布鲁氏菌病罕见并发症及诊断测试回顾：病例报告
抽象的
布鲁氏菌病是全球最常见的人畜共患疾病之一，其最常见的并发症为骨关节并发症，尤其是脊椎系统受累，而肺部并发症、胸椎间盘炎及硬膜外脓肿的报道及同期报道较少。
一名 17 岁的亚裔女性患者，T11-12 椎体水平发现椎间盘炎，随后出现硬膜外和椎旁脓肿，之后发现脓胸，患者无其他疾病。患者使用过多种抗生素，细菌学无法证实该疾病。玫瑰红试验也呈阴性。但在血液和胸水样本中检测到高滴度的布鲁氏菌阳性。双侧脓胸需要引流。由于多种并发症，病程延长。患者通过长期布鲁氏菌病联合治疗治愈。
尽管有些布鲁氏菌病很罕见，但它是一种人畜共患疾病，可引起许多并发症。诊断的黄金标准是血液培养或组织培养中细菌的生长。然而，分离微生物可能非常困难。临床怀疑和血清学检测是重要的指导。
背景
布鲁氏菌病是一种全球常见的人畜共患疾病，由布鲁氏菌属细菌引起，临床表现多样。由于未确诊且未得到充分治疗，可能导致长期患病和各种并发症。该病是世界范围内重要的公共卫生问题，在许多发展中国家很常见，尤其是地中海盆地、北非和东非、中东和阿拉伯半岛。据世界卫生组织报告，每年报告的布鲁氏菌病病例超过 50 万例，尤其是来自发展中国家，估计每确诊一例布鲁氏菌病就有四例未被发现的病例[1]。我国是该病的流行国，传统的农耕方式、生活方式和新鲜乳制品的消费是布鲁氏菌病高发病率的原因之一。血清流行率研究报告的发病率为 1.3–26.7%，最高发病率主要出现在安纳托利亚东南部各省[2]。
布鲁氏杆菌病的临床表现多种多样，可引起多种系统相关并发症。最常见的是骨关节并发症（10-85%），尤其是脊椎系统受累 [3]。布鲁氏杆菌性脊柱炎和椎间盘炎主要影响腰椎（60%），其次是胸椎（19%），极少影响颈椎节段（12%）。脊柱硬膜外脓肿是一种更严重的临床形式，继发于椎间盘炎。据报道其发病率为 1/10,000，文献中很少有病例 [4]。硬膜外脓肿扩散到椎旁区域的情况要少得多 [5]。
另一方面，由于诊断方法和治疗手段的改进，肺布鲁氏菌病是一种非常罕见的并发症。文献中报道的发病率为 1-10% [6]。检测到的肺部病变包括实质性结节、大叶性肺炎或胸腔积液。脓胸报告仅限于少数病例 [7]。
在我们的病例报告中，我们介绍了一例 17 岁患者的病例，该患者患有影响下胸椎的椎间盘炎和椎旁脓肿，以及布鲁氏菌病，脓肿继发双侧脓胸，但不伴有肺部感染，并且我们分享了用于诊断该病例的血清学测试以及我们在这些测试中遇到的困难。
病例介绍
A 17-year-old Asian female patient living in a rural area and whose family is engaged in animal husbandry had abdominal pain, lower back pain, and increased fever, especially at night, which started approximately 1 month before the admission to our emergency department. She had no history of disease and drug use. There was no chronic disease in her family. She went to different polyclinic branches in many hospitals with these complaints. During this time, in these sections, after receiving various diagnoses and treatments such as urinary infection and lumbar discopathy, she was diagnosed at another center with brucellosis after her standard tube agglutination test (STA) was positive at 1/320 titer, and her treatment was arranged in the form of a combination of doxycycline (100 mg; twice a day) and rifampicin (600 mg; once a day). Although the treatment was given to the patient, her complaints continued, and her lower back pain worsened, so she came to our emergency department and was consulted by the department of infectious diseases. On admission, her fever was 37.8 °C, and other vital signs were stable. On physical examination, diffuse tenderness was detected on palpation in the thoracolumbar vertebrae. Other physical examination findings were normal. In the examinations performed, hemoglobin (Hb) level was 10.4 g/dL, white blood cell count was 10,900 (53% neutrophils, 35% lymphocytes), C-reactive protein (CRP) was 92.9 mg/L (0–5 mg/L), erythrocyte sedimentation rate was 71 mm/hour, Rose Bengal plate test (RBPT) was negative, and posteroanterior (PA) chest X-ray was found normal. The brucellosis treatment the patient was taking was continued. Blood cultures were taken after admission. Although the lumbar magnetic resonance (MR) imaging was normal, on contrast-enhanced thoracic vertebra MR examination, bone marrow edema in T11 and T12 vertebrae in this disc space, mild hyperintense signal change in T2W disc space on contrast-enhanced examination, and intense enhancement of the described vertebrae were observed. Spondylodiscitis was considered. At the same time, a T1W hypointense, T2W hyperintense intense peripheral enhanced signal area was detected at this level, reaching a thickness of approximately 2 mm, which may be compatible with epidural abscess and paravertebral abscess in the anterior paravertebral area (Figs.1,2). Ceftriaxone (1000 mg; twice a day) was added to the treatment that the patient was taking and continued. She needed serious analgesics due to severe pain. Surgical intervention was not considered for the patient by the department of neurosurgery since there was no neurological finding on physical examination. Our request for interventional sampling was not accepted. TheBrucellaagglutination test with Coombs performed in our microbiology laboratory was positive at a titer of > 1/1280. There was no contact history regarding tuberculosis, and the purified protein derivative (PPD) test was negative. No growth was detected in blood cultures during and after this period. The patient, who did not have a fever after hospitalization, complained of a fever reaching 39 °C on the fourth day. On the days following the development of fever, the control white blood cell value was 21,000, and CRP was 420 mg/L; the possibilities for another focus of infection, progression of the current complication, or another complication were evaluated. As a result of the examinations, empyema was detected in the left lung, transferred to the department of thoracic surgery, and tube thoracostomy (closed underwater drainage) was performed. An exudate-like fluid was detected with drainage and a hemopurulent appearance. On gram examination, there were plenty of leukocytes, and no microorganisms were seen. There was no growth in the pleural fluid culture. The data obtained during this intervention were limited due to insufficient examination requests. The patient’s treatment was continued during this period by changing with doxycycline, trimethoprim/sulfamethoxazole (TMP/SXT) (10 mg TMP/kg/day intravenously divided every 6–12 hours). After the necessity of tube thoracostomy disappeared, the patient was taken back to our service to continue the treatment. On the eighth day following the drainage, the patient developed a fever again, and the acute phase values increased. Thoracic computed tomography (CT) was performed by taking a blood culture. Pleural fluid appearance with dense content, reaching a thickness of 3 cm in the thickest part on the right and 25 mm in the thickest part on the left, and containing air values on the left; pleural fluid with a thickness of approximately 1 cm between the leaves of the mediastinal pleura in the right paracardiac area, the largest in the paracardiac and prevascular areas in the mediastinum; and a few lymph nodes with a short diameter of 7 mm were detected (Figs.3,4).

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