Original Investigation / Özgün Araştırma DOI: 10.5578/ced.202045 • J Pediatr Inf 2020;14(3):e106-e110 Fever, Malaise and Arthralgia: Brucellosis or Salmonellosis in the Differential Diagnosis in an Endemic Area Ateş, Halsizlik ve Artralji: Endemik Bir Bölgede Ayırıcı Tanıda Bruselloz ve Salmonelloz Başak Yıldız Atikan1(İD), Gülhadiye Avcu1(İD) 1 Clinic of Pediatric Infectious Diseases, Balikesir Ataturk City Hospital, Balikesir, Turkey Cite this article as: Yıldız Atikan B, Avcu G. Fever, malaise and arthralgia: brucellosis or salmonellosis in the differential diagnosis in an endemic area. J Pediatr Inf 2020;14(3):e106-e110. Abstract Öz Objective: Brucellosis and salmonellosis are both infectious, zoonotic Giriş: Bruselloz ve salmonelloz ülkemizde endemik olarak görülen en- and endemic diseases in Turkey. In this study, we aimed to report a group feksiyöz ve zoonotik hastalıklardır. Bu çalışmada hastanemize ateş, hal- of pediatric patients admitted to the hospital with fever, malaise and ar- sizlik ve eklem ağrısı yakınması ile başvuran ve bu iki hastalık açısından thralgia and diagnosed with either of the diseases. tetkik edilerek biri ile tanı almış pediatrik olgular geriye dönük olarak Material and Methods: We retrospectively analysed hospital records for incelenmesi amaçlanmıştır. gender, age, consumption of raw milk products, laboratory results, organ Gereç ve Yöntemler: Hastaların yaş, cinsiyet, çiğ süt ve süt ürünü tü- involvement, treatment choices and course of the disease. ketim öyküleri, klinik ve laboratuvar bulguları, organ tutuluşları, tedavi Results: Out of a total of 36 children, 30 were diagnosed with brucellosis uygulamaları ve prognozları retrospektif olarak değerlendirilerek sunul- and 6 with salmonellosis in two years. A total of 20 patients of 30 cases muştur. (66%) diagnosed with brucellosis notified exposure to animals. Except Bulgular: İki yıllık süreçte toplam 36 olgunun 30’u bruselloz, 6’sı salmo- two of these patients, they usually confirmed that they consumed raw nelloz tanısı almıştır. Brusella tanısı alan 30 olgunun 20’si hayvan teması milk or cheese made with unpasteurized milk. Only 2 cases of the resid- olduğunu ve 2 olgu dışında hepsi çiğ süt ve süt ürünü tüketimi olduğunu ual 6 cases diagnosed with salmonellosis had contact with animals and belirtmiştir. Salmonelloz tanısı alan 6 olgunun ise 2’sinin ailesi ise hayvan- consumed raw milk or meat products. Their sources of infections remain cılıkla uğraşmakta olup, diğer olgularda enfeksiyon kaynağına dair bir gös- unclear. Fever, malaise and arthralgia were most frequent symptoms, terge bulunamamıştır. Ateş, halsizlik ve artralji en sık görülen semptomlar and hepatosplenomegaly was the most common extraarticular man- olup her iki hastalıkta hepatosplenomegali en sık görülen ekstraartiküler ifestation in both conditions. All patients are in remission except two bulgudur. Bruselloz tanılı 17 olgudan 3’ünde relaps görülmüştür. İzlemde cases of brucellosis with disease relapse in follow up, and one case with hemofagositoz gelişen ve kemoterapi ihtiyacı doğan bir olgu dışında tüm hemophagocytosis and prolonged disease and the need for additional olgularda remisyon sağlanmıştır. chemotherapy. Sonuç: Her iki hastalığa yönelik eradikasyon programlarının uygulan- Conclusion: Despite effective eradication programmes for both diseas- ması ve kontrol çabalarına rağmen özellikle bruselloz, endemisite gös- es, they still remain important health problems and cause disease bur- termesi açısından ülkemizde hâlâ önemli bir sağlık sorunu olarak karşı- den. mıza çıkmaktadır. Keywords: Brucellosis, salmonellosis, childhood Anahtar Kelimeler: Bruselloz, salmonelloz, çocukluk çağı Correspondence Address/Yazışma Adresi Başak Yıldız Atikan Balıkesir Atatürk Şehir Hastanesi, Çocuk Enfeksiyon Hastalıkları Kliniği, Balıkesir-Türkiye E-mail: [email protected] ©Copyright 2020 by Pediatric Infectious Diseases and Immunization Society. Received: 06.11.2019 Accepted: 15.01.2020 Available Online Date: 27.11.2020 Available online at www.cocukenfeksiyon.org Yıldız Atikan and Avcu J Pediatr Inf 2020;14(3):e106-e110 Brucellosis and Salmonellosis e107 Introduction both diseases. Titers higher than 1/100 in STA for salmonello- sis were reported as positive. Blood cultures were drawn from Children with fever, malaise and arthralgia are often patients with high fever. pre-diagnosed with several conditions including infectious, rheumatological and hematological diseases. Screening tests Results include mostly complete blood count, blood differential to ex- A total of 36 children who were admitted to the hospital clude hematological diseases, inflamatory markers like C-reac- between November 2017 and November 2019 with fever, tive protein and spesific tests according