Annals ofthe Rheumatic Diseases 1990; 49:896-900

Osteoarticular brucellosis in children

Youssef A Al-Eissa, Abdulmajeed M Kambal, Abdullah A Alrabeeah, Asaad M A Abdullah,Nasir A Al-Jurayyan, Nuhad M Al-Jishi

AbstractThe findings in 40 children (24 female, 16male) with osteoarticular complications ofbruceliosis are presented. Raw milk was themain source of infection. Most patients hadacute onset of fever, arthralgia, and myalgia.Arthritis was the presenting symptom in allpatients, of whom two also had osteomyelitis.Arthritis was monoarticular in 28 (70%) of 40cases with predilection for large weight-bearingjoints. Spine and smali joints were spared.Brucella melitensis was detected in 23/31(74%) cases. Mild anaemia, leucopenia,increased liver enzymes, positive acute phasereactants, and low titres of autoantibodieswere prominent non-specific laboratory find-ings. Bone scintigraphy was more helpful thanconventional radiography in detecting hip andsacroiliac joint disease. Treatment with acombination of antibiotics for six weeks ormore resulted in a cure rate of 92-5%. Earlyrecognition of infection, prolonged treatment,and long term follow up should improve theoutcome of patients.

Department ofPaediatrics,King Khalid UniversityHospital, College ofMedicine, King SaudUniversity, Riyadh,Saudi ArabiaY A Al-EissaA M A AbdullahN A Al-JurayyanN M Al-JishiDepartment ofMicrobiology,King Khalid UniversityHospital, College ofMedicine, King SaudUniversity, Riyadh,Saudi ArabiaA M KambalDepartment of Surgery,King Khlid UniversityHospital, College ofMedicine, King SaudUniversity, Riyadh,Saudi ArabiaA A AhrabeeabCorrespondence to:Dr Youssef A Al-Eissa,Department of Paeditarics(39), College of Medicine,King Saud University,PO Box 2925, Riyadh 11461,Saudi Arabia.Accepted for publication28 December 1989

Brucellosis constitutes a major health problemin many parts of the world, including theMiddle East.' The disease due to Brucellamelitensis is a common infection in domesticanimals2 and the human population in SaudiArabia.' The recent surge in the incidence ofbrucellosis in that country has been linked tothe widespread animal husbandry and the pre-vailing habit of ingesting raw milk or itsproducts.3 6

Musculoskeletal involvement was firstreported by Kennedy in the early part of thiscentury.7 Since then, there have been furtherreports from countries where the disease iscommon.A 8-18 Bone and joint disease, whichincludes suppurative arthritis, spondylitis, andosteomyelitis, is considered to be the mostcommon complication of brucellosis.6 18 Thereported prevalence of osteoarticular compli-cations varies from 11% to 85% in the publishedseries.'0 This variation has been attributed todifferences in the pathogenicity of the infectingbrucella species, with B melitensis producing themost serious illness, to differences in the hostand environmental factors of the populationstudied, or to discrepancies in the diagnosticcriteria.'4 18

Previous descriptions of the osteoarticularpattern in patients with brucellosis have beenbased mainly on series of adult cases. In thisreport we describe the clinical presentations,laboratory and radiological findings, and the

outcome of treatment in a group of 40 childrenwith osteoarticular brucellosis.

Subjects and methodsDuring the four year period between January1985 and December 1988 106 children withbrucellosis were seen at the King KhalidUniversity Hospital; 40 (38%) of these (24female, 16 male) with osteoarticular complica-tions form the body of subjects of this study.Their mean age was 8-2 years (range 2 to 14).All were Saudi nationals and 29 (72-5%) of themwere school age children. Of the 40 patients, 33(83%) had previously consumed raw milk, 13(33%) had close contact with domestic animals,and three (8%) had no clear exposure to a sourceof infection. The diagnosis of brucellosis wasmade on the basis of a clinical picture consistentwith the disease and one or more of threelaboratory criteria: isolation of the organismfrom blood or synovial fluid, or both; brucellaagglutination of t 1/160; and a fourfold rise intitres following the onset of symptoms.

