| Abstract|| |
Brucellosis is one of the most important zoonotic diseases. Several complications may be seen during its clinical course. Here, we describe a patient who presented with complaints of fatigue, malaise, and intensive lumbar pain. He had been suffering from these complaints for nearly 1 month. It was learned that he lived in rural area, made and ate his own cheese. The Rose Bengal test was positive and Brucella standard tube agglutination was positive at 1/320 titer. Pedro Pons' sign, an osteoarticular complication of brucellosis, was revealed with the aid of radiologic imaging. Osteoarticular involvement is common in the course of brucellosis. Deformation in vertebrae formerly known as Pedro Pons' sign should be thought in brucellosis patients suffering from lumbar pain.
Keywords: Brucellosis, Pedro Pons′s sign, spondylitis, spondylodiscitis
|How to cite this article:|
Tuna N, Ogutlu A, Gozdas HT, Karabay O. Pedro Pons' sign as a Brucellosis complication. Indian J Pathol Microbiol 2011;54:183-4
| Introduction|| |
Brucellosis More Details is one of the most common zoonoses throughout the world. The disease is endemic in many regions such as Mediterranean Europe, the Middle East, and South American countries. Any organ or body system may be involved during its clinical course. Most frequent sites of involvement of the Brucella More Details bacteria are the bones and joints. Sacroileitis, spondylitis, and spondylodiscitis are the most common osteoarticular complications.  In brucellosis, early radiologic findings are not specific to disease.  On the other hand, radiologic findings indicative of brucellosis may be observed in most chronic cases. Radiologic manifestation, known as the Pedro Pons' sign, may be noted in vertebral involvement. Radiological findings of brucellosis are not sufficiently recognized by many clinicians in endemic regions. This study aimed to show and discuss a case of Pedro Pons' sign with reference to the relevant literature.
| Case Report|| |
A 42-year-old male patient who had the complaints of fatigue, malaise, and severe lumbar pain was admitted to our local tertiary hospital. It was learned that he was a stockbreeder and he ate the cheese which is made by him. His examination revealed the following: blood pressure 110/70 mmHg, heart rate 80/min., body temperature: 36.5°C, and he described lumbar pain by leg movements. Other findings of physical examination were normal. Laboratory findings were as follows: white blood cells: 7400/mm 3 , hemoglobin: 12.5 g/dl, hematocrit: 35.7%, platelets: 247000/mm 3 , alanine aminotransfere: 96 IU/l, aspartate aminotransferase: 97 IU/l, gama-glutamil-transferase: 111 IU/l, alkaline phosphatase: 157 IU/l, albumin: 3.0 g/dl, total protein: 5.8 g/dl, erythrocyte sedimentation rate: 23 mm/h. Because the patient's history included stockbreeding and consumption of raw milk products, suggesting brucellosis, he underwent Rose Bengal and standard tube agglutination (STA) tests. The Rose-Bengal test was positive and Brucella STA was positive at 1/320 titer. Lateral and oblique lumbo-sacral radiographs were taken to investigate the patient's lumber pain and painful leg movements. These radiologic imagings revealed parrot's peak appearance (Pedro Pons' sign) at the anterior superior end of the L4 vertebra which is characterized by osteosclerosis and osteophyte formation [Figure 1] and [Figure 2].
Lumbosacral magnetic resonance imaging (MRI) revealed decreased height and intensity of the L4-L5 intervertebral disc and enhancement of the homogeneous contrast material in L4 and L5 vertebra corpus around the disk and the paravertebral soft tissue, which was interpreted to be indicative of inflammatory changes. Antibiotic treatment (doxycyline 200 mg/d and rifampicin 600 mg/d) was initiated and the patient's complaints were diminished gradually. He was discharged from hospital and recommended to complete his treatment to 90 days.
| Discussion|| |
Brucellosis is a zoonosis caused by Brucella species. It specifically affects animals such as sheep, goat, cattle, cow, and pigs and is transmitted to humans directly or indirectly from these animals. Brucellosis is a sporadic disease observed in animals in certain parts of the world and may cause disease in humans following consumption of milk and dairy products contaminated with the Brucella during production of these products. , Also known as the Malta fever More Details, the disease may be presented with nonspecific signs and symptoms including fever, night sweat, weakness, lack of appetite, and weight loss. It may be confused with many other conditions due to nonspecific nature of signs and symptoms. 
Several studies have reported the frequency of bone and joint involvement ranging from 10% to 85%. Spondylitis usually occurs in elder males while sacroiliac bone involvement may be observed in both genders regardless of age.  Varying frequencies of spondylitis have been reported in brucellosis cases with musculoskeletal system involvement, ranging from 10% to 58%.  The most common organ of involvement is the lumbar vertebra, followed by cervical and thoracic involvements, respectively.  L4-L5 vertebral involvement is especially more common. Back pain and especially lower back pain are noted for these patients, in addition to other systemic findings.  The disease is more common among the elderly and frequently goes unnoticed for extended periods of time before diagnosis. 
Radiologic changes in brucellosis are most evident at the edges of the vertebra corpora. Destructive changes and reactive bone sclerosis may usually be observed at several levels of the vertebra with direct radiography. Spinal brucellosis first invades the superior end plate since this site is rich in venous feeding. The vertebral body is initially affected, followed by involvement of the adjacent disk space and adjacent disk body. During the early phase of disease, bone destruction occurs at the superior vertebral end plate, whereas the osteophyte formation develops during bone recovery.  Development of sclerosis at the vertebrae and formation of osteophytes are other characteristics observed with X-ray. Narrowing of intervertebral spaces, erosion, sclerosis, vertebral collapse, and osteomyelitis may occur as the disease progresses.  Fusion of the vertebrae may develop during late phases. Vertebral damage may sometimes lead to abscess formation during the course of the disease.  Osteoporosis and anterosuperior epiphysitis (sclerotic epiphysitis) may be seen as moth hole appearance at the anterosuperior corner of the vertebral corpus with radiological imagines. This finding was named as "Pedro Pons' sign" after Pedro Pons' and Farreras first described it in 1944.  Pedro Pons' sign, known as anterior superior end erosion, which occurs together with rounding of the vertebral end and level deformity, is a characteristic radiologic finding of brucellar spondylitis. 
| Conclusion|| |
Several complications may be seen in the course of brucellosis. Of these, bone and joint pain are much more important. Particularly in endemic regions, patients with joint back pain, fever, sweat, and weight loss should be assessed for brucellosis and its osteoarticular complications. Bone scintigraphy and MRI may be considered in selected patients with brucellosis since these are useful for early diagnosis.
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Department of Infectious Diseases and Clinical Microbiology, Sakarya Training and Research Hospital
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]