Symptoms of brucellosis in adults

The incubation period for acute onset of brucellosis lasts about 3 weeks, however, if the disease begins as a primary latent, after which symptoms of brucellosis then appear, then the incubation period can last several months. Symptoms of brucellosis have necessitated the development of a classification of clinical forms. Brucellosis does not have a single classification.

The most justified classification of clinical forms of brucellosis is that proposed by N.I. Ragoza (1952) and based on the clinical-pathogenetic principle. N.I. Ragoza demonstrated the phased nature of the brucellosis process dynamics. He identified four phases:

• compensated infection (primary latent):
• acute sepsis without local lesions (decompensation),
• subacute or chronic recurrent disease with the formation of local lesions (decompensation or subcompensation);
• restoration of compensation with or without residual effects.

These phases are closely related and five clinical forms of brucellosis have been identified:

• primary latent;
• acute septic;
• primary chronic metastatic;
• secondary chronic metastatic;
• secondary latent.

The septic-metastatic form is singled out as a separate variant, which includes those cases where individual focal changes (metastases) are detected against the background of the acute septic form. The classification shows the dynamics of the further development of each form.

Brucellosis of the primary latent form is characterized by a state of practical health. Its inclusion in the classification of clinical forms is due to the fact that when the body's defenses are weakened, it can develop into either an acute septic or a primary chronic metastatic form. With a thorough examination of individuals with this form of brucellosis infection, it is sometimes possible to detect symptoms of brucellosis in the form of a slight increase in peripheral lymph nodes, subfebrile condition, and increased sweating during physical exertion. However, these individuals consider themselves healthy and fully retain their ability to work.

The acute septic form is characterized by high fever (39-40 °C and above), the temperature curve in some cases tends to be undulating, often of an irregular (septic) type with a large daily amplitude, repeated attacks of chills and sweating. Despite the high and very high body temperature, the patient's well-being remains satisfactory (at a temperature of 39 °C and above, the patient can read, watch TV, etc.). There are no other signs of general intoxication.

Moderate enlargement of all groups of lymph nodes is typical, some of them are sensitive to palpation. By the end of the first week of the disease, the liver and spleen often enlarge. Leukopenia is noted when examining peripheral blood, ESR is not elevated. The main difference of this form is the absence of focal changes (metastases). Without antibiotic therapy, fever can last 3-4 weeks or more. This form does not threaten the life of the patient and even without etiotropic treatment ends in recovery. In this regard, the acute septic form of brucellosis cannot be considered sepsis, but should be considered as one of the variants of brucellosis.

Chronic forms of brucellosis in some cases develop immediately, bypassing the acute phase, in other cases the signs of chronic brucellosis appear some time after the acute septic form of brucellosis. The symptoms of brucellosis of the primary and secondary chronic metastatic form do not differ in any way. The only difference is the presence or absence of the acute septic form in the anamnesis.

Symptoms of chronic brucellosis are characterized by a syndrome of general intoxication, against the background of which a number of organ lesions are observed. Long-term subfebrile temperature, weakness, increased irritability, poor sleep, loss of appetite, and decreased performance are noted. Almost all patients have generalized lymphadenopathy, and along with relatively recently appeared enlarged nodes (soft, sensitive or painful on palpation), small, very dense painless sclerotic lymph nodes (0.5-0.7 cm in diameter) are noted. An enlarged liver and spleen are often detected. Against this background, organ lesions are detected.

The most typical lesions affect the musculoskeletal system. Patients complain of pain in the muscles and joints, mainly in the large ones. Polyarthritis is characteristic of brucellosis; new joints are involved in the process with each exacerbation. The knee, elbow, shoulder, and hip joints are most often affected, and the small joints of the hand and feet are rare. Periarthritis, paraarthritis, bursitis, and exostoses are characteristic. The joints swell, their mobility is limited, and the skin above them is usually of normal color. Impaired mobility and deformation of the joints are caused by the proliferation of bone tissue. The spine is affected, most often in the lumbar region.