All patients were admitted during their initialpresentation to the hospital and the followingstudies were carried out for each patient:complete blood cell count, erythrocyte sedi-mentation rate (Westergren method); liver andrenal function profiles, brucella titre (standardtube agglutination method using Wellcomestained brucella antigens); and urine analysis.Two blood cultures and, if indicated, synovialfluid cultures inoculated into bottles of trypticsoy broth and thioglycolate broth (Difco) wereobtained from 31 patients. Antistreptolysin 0titre (haemolysin test, normal < 166 Toddunits/l) was measured in 28 patients. Twentyfour patients were tested for C reactive protein(latex agglutination test, normal <8 mg/I);rheumatoid factor (latex agglutination test,negative < 1/20); and antinuclear antibody(indirect fluorescent antibody technique, nega-tive < 1/40). Plain radiography, isotopic scan ofbone and joint, and electrocardiography wereperformed when indicated.

Patients were treated with oral trimethoprimsulphamethoxazole (co-trimoxazole) or tetra-cycline for at least six weeks in combinationwith intramuscular streptomycin for the firstthree weeks or oral rifampicin for a minimum ofsix weeks. In cases ofosteomyelitis a combinationof co-trimoxazole and rifampicin for 12 weekstogether with streptomycin for the first threeweeks was given. Tetracycline was only given tochildren older than 8. Patients were followed upfortnightly until the end of the treatmentperiod, monthly for three months, and there-

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after every three months. Relapse was judgedby a recurrence of symptoms and signs of thedisease, a positive blood culture, or a risingantibody titre after treatment, in the absence ofre-exposure to infection.

ResultsDuration of illness ranged from four to 150 days(mean 32-7). It was less than two weeks in 17(43%) of the cases, two to 12 weeks in 20 (50%),and more than 12 weeks in three (8%). Table 1shows the clinical manifestations in the 40patients with osteoarticular brucellosis. All the40 patients presented with true arthritis, whichwas manifested by pain, periarticular soft tissueswelling with or without obvious intra-articulareffusion, limitation of motion, various degreesof hotness, and, rarely, by erythema. Table 2shows the distribution of the joints affected in40 patients with arthritis. Arthritis was mono-articular in 28 cases (70%) and pauciarticular inthe remainder. No difference in the sex distri-bution of the patients with monoarthritis asopposed to pauciarthritis was seen. In preschoolchildren monoarthritis represented 91% of jointdisease compared with 62% in older ones, butthe difference was not statistically significant.Of the 12 patients with pauciarthritis, twopatients each had both hips, knees or sacroiliacjoints affected respectively and six patients hadthree or four asymmetrical joints involved.Most patients with multiple joint disease tendedto have an additive rather than a migratoryarthritis. Spondylitis and arthritis of small jointsof the hands and feet were not seen. Two femalepatients with arthritis of the hip had osteo-myelitis of the adjacent proximal end of thefemur; in one operative decompression,debridement and drainage of the hip joint wasnecessary.

Table 1 Clinical manifestations in the 40 children withosteoarticular brucellosis

Symptomlsign Number of patients (%)

Fever 37 (93)Arthralgia 36 (90)Myalgia 24 (60)Weight loss 20 (50)Anorexia 18 (45)Low backache 8 (20)Sweating 6 (15)Arthritis 40 (400)Splenomegaly 10 (25)Hepatomegaly 8 (20)Lymphadenopathy 8 (20)Osteomyelitis 2 (5)

Table 2 Distribution ofjoints affected and articular patternin 40 patients with arthritis

Joints Pattern of arthritis Totalaffected

Monoarticular Pauciarticular(n= 28) (n= 12)

Hip 17 7 24 (41)Knee 8 1 3 21(36)Ankle 2 3 5 (8)Sacroiliac - 5 5 (8)Wrist 1 1 2 (3)Elbow - 1 1 (2)Shoulder - 1 1 (2)

Total number 28 31 59

*Shown as a percentage of the total number of joints affected.

