trimethoprim--sulfamethoxazole-drug-combination and Spondylitis--Ankylosing

A 33-year-old woman with increasing back pain was referred to our hospital 8 years ago. As she had ankylosing sacroilitis and peripheral arthritis she was diagnosed as having ankolysing spondylitis with involvement of the peripheral joints. She recently developed persistent diarrhea, abdominal symptoms and weight loss.. Laboratory findings revealed a chronic inflammatory disease. Infection of the gastrointestinal tract was excluded. Duodenal biopsy was normal on PAS staining, Tropheryma whipplei-DNA was detected by the polymerase chain reaction (PCR).. Initially the patient was treated for 6 months with diclofenac and ibuprofen without improvement of her condition. As the spondylitis persisted, she was given anti-TNF-alpha treatment 7 years after the onset of symptoms. When Whipple's disease was diagnosed this treatment was stopped and antibiotics (ceftriaxone) was started and then continued with co-trimoxazole for one year with significantly improvement in her condition.. In patients presenting with symptoms involving several organs, rare systemic diseases should be considered. If symptoms are typical of Whipple's disease, but duodenal biopsies are negative on PAS staining, a sensitive PCR assay may detect T. whipplei-DNA confirming this infection. Appropriate antibiotic treatment can then be initiated.

Topics: Adult; Anti-Bacterial Agents; Anti-Inflammatory Agents, Non-Steroidal; Biopsy; Ceftriaxone; Diagnosis, Differential; Diclofenac; DNA, Bacterial; Duodenum; Etanercept; Female; Humans; Ibuprofen; Immunoglobulin G; Polymerase Chain Reaction; Receptors, Tumor Necrosis Factor; Spondylitis, Ankylosing; Treatment Outcome; Trimethoprim, Sulfamethoxazole Drug Combination; Tropheryma; Tumor Necrosis Factor-alpha; Whipple Disease

It is occasionally difficult to distinguish the features of spinal brucellosis from those of ankylosing spondylitis (AS), and the resultant delayed diagnosis may allow insidious progression of the complications of the brucella infection. The case of a 33-year-old male HLA-B27-positive patient with known diagnosis of AS for 7 years, who developed a paravertebral abscess in the left erector spinae muscle due to brucellosis, is presented in this paper. This case report illustrates two important points; first, co-occurrence of AS and brucellosis in the same patient, and second, posterior element involvement with abscess formation in erector spinae muscle, which has not been previously reported. Magnetic resonance imaging is a sensitive method for detecting spinal brucellosis and extent of infection throughout paravertebral structures. Clinicians serving patients from areas with endemic brucellosis should not overlook the possibility of this infection in the presence of axial musculoskeletal symptoms, even among patients with AS.

Topics: Abscess; Adult; Anti-Bacterial Agents; Brucella; Brucellosis; Diclofenac; Doxycycline; Drug Therapy, Combination; Humans; Lumbosacral Region; Magnetic Resonance Imaging; Male; Muscle, Skeletal; Myositis; Osteomyelitis; Spondylitis, Ankylosing; Streptomycin; Sulfasalazine; Trimethoprim, Sulfamethoxazole Drug Combination

Between 1974 and 1989 we prospectively observed 530 patients with brucellosis. The findings for 62 patients (42 males and 20 females; mean age, 34.7 years) with 63 episodes in which the sacroiliac joint was involved (the most frequent osteoarticular location [11.7%]) were analyzed. Ten of the older patients (mean age, 55.3 years) had concomitant spondylitis. Systemic symptoms were usually important, and characteristic pain and findings of sacroiliitis were observed in approximately 75% of cases. Blood cultures were positive for Brucella melitensis for 44 patients. The most frequent radiographic findings were blurring of articular margins (42 cases) and widening of the sacroiliac space (20 cases). No radiographic anomalies were detected in 13 cases. Results of 99mTc and gallium-67 bone scans were abnormal in approximately 90% of cases (abnormalities were often mild). Overall, clinical, radiographic, and isotopic bone scan findings were sensitive and useful, although they were occasionally minimal or difficult to evaluate, making diagnostic findings confusing or misleading. Brucellar sacroiliitis is a mild disease associated with a good outcome similar to that observed for patients with uncomplicated brucellosis.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anti-Bacterial Agents; Arthritis, Infectious; Brucella melitensis; Brucellosis; Chi-Square Distribution; Child; Female; Follow-Up Studies; Humans; Macrolides; Male; Middle Aged; Prospective Studies; Radiography; Radionuclide Imaging; Sacroiliac Joint; Spondylitis, Ankylosing; Treatment Outcome; Trimethoprim, Sulfamethoxazole Drug Combination