title: Brucella melitensis prosthetic joint infection in a traveller returning to the UK from Thailand: Case report and review of the literature.
abstract: BACKGROUND
  Brucella spp. prosthetic joint infections are infrequently reported in the literature, particularly in returning travellers, and optimal treatment is unknown.
  
  
  METHODS
  We describe a prosthetic joint infection (PJI) caused by Brucella melitensis in a traveller returning to the UK from Thailand, which we believe to be the first detailed report of brucellosis in a traveller returning from this area. The 23 patients with Brucella-related PJI reported in the literature are summarised, together with our case.
  
  
  RESULTS
  The diagnosis of Brucella-related PJI is difficult to make; only 30% of blood cultures and 75% of joint aspiration cultures were positive in the reported cases. Culture of intraoperative samples provides the best diagnostic yield. In the absence of radiological evidence of joint loosening, combination antimicrobial therapy alone may be appropriate treatment in the first instance; this was successful in 6/7 [86%] of patients, though small numbers of patients and the likelihood of reporting bias warrant caution in drawing any firm conclusions about optimal treatment. Aerosolisation of synovial fluid during joint aspiration procedures and nosocomial infection has been described.
  
  
  CONCLUSIONS
  Brucella-related PJI should be considered in the differential of travellers returning from endemic areas with PJI, including Thailand. Personal protective equipment including fit tested filtering face piece-3 (FFP3) mask or equivalent is recommended for personnel carrying out joint aspiration when brucellosis is suspected. Travellers can reduce the risk of brucellosis by avoiding unpasteurised dairy products and animal contact (particularly on farms and abattoirs) in endemic areas and should be counselled regarding these risks as part of their pre-travel assessment.
authors: Tropical and Infectious Disease Unit, Royal Liverpool University Hospital, Liverpool, UK; Wellcome Trust Liverpool Glasgow Centre for Global Health Research, Liverpool, UK. Electronic address: joseph.lewis@liverpool.ac.uk.
authors: Joseph M
authors: JM
authors: Lewis
authors: Brucella Reference Unit, Liverpool Clinical Laboratories, Royal Liverpool University Hospital, Liverpool, UK.
authors: Jonathan
authors: J
authors: Folb
authors: Department of Orthopaedics, Royal Liverpool University Hospital, Liverpool, UK.
authors: Sanjay
authors: S
authors: Kalra
authors: Tropical and Infectious Disease Unit, Royal Liverpool University Hospital, Liverpool, UK; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
authors: S Bertel
authors: SB
authors: Squire
authors: Tropical and Infectious Disease Unit, Royal Liverpool University Hospital, Liverpool, UK; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
authors: Miriam
authors: M
authors: Taegtmeyer
authors: Tropical and Infectious Disease Unit, Royal Liverpool University Hospital, Liverpool, UK; Brucella Reference Unit, Liverpool Clinical Laboratories, Royal Liverpool University Hospital, Liverpool, UK; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK; NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, L69 7BE, UK.
authors: Nick J
authors: NJ
authors: Beeching
mesh_terms: D000328:Adult; D000368:Aged; D000818:Animals; D017347:Brucella melitensis / Q000187:drug effects / Q000302:isolation & purification*; D002006:Brucellosis / Q000097:blood* / Q000175:diagnosis* / Q000188:drug therapy / Q000453:epidemiology; D004318:Doxycycline / Q000627:therapeutic use; D005260:Female; D006801:Humans; D007596:Joints / Q000382:microbiology*; D008297:Male; D008875:Middle Aged; D016459:Prosthesis-Related Infections / Q000175:diagnosis* / Q000188:drug therapy / Q000382:microbiology; D012293:Rifampin / Q000627:therapeutic use; D013785:Thailand / Q000453:epidemiology; D014195:Travel; D006113:United Kingdom; D055815:Young Adult
chemical_list: D004318:Doxycycline; D012293:Rifampin
keywords: Brucellosis; Prosthetic joint infection; Returning traveller; Travel medicine