Table 3 Initial laboratory findings in 40 patients witharthritis

Laboratory test Number ofpatients (%)

Anaemia 16 (40)Leucopenia 14 (35)Lymphopenia 15 (38)Neutropenia 13 (33)ESRt (mm/h)2040 11 (28)>40 17 (43)

Positive C reactive protein 8 (33)*Positive antinuclear antibody 6 (25)SPositive rheumatoid factor 5 (21)*Increased liver enzymes 16 (40)

*Percentage refers to 24 patients tested.tESR=erythrocyte sedimentation rate.

Thirty six of the 40 patients also had arthralgiain joints other than the joints affected byarthritis; the arthralgia manifested as inter-mittent or migratory pain of large or smalljoints, or both, with or without limitation ofmovements.

Table 3 presents the initial laboratory find-ings. Mild anaemia was present in 16 (40%)patients and correlated closely with the durationof illness. The peripheral blood picture did notshow leucocytosis or relative lymphocytosis.The antistreptolysin 0 titre was normal in all 28patients tested. Low titres of antinuclear anti-body (range 1/40-1/80) were detected in six(25%) and rheumatoid factor (range 1/20-1/60)in five (21%) of 24 patients evaluated. Five ofthe six patients with positive antinuclear anti-body test and all five patients with positiverheumatoid factor had positive brucella bloodcultures. All 40 patients had significant brucellaagglutination titres ranging from 1/160 to1/20 480. The lowest titre was 1/160, found inthree patients with positive blood cultures. Bmelitensis was isolated from the blood of 22(7 1%) of 31 patients tested. All other bio-chemical tests and electrocardiograms werenormal.

Synovial fluid was obtained from nine

Figure 1 A 6year old girl with afive month history ofrighthip pain and limping. Radiograph ofthe pelvis showsadvanced destruction and deformity ofrightfemoral head andacetabulum.

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destructive hip arthritis and femoral osteo-myelitis. Three patients were lost to follow up.There were three relapses among the remaining37 patients, who have been followed up for anaverage of 12 months (range 9-36). All threerelapses were treated successfully with anothersix week course of antibiotics. Only one patientstill has considerable functional limitation of thehip joint and significant shortening of theaffected limb as a result of severe destructivehip arthritis (fig 1).

Ad"

Figure 2 An llyear old girl with right hip and back pains.Posteior scintigram discloses increased uptake in the right hipand sacroiliac joints.

patients. It varied from cloudy straw-colour tothick yellow. The mean leucocyte count was14 3x 109/1 (range 4 2-32 8x 109/l) with variablepolymorphonuclear or mononuclear pre-dominance. The mean glucose content was 4-1mmol/l (range 2 1-5 9 mmol/l) and the meanprotein content 49 g/l (range 31-64 g/W). Bmelitensis was recovered from the synovial fluidculture in six patients, of whom one had anegative blood culture. Hence, brucella wasdetected in 23 (74%) of 31 patients by blood andsynovial fluid cultures.

Plain radiographs, obtained in 14 patients,generally showed normal findings or merelyconfirmed periarticular soft tissue swelling orintra-articular effusion. In one patient only theplain radiograph showed severe articular des-truction of the hip joint extending into theadjacent bones (fig 1). Technetium-99m bonescan was performed in eight patients with lowbackache as part of the initial evaluation ofspinal involvement. There was no scintigraphicevidence of spondylitis in any of the eightpatients, but increased uptake was noted in thehip and sacroiliac joints of four and two patientsrespectively (fig 2). Plain radiographs of thespine and pelvis were normal in all eightpatients. Scintigraphic studies in four patientswith clinically suspected osteomyelitis of thelong bones disclosed increased radionuclideuptake in the upper femoral metaphysis of onepatient, decreased uptake in the epiphysis andhead of the femur of another patient, who alsohad radiographic evidence of severe hip jointdestruction, and a normal scan in the remainingtwo patients.

