Epidemiology and laboratory testing of Brucella spondylitis

Epidemiology and laboratory testing of Brucella spondylitis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Epidemiology and laboratory testing of Brucella spondylitis Yan-peng Lu, Wei-qi Qiu, Tao Zhang, Qian-xi Cheng, Yizhe Wang, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4794081/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Nov, 2024 Read the published version in Scientific Reports → Version 1 posted 10 You are reading this latest preprint version Abstract The average age of patients with BS was 52.29±9.46 years, comprising 136 males and 31 females. Risk factors for BS include close contact with cattle and sheep and consumption of unpasteurized food. The positive detection rate using combined Rose Bengal Test (RBT) and Standard Agglutination Test (SAT) was 94.6%, whereas the positive rate for blood culture was only 7.8%. The most common clinical manifestations were fever (81.4%), back pain (88.6%), sweating (61.1%), fatigue (69.5%), and anorexia (65.3%). Hematological examinations often revealed decreased hemoglobin (18.0%), increased platelets (18.0%), elevated erythrocyte sedimentation rate (ESR) (88.0%), elevated C-reactive protein (CRP) (78.4%), elevated Alanine aminotransferase (ALT) (18.6%), and decreased K+(23.4%). The imaging examinations revealed that the lumbar spine, particularly L4/5 (41.3%), is the most frequently affected vertebral level in BS. After treatment, the overall recurrence rate was 3.0%. In endemic areas, clinicians should be vigilant for BS in patients presenting with back pain and unexplained fever, particularly those with a history of close contact with cattle and sheep. The RBT and SAT tests show a high positivity rate of 94.6%, establishing them as the preferred diagnostic methods. This study enhances clinicians' comprehension of BS characteristics and lays a robust theoretical groundwork for disease prevention and monitoring. Health sciences/Medical research/Epidemiology Health sciences/Medical research/Pre clinical studies brucella spondylitis epidemiology hematology treatment Figures Figure 1 Figure 2 Introduction Brucellosis, caused by bacteria belonging to the genus Brucella, is a prevalent zoonotic infectious disease[ 1 , 2 ]. According to surveillance data from China, the overall incidence of brucellosis rose from 0.92 per 100,000 in 2004 to 4.2 per 100,000 in 2014. Subsequently, the incidence sharply declined in 2015 but began a steady increase in 2017, reaching 4.95 per 100,000 in 2021, surpassing the peak observed in 2014. The disease predominantly affects pastoral regions such as Northeast China, Northwest China, Inner Mongolia, and the Qinghai-Tibet Plateau. Recently, high-incidence areas have shown an expanding trend southward[ 3 ]. Presently, brucellosis prevalence continues to rise in previously affected regions, with new epidemic areas emerging gradually[ 4 ]. The primary factors contributing to this trend may include the growing demand for cattle and sheep due to economic development, resulting in an increase in the number of individuals involved in livestock farming and slaughtering. Moreover, inadequate supervision and epidemic prevention measures, coupled with low self-protection awareness, have led to a yearly increase in the incidence rate of brucellosis. BS ranks among the most prevalent osteoarticular complications of brucellosis, affecting approximately 2–77% of all brucellosis patients[ 5 ]. It develops when infectious microorganisms invade the spine through various routes, including direct external bacterial inoculation, contiguous spread from adjacent infected sites, dissemination through the nutrient arteries of the vertebral body[ 6 ], or rarely, retrograde spread through the Batson venous plexus[ 7 ]. This condition predominantly affects the spine, particularly the lumbar vertebrae, manifesting as chronic back pain, fever, night sweats, and weight loss[ 8 ]. Given its symptomatology's resemblance to that of numerous other spinal diseases, diagnosing BS is frequently delayed or misinterpreted. This study analyzes the epidemiology, clinical manifestations, laboratory data, imaging