Poster Number-66 - Brucellosis Bursitis : A not so Uncommon yet so Easily Missed Differential Diagnosis of Knee Pain - A Unique Case Report of Symptomatic Dual Knee Bursitis

Report: 25 years old Arab male attended Physical Medicine Department for the first time with complaints of knee pain, stiffness and difficulty in walking.  Detailed history revealed the following: History of first episode of knee pain with swelling 2 months earlier for which he had been treated in a private clinic symptomatically and improved partially. No history of trauma or sports injury. MRI then had showed medial meniscus Gr I changes with mild joint effusion. 2 weeks after this, he had been admitted to  the Medical ward of regional hospital with gastro enteritis and fever.  Blood test for Brucella antibody was positive and he was started on a course of antibiotics including Doxycycline and Rifampicin. Subsequently, Streptomycin had also been added. He recovered well and he was referred to our department for knee pain management with the diagnosis of medial meniscus degeneration.  Patient gave history of handling camels as part of family business.
Clinical examination of knee showed tenderness over the lateral suprapatellar  and infrapatellar  regions. Knee flexion was painful and restricted to 120 degrees. Patient walked with a mild limp.
Ultrasonogram examination was done in the same visit in our clinic and it revealed anechoic fluid in the suprapatellar pouch and in the deep infrapatellar bursa. A diagnosis of suprapatellar and deep infrapatellar bursitis due to Brucellosis was made.

Management: The patient was assured that his knee pain was due to Brucella bursitis and he was advised to continue his antibiotics course, avoid any strenuous activities and perform simple knee exercises at home.  Low Level Laser therapy was initiated. After 3 weeks, follow up Ultrasonogram showed no fluid in the infrapatellar bursa and very minimal fluid in the suprapatellar bursa. There was no tenderness in the knee, range of motion was full and gait was normal.

Results:

Discussion: Prepatellar bursitis is the most common presentation when knee joint is affected. Our patient presented with suprapatellar and deep infrapatellar bursitis.  Management of bursitis  is strict regimen of antibiotics. Our patient was well managed with  3 weeks of Streptomycin and is still continuing the 12 weeks course of Doxycycline and Rifampicin.  

Conclusion:

Conclusion: Ours is a unique report of dual knee bursitis  in Brucellosis . It is important to have a high index of suspicion in endemic places when a young patient presents with non traumatic joint  pain and effusion. Musculoskeletal Ultrasonogram is useful for diagnosis, follow up and monitoring bursitis in Brucellosis.

References: 1. Traboulsi, R., Uthman, I. & Kanj, S.S. Prepatellar Brucella melitensis bursitis: case report and literature review. Clin Rheumatol 26, 1941–1942 (2007). https://doi.org/10.1007/s10067-007-0565-6
2. Arkun R, Mete BD. Musculoskeletal brucellosis. Semin Musculoskelet Radiol. 2011 Nov;15(5):470-9. doi: 10.1055/s-0031-1293493. Epub 2011 Nov 11. PMID: 22081282.