All 40 patients were admitted to hospital foran average of 12 days (range 8-46). Initialclinical improvement occurred after an averageof five days' treatment with antibiotics, andsigns of arthritis resolved completely within oneto two weeks later in all but one who had

DiscussionIt is not well known that brucellosis due to Bmelitensis is quite common among children inareas where the disease is endemic. 9 A few casereports and a handful of series of cases ofosteoarticular brucellosis in children have beendescribed.8 13 15 16 20 We found osteoarticularcomplications in 40 (38%) of 106 cases com-parable with the incidence of 33-8% reported byGotuzzo et al14 and 37-4% observed by Mousa etal,'7 but both these studies considered only asmall number of children.As brucellosis is notoriously a multisystem

disease with varied manifestations, epidemio-logical information is considered the key todiagnosis.2' The infection in our cases was dueto consumption of raw milk and contact withpotentially infected animals. Absence ofrecognised exposure to contaminated animalsand its products does not preclude the diagnosis,however, as three (8%) of our 40 patients had nosuch exposure.

In this study all patients but three had anacute onset with significant constitutional upsetand a short duration-less than three months-of illness before presentation. One patient whohad significant damage to the hip joint had thelongest delayed presentation-five months.Although no significant difference in the sexdistribution of brucellosis below the age of 14has been observed by others,'9 female subjectsshowed preponderance over male subjects andschool-age children over toddlers in osteo-articular complications in our series. Femalepredominance has been noted in two other smallseries of children with osteoarticular brucel-losis'3 " but has not been sufficiently empha-sised. Further evidence of this tendency wasreported by Gotuzzo et al, who noted thatarticular manifestations were more common inwomen than in men among 39 Peruvian familieswith brucellosis.'8 The role of age and sex ininfluencing the propensity to osteoarticulardisease in brucellosis has yet to be clarified.

Peripheral arthritis has been described as thecommonest form of osteoarticular complicationsin acute brucellosis.' '8 22 This was the case in37 (93%) of our 40 cases. Moreover, arthritiswas monoarticular in two thirds ofour cases andhad a predilection for large weight-bearingjoints. Monoarticular arthritis was morecommon among the younger than the olderchildren. The vast majority of our patients withmonoarticular or pauciarticular arthritis had hipand knee joints predominantly affected, asfound by other workers. ' " Sacroiliitis, seencommonly in young adults,'4 occurred in only

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three (8%) of our 40 patients; all were femaleand older than 10. Of special interest andparticular significance is the absence of spinaland small joint disease among our cases incontrast with the findings in adults.' 10 11 14 17The results of this study show that brucellararthritis usually runs a benign course andresponds readily to antibiotic treatment. This isconsistent with published reports.4 1417 Itrarely progresses to osteoarticular destruction 8;this occurred in only one of our cases.

It is currently believed that infectious andreactive arthritides occur in brucellosis,'4 23 asin other bacterial infections. In the presentseries the absence of initial migratory patternand of recurrences of arthritis after treatment,the biochemical and bacteriological findings ofsynovial fluid, and the clearcut effect of anti-biotic treatment on the course of arthritis allargue strongly against reactive arthritis. Ourdata, nevertheless, do not exclude the possibledevelopment of reactive arthritis in patientswith brucellosis. Different osteoarticularpatterns of the disease may be produced by thesame or different brucella species dependingupon the host's reaction, as with salmonellaorganisms.24

Osteomyelitis of the long bones, a rarecomplication of brucellosis,9 12 16 wasdiagnosedin two female patients and was coexistent withdestructive hip arthritis in one. Both patientswere treated successfully with a combination ofthree antibiotics for 12 weeks.Although haematological abnormalities were

common accompaniments of brucellosis, thelack of a consistent pattern precluded theirdiagnostic value. Mild anaemia and leucopeniahave been reported to occur frequently inpatients with brucellosis.3 13 25 These abnor-malities were found in more than one third ofour cases. In contrast with published reportsemphasising the presence of the characteristiclymphocytosis,'6 26 our patients had normalleucocyte count or leucopenia with lymphopeniaor neutropenia. The erythrocyte sedimentationrate and C reactive protein may or may not beraised and are only of prognostic significance ifthe level was previously raised.'0 The erythro-cyte sedimentation rate and C reactive proteinwere raised in two thirds and one third of ourpatients respectively.Immune abnormalities wre reported in active