to the pre-diagnosis malaise and arthralgia and suspected with brucellosis or sal- like arthritis, osteomyelitis and many other conditions. How- monellosis and diagnosed with one of these diseases via stan- ever, if a disease is frequently seen or endemic in an area, it is dard agglutination tests were included into the study. Their possible to request some tests in first line. Serum agglutina- clinical and laboratory findings, treatment modalities, prog- tion tests for human brucellosis and salmonellosis have such nosis and complications were evaluated. Out of these 36 chil- an importance if the patient is living in an area, where animal dren, 30 were diagnosed with brucellosis and 6 with salmo- disease is endemic and raw milk products are consumed. Both nellosis. Sixteen were females (44%) and 20 were males (56%) diseases are systemic and can lead to different clinical pic- with an age range 3-17 and a median age of 8.6. A total of 20 tures. Brucellosis caused by bacteria Brucella spp. is a small, patients of the 30 cases (66%) diagnosed with brucellosis no- non-motile, non-spore-forming gram-negative coccobacilli tified exposure to animals as a possible infection source. Only (1). People in our country are still at high risk to acquire the two of these patients denied consumption of raw milk and disease via contact with sick animals or consumption of their dairy products. The rest confirmed usually that they had con- milk and dairy products despite efforts to eradicate the dis- sumed cheese made with unpasteurized milk. Only 2 cases of ease (2). Moreover, salmonellosis is caused by an important the residual 6 cases diagnosed with salmonellosis had contact human pathogen which is named Salmonella spp. and can with animals and consumed raw milk or meat products. Their lead to considerable morbidity and mortality due to intestinal sources of infections remain unclear. and extraintestinal manifestations in the human body world- wide. People are infected mostly by eating foods like raw Fever (21/30 cases of brucellosis, 6/6 of cases diagnosed meat, poultry, eggs, and vegetables which are washed with with salmonellosis), malaise and arthralgia were most fre- contaminated water (3). Since both clinical entities can rep- quent symptoms and the reason for examinations. Hepato- resent with similar manifestations, diagnostic tests are usual- splenomegaly was the most common extraarticular mani- ly added in first line request for examination. This study was festation in both conditions. Physical signs and symptoms, conducted with the purpose of showing ongoing importance, laboratory findings of both disease groups are listed in Table similarities and high frequency of both diseases in childhood. 1. Standard tube agglutination tests and blood cultures were used for diagnosis, and patients were found positive either for Materials and Methods brucellosis or salmonellosis. Only in one patient, who had liver The study was conducted in an endemic area in Turkey involvement and a high titer as 1/5120 at the time of diagno- between November 2017 and November 2019. Thirty-six chil- sis, Brucella spp. was grown in the fifth day of incubation with dren admitted to the hospital with fever, fatigue and arthral- BACTEC. Serological tests in brucellosis cases were repeated gia and examined for endemic diseases especially if they had at the two weeks, one month and 3 months and if necessary, animal contact and found to be positive for brucellosis or sal- in follow up in case of relapse. The tests were repeated at the monellosis were included to the study. Hospital records were end of the treatment course and also if necessary, in patients screened for gender, age, consumption of row milk products, with salmonellosis. laboratory results, organ involvement, treatment choices and Children with brucellosis under the age of 8 years were course of the disease. The study was approved by the local treated with an aminoglycoside antibiotic for 5 to 7 days with Ethics Committee. combination of rifampicin and sulphamethoxazole/trimetho- Microbiological Methods prim for 6 weeks. Older children were treated also with an ami- noglycoside with combination of doxycycline and rifampicin The diagnosis of acute brucellosis was based on positive also for 6 weeks. Disease relapse was seen in four of the total culture or a single standard tube agglutination test (STA) of 30 brucellosis cases. Patients with salmonellosis were treat- against Brucella spp. of ≥ 1/160. ed with cephalosporins firstly with a parenteral ceftriaxone For invasive salmonellosis, there are no reliable and rap- followed by a third-generation oral cephalosporin until their id diagnostic tests available. Blood culture remains the gold symptoms resolved. standard but is insensitive, slow,