findings, and treatment outcomes of 167 BS patients. Its aim is to provide healthcare providers in endemic areas with comprehensive BS data to facilitate prompt diagnosis and appropriate treatment selection. Furthermore, this research contributes robust data supporting national measures for brucellosis prevention and control. Patients and methods Ethics Statement This study was approved by the Ethics Committee of the 940th Hospital of Joint Logistics Support Force of Chinese PLA and was conducted in accordance with the principles of the Helsinki Declaration. All patients admitted to the hospital signed informed consent forms for the use of their clinical data for scientific research. Patient Population This study examined the medical records of patients diagnosed with BS who received hospitalization and treatment at the Department of Spine Surgery, The 940th Hospital of Joint Logistics Support Force of Chinese PLA, from 2014 to 2023. Following meticulous screening involving detailed laboratory and imaging examinations, 167 patients met the inclusion criteria for the study. Diagnosis of BS Following the Chinese diagnostic criteria for brucellosis (Health Standard No. WS 269-2019): Epidemiological History: This includes a history of close contact with livestock or animal products suspected of Brucella infection, consumption of raw cattle or sheep milk and meat products, residing in brucellosis endemic areas, or involvement in Brucella culture, testing, or vaccine production and use. Clinical Manifestations: Symptoms comprise fever lasting several days to weeks (including low-grade fever), excessive sweating, fatigue, muscle, and joint pain. Laboratory Initial Screening: a) Positive RBT b) Positive Colloidal Gold Immunochromatography Assay (GICA) c) Positive Enzyme-Linked Immunosorbent Assay (ELISA) d) Brucella culture smear indicating suspected Brucella on Gram staining. Laboratory Confirmatory Diagnosis: a) Isolation of Brucella from the patient's blood, bone marrow, other body fluids, or excretions b) SAT titer of 1:100++ or higher, or 1:50++ or higher if clinical symptoms persist for over a year c) Complement Fixation Test (CFT) titer of 1:10++ or higher d) Coomb’s Test titer of 1:400++ or higher Patients meeting criteria 1 and 2 are considered suspected cases, those meeting criterion 3 are clinically diagnosed, and those meeting criterion 4 are confirmed cases. For patients suspected of spinal involvement, MRI scans are employed to identify affected segments and assess the extent of involvement in vertebral bodies, endplates, intervertebral discs, paravertebral soft tissue, and the epidural space, thereby aiding BS diagnosis. Cases are categorized based on symptom duration: Acute (6 months). Research data on BS Upon admission, all patients underwent combined RBT and SAT testing, along with blood cultures. A single researcher documented each patient's demographics, clinical manifestations, and epidemiological history, encompassing gender, age, consultation timing, place of residence, season of symptom onset, illness duration, history of close contact with cattle and sheep, and consumption of raw beef, lamb, and dairy products. Initial laboratory test results at admission were also recorded, including complete blood count, blood biochemistry, liver and kidney function tests, ESR, CRP, and screenings for infectious diseases (syphilis, HIV, hepatitis B, hepatitis C, and tuberculosis). Treatment According to the treatment guidelines issued by the Chinese Center for Disease Control and Prevention, the principles of Brucellosis treatment emphasize early initiation, combination therapy, adequate dosage, and sufficient duration of medication, with potential extension to prevent recurrence and chronicity. Common regimens typically involve doxycycline in combination with rifampicin or streptomycin. Patients presenting with complications may also receive third-generation cephalosporins or quinolone antibiotics. In this study, patients received Brucella-specific treatment adhering to these guidelines, which included intravenous ceftriaxone (2 grams daily), oral doxycycline (0.2 grams daily), oral rifampicin (0.1 grams daily), and hepatoprotective