brucellosis,4 14 22 as in other infectious dis-orders.27 The present findings ofweakly positivetitres of circulating antinuclear antibodies in six(25%) and rheumatoid factor in five (2 1%) of 24patients tested compare well with an incidenceof 25% and 37-5% respectively in a group ofpatients evaluated by Bocanegra et al.22 It isnoteworthy that these positive results weredetected mostly in older children with positivebrucella culture and with different articularpatterns. The exact significance of these findingsis not clear. The multisystem involvement inthis infection is more suggestive of an immunecomplex process, however. Bocanegra et alshowed the presence of circulating immunecomplexes in 915% of their patients withbrucellosis.22Although isolation of the causative organisms

provides unequivocal evidence of brucellosis,the diagnosis is usually made by demonstratinga significant or rising brucella antibody titre. A74% isolation rate ofB melitensis in our series iscomparable with the 77% reported by Norton4but is higher than that reported by others.'1'7The findings in synovial fluid are similar tothose seen in other forms of septic arthritis.Several investigators have assessed the value ofsynovial tissue and fluid findings in the diagnosisof brucellar arthritis.4 12 14 17 20 Coventry et alnoted that the isolation of brucella organismsincreases significantly when synovial tissuerather than fluid is cultured as these organismsare intracellular inhabitants and are freed inter-mittently into body fluids.28 Thus it is difficultto know whether arthritis is truly reactive or notwhen the aspirated synovial fluid is sterile, as itwas shown to be in three of our nine cases.In our experience synovial fluid aspiration israrely necessary for the diagnosis of acutebrucellar arthritis. Joint decompression ismandatory, however, if a large tense effusion isaccumulated where the blood supply to the jointmay be compromised.The value of radiographic and scintigraphic

abnormalities in osteoarticular brucellosishas been assessed in detail by other investi-gators.5 6 14 In this study we found that bonescintigraphy is more helpful than conventionalradiography in localising a deep infection in thehip or the sacroiliac joint.The efficacy of chemotherapy for any infec-

tion is largely judged by the rate of cure and theincidence of sequelae. The unpredictable relapseafter treatment, however, has remained asignificant problem in brucellosis as the organ-isms are facultative intracellular pathogensrelatively inaccessible to antibiotics.29 Further-more, relapses are almost invariably associatedwith insufficient duration of treatment or failureof patients to take prescribed drugs.30 The mostoutstanding result from this series of cases is thelow relapse rate after treatment with two orthree antibiotics combined for a minimum of sixweeks. Similar results have been reported withone or two drugs given for short duration.'6

In conclusion, the present series suggests thatthe incidence of brucellosis in children may behigher than is usually realised. The prevalenceofosteoarticular complications in children seemsto be similar to that in adults, but the pattern ofbone and joint disease is different. Peripheralarthritis is the predominant form in childrenand is more commonly monoarticular withpredilection for large weight-bearing joints. Ageand sex seem to have an influence on theincidence and the expression ofthe osteoarticularmanifestations of brucellosis in children.Diagnosis of brucellosis should be consideredwhenever there is a febrile illness associatedwith rheumatological complaints. Early recog-nition of the infection, prolonged antibiotictreatment, and careful long term follow upshould improve the outcome of patients.

1 Matyas Z, Fujikura T. Brucellosis as a world problem. DevBiol Stand 1984; 56: 3-20.

2 Radwan A I, Asmar J A, Frerichs W M, Bekairi S I, Al-Mukayel A A. Incidence of brucellosis in domestic

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livestock in Saudi Arabia. lrop Anim Health Prod 1983; 15:139-43.

3 Kambal A M, Mahgoub E S, Jamloom G A, ChowdhuryM N H. Brucellosis in Riyadh, Saudi Arabia. A microbio-logical and clinical study. Trans R Soc Trop Med Hyg 1983;77: 820-4.

4 Norton W L. Brucellosis and rheumatic syndromes in SaudiArabia. Ann Rheum Dis 1984; 43: 810-5.

5 Rajapakse C N A, Al-Aska A K, Al-Orainey I, Halim K,Arabi K. Spinal brucellosis. Br Rheumatol 1987; 26:28-31.

6 Madkour M M, Sharif H S, Abed M Y, Al-Fayez M A.Osteoarticular brucellosis: results of bone scintigraphy in140 patients. AJR 1988; 150: 1101-5.

7 Kennedy J C. Notes on case of chronic synovitis, or bursitis,due to organism of the Mediterranean fever. J7 R Army MedCorps 1904; 2: 178-80.