Sacroiliitis is typical for brucellosis, its diagnostic significance is extremely high, since other etiologic agents cause it very rarely. There are a number of diagnostic techniques for detecting sarcoileitis. Eriksen's symptom is informative: the patient is placed on a dressing table and pressure is applied to the iliac crest when lying on the side or the anterior superior iliac crests are squeezed with both hands when lying on the back. With unilateral sacroiliitis, pain occurs on the affected side, with bilateral, pain is noted in the sacrum on both sides.

To diagnose sacroiliitis, the presence of other symptoms is also checked: Nachlass, Larrey, John-Behr, Hanslen, Ferganson, etc.

Nachlass's Symptom: with the patient lying face down on the table, bend his legs at the knee joints. When raising the limb, pain appears in the affected sacroiliac joint. Larrey's Symptom: the patient is placed on the table in a supine position. The doctor stretches the protrusions of the iliac wings to the sides with both hands, causing pain on the affected side (in case of unilateral sacroiliitis). John-Behr's Symptom: the patient is in a supine position, and when pressing on the pubic symphysis perpendicularly downwards, he feels pain in the sacroiliac joint.

In chronic forms of brucellosis, not only the joints but also the muscles are often affected. Myositis manifests itself as dull, prolonged pain in the affected muscles, the intensity of which is often associated with changes in the weather. During palpation, more often in the muscles of the limbs and lower back, more painful areas are determined, and painful seals of various sizes and shapes are felt in the thickness of the muscles. Most often they are palpated as cords, ridges, less often have a round or oval shape. Over time, muscle changes in one area pass, but inflammatory foci appear in other muscle groups. After the introduction of a specific antigen (for example, when performing the Burnet test), pain in the area of the affected muscles noticeably increases, and sometimes an increase in the size of the inflammatory infiltrate can be determined.

In addition to myositis, fibrositis (cellulitis) is often detected in patients with brucellosis (up to 50-60%), which can be localized in the subcutaneous tissue on the shins, forearms, and especially often on the back and lower back. The size of the fibrositis (cellulitis) area varies from 5-10 mm to 3-4 cm. At first, they are palpated as soft oval formations, painful or sensitive to palpation (sometimes patients themselves pay attention to their appearance). Later, they decrease in size, can completely dissolve or become sclerotic and remain for a long time in the form of small dense formations, painless to palpation. During exacerbations, new fibrositis may appear.

Damage to the nervous system in chronic brucellosis most often manifests itself as neuritis, polyneuritis, radiculitis. Damage to the central nervous system (myelitis, meningitis, encephalitis, meningoencephalitis) is rare, but these complications are long-term and quite severe.

Changes in the reproductive system in men are expressed by orchitis, epididymitis, decreased sexual function. In women, salpingitis, metritis, endometritis are observed. Amenorrhea occurs, infertility may develop. Pregnant women often have abortions, stillbirths, premature births. Congenital brucellosis in children has been described.

Sometimes eye lesions are observed (iritis, chorioretinitis, uveitis, keratitis, optic nerve atrophy, etc.).

Airborne infections often result in sluggish brucellosis pneumonia, which is unsuccessfully treated with antibiotics.

Myocarditis, endocarditis, aortitis and other cardiovascular lesions are possible.

The secondary-chronic form proceeds in the same way as the primary-chronic form. Both end in a transition to the secondary-latent form, which can recur repeatedly.

The secondary latent form differs from the primary latent form in that it significantly more often develops into manifest forms (relapses); in addition, against the background of secondary latency, the development of various residual phenomena after chronic forms is possible (limited joint mobility, infertility, visual impairment, etc.).

The symptoms of brucellosis and its course depend on the type of pathogen. In sheep brucellosis (Brucella melitensis), the disease often begins with an acute septic form and is more severe; in case of infection from cows (Brucella abortus), it often occurs as a primary chronic metastatic or even as a primary latent form. However, it should be taken into account that when keeping livestock (sheep and cows) together, cows are sometimes infected by sheep, and then a person becomes infected from cows with Brucella melitensis.

Complications caused by secondary flora are rare.

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