and joint tuberculosis requires a minimum of 12 months of therapy,46,47 where there are reported shorter courses, such as 6 or 9 months, which may be appropriate for TS.11,29,46 The preferred duration of therapy for BS should be continued for at least for 3 months or longer4 because of high relapse rates. In our study, whereas half of cases with brucellosis received therapy for more than 3 months, duration of medical treatment were at least 9 months in survivors in TS. Duration of therapy varied according to clinical response and presence of abscess for both diseases.

Surgery is necessary as an adjunct to antibiotic therapy if the vertebral infection produces an abscess, vertebral collapse, or neurological compression.1,6,7,12 The proportion of patients who received surgical treatment varied widely across recent studies from 7% to 55% in TS1,8,11,29 and 3% to 33% in BS.11,13-15,18,19 Need for surgical treatment in 72.1% of our cases with tuberculosis was higher than previously reported rates. This could be explained by advanced stages of tuberculosis in most of our cases; 18.2% of our BS cases were operated on the provided belief of cord compression because of paraspinal soft-tissue involvement similar with the previous reports.

The prognosis in general is good with adequate treatment sustained for an appropriate length of time for both diseases. The diversity of criteria used for evaluation of treatment in each one may cause variations in the results obtained by different researcher. Our series showed a 93.2% favorable outcome in brucellosis and a 74.4% in tuberculosis, which are similar with previously reported rates.10,11,13-15,27-29 The higher rate of unfavorable outcome and death in our cases with tuberculosis than in brucellosis may partially be explained by larger diagnostic delay and more destructive process.20 In the present study, relapse rate was 2.3% in BS, occurring in 4% to 55% according to various studies.11,13,18,22 No relapse was seen in our cases with tuberculosis. This is similar to the study reported by Alothman et al.29 This fact may possibly reflect to be given the adequate treatment duration as we stated above.

Regarding to the outcome, it is important to have a high level of clinical suspicion, especially in patients in countries with a high prevalence of tuberculosis or brucellosis. Our study confirmed that documented history, clinical presentation, laboratory and histological examination, and radiographic imaging can be highly suggestive of spinal tuberculosis and brucellosis. Once the diagnosis of spondylitis is made, even in the absence of positive culture, serum agglutination test, history of fever, night sweating, arthralgia, and the radiological findings of disk involvement will be helpful for the diagnosis of brucellosis, whereas history of contact with active pulmonary tuberculosis or recently or formerly diagnosed tuberculosis, malaise, neurological complaints, higher ESR and CRP, and radiological findings of vertebral destruction and compression, epidural and paravertebral soft-tissue involvement, and abscess and thoracic vertebra involvement with or without kyphosis can be used for the early diagnosis of tuberculosis. In endemic areas, this may be sufficient for empirical treatment for both diseases. A good outcome is expected if the diagnosis is made in early stages before the appearance of spinal deformity.

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