8 O'Donoghue A F. Septic arthritis in the hip caused byBrucella melitensis. Journal ofBone and ointSurgeny 1933;

15: 506-8.9 Lowe G H Jr, Lipscomb P R. Brucellosis osteomyelitis.

Report of two cases in which shafts of the long bones wereinvolved. Surgery 1947; 22: 525-9.

10 Rotes-Querol J. Osteo-articular sites of brucellosis. AnnRheum Dis 1957; 16: 63-8.

11 Gonado W, Craig A J. Brucellosis myelopathy. J7 Bone JointSurg [Am] 1958; 40: 1380-8.

12 Kelly P J, Martin W J, Schirger A, Weed L A. Brucellosis ofthe bones and joints. Experience with thirty-six patients.JfAMA 1960; 174: 347-53.

13 Adam A, MacDonald A, MacKenzie I G. Monoarticularbrucellar arthritis in children. Bone Joint Surg [Br/ 1967;49: 652-7.

14 Gotuzzo E, Alarcon G S, Bocanegra T S, et al. Articularinvolvement in human brucellosis: a retrospective analysisof 304 cases. Semin Arthritis Rheum 1982; 12: 245-55.

15 Gomez-Reino F J, Mateo I, Fuertes A, Gomez-Reino J J.Brucellar arthritis in children and its successful treatmentwith trimethoprim-sulphamethoxazole (co-trimoxazole).Ann Rheum Dis 1986; 45: 256-8.

16 Lubani M, Sharda D, Helin I. Brucella arthritis in children.Infection 1986; 14: 233-6.

17 Mousa A R M, Muhtaseb S A, Almudallal D S, Khodeir S M,Marafie A A. Osteoarticular complications of brucellosis: a

study of 169 cases. Rev Infect Dis 1987; 9: 531-43.18 Gotuzzo E, Seas C, Guerra J G, et al. Brucellar arthritis: a

study of 39 Peruvian families. Ann Rheum Dis 1987; 46:506-9.

19 Feiz J, Sabbaghian H, Miralai M. Brucellosis due to B.melitensis in children. Clinical and epidemiologicalobservations on 95 patients studied in Central Iran. C'linPediatr 1978; 17: 904-7.

20 Makin M, Alkalaj 1, Rozansky R. Mono-articular brucellararthritis. J7 Bone Joint Surg [Am] 1957; 39: 1183-6.

21 Arnow P M, Smaron M, Ormiste V. Brucellosis in a group oftravelers to Spain. 7AMA 1984; 251: 505-7.

22 Bocanegra T S, Gotuzzo E, Castaneda 0, Alarcon G,Espinoza L. Rheumatic manifestations of brucellosis. AnnRheum Dis 1986; 45: 526.

23 Hodkina L, Gomor B, Meretey K, et al. HLA-B27-associatedspondylarthritis in chronic brucellosis. Lancet 1978; i: 499.

24 Carroll W L, Balistreri W F, Brilli R, Parish R A, GreenfieldD J. Spectrum of Salmonella-associated arthritis. IPediatri'cs1981; 68: 717-20.

25 Crosby E, Llosa L, Quesada M M, Carrillo C, Gotuz.zo E.Hematological changes in brucellosis. Infect D)is 1984;150: 419-24.

26 Yow M D. Brucellosis. In: Feigin R D, Cherry J D, eds.Textbook ofpaediatric infectious diseases. I st ed. Philadelphia:Saunders, 1981: 828-33.

27 Martini A, Lorini R, Zanaboni D, Ravelli A, Burgio R G.Frequency of autoantibodies in normal children. Am 7 I)is

Child 1989; 143: 493-6.28 Coventry M B, Ivins J C, Nicholas D R, Weed L A. Infection

of the hip by Brucella suis. JAMA 1949; 141: 320-5.29 Williams E. Brucellosis. Practitioner 1982; 226: 1507-17.30 Bennett J E. Brucellosis. In: Wyngaarden J B, Smith L H, Jr,

eds. Cecil textbook of medicine. 17th ed. Philadelphia:Saunders, 1985: 1614-7.

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