drugs (0.6 grams daily). For patients experiencing relapse (characterized by unexplained pain, fever, night sweats, weight loss, elevated ESR and CRP, new vertebral lesions, or increasing SAT titers) and those with spinal involvement, treatment was extended beyond six months until SAT titers dropped below 1:50 upon reevaluation. Patients suffering severe pain or significant neurological impairment that affected daily life underwent aggressive surgical intervention. Surgical indications included: 1) persistent back pain after >3 courses of drug therapy or stubborn lumbar pain due to intervertebral disc damage; 2) large, difficult-to-absorb paraspinal/psoas abscesses; 3) vertebral lesions ≥1 cm, facet joint destruction, pathological fractures affecting spinal stability; 4) intraspinal abscesses, inflammatory granulomas, necrotic intervertebral discs causing compression of the spinal cord, cauda equina, or nerve roots. Patients meeting these criteria underwent a 5-day course of Brucella-specific antibiotic treatment before surgery. Surgery proceeded once liver and kidney function normalized, ESR was < 45 mm/h, and anemia and malnutrition were corrected. Early surgical intervention was crucial for cases where neurological symptoms progressively worsened to preserve nerve function. Data analysis Continuous, discrete, and rating variables are presented as mean standard deviation (SD), and categorical variables are expressed as frequencies or percentages. All statistical analyses were performed using SPSS version 29.0 statistical software (SPSS Inc.,Chicago, IL, USA). Results Demographic and epidemiological characteristics This study included a total of 167 patients. The data indicates a predominant male incidence, comprising 81.4% (136) of the total patients, with females constituting only 18.6% (31). Moreover, the patients' average age was 52.29±9.46 years, with 66.5% (111) falling within the 41-60 age range. The peak number of patients treated at our hospital was in 2015, with 35 (21.0%) admissions (Figure 1). While patient numbers have fluctuated over time, an overall slow increasing trend is observed. Epidemiological data reveal that 143 (85.6%) patients resided in rural areas, with the remaining 24 (14.4%) residing in urban areas. Of these, 128 (76.6%) patients had a documented history of contact with cattle or sheep, 13 (7.8%) had consumed unpasteurized cattle and sheep meat or raw milk, and the cause of disease in 26 (15.6%) patients remained unknown. In patients experiencing symptoms for the first time, the seasonal distribution was as follows: 63 patients (37.7%) in spring, 37 patients (22.2%) in summer, 33 patients (19.7%) in autumn, and 34 patients (20.4%) in winter. Cases were classified based on symptom duration into acute (31.7% [53]), subacute (24.0% [40]), and chronic (44.3% [74]). (Table 1) Clinical characteristics and complications All patients presented clinical symptoms associated with BS upon admission, including fever (81.4%), excessive sweating (61.1%), fatigue (69.5%), back pain (88.6%), anorexia (65.3%), hepatomegaly (15.6%), and splenomegaly (4.2%). Additionally, some patients presented with neurological symptoms upon initial diagnosis, including limb pain and numbness (67.7%), sensory loss (28.1%), and restricted mobility (45.5%). (Table 2) Laboratory findings Among the 167 patients, 158 (94.6%) tested positive for both RBT and SAT, whereas 13 patients (7.8%) tested positive via blood culture. Abnormal hematological findings included: WBC count >9.5×10^9/L (9.6%) or 7×10^9/L (3.6%) or <2×10^9/L (8.4%), decrease in hemoglobin (male<130 g/L, female300×10^9/L (18.0%) or 15mm/h (88.0%), CRP >0.8mg/dL (78.4%), Aspartate aminotransferase (AST) >40U/L (9.6%), ALT >40U/L (18.6%), and K + <3.5mmol/L (23.4%). Infectious disease tests revealed that 4.8% (8) of patients had hepatitis B, 1.2% (2) had hepatitis C, 1.8% (3) had syphilis, and 2.4% (4) had tuberculosis, with no patients testing positive for HIV. (Table 3) Imaging findings After admission, all patients underwent MRI examinations, revealing involvement of various spinal segments: 142 patients (85.0%) had lumbar spine involvement, 15 patients (9.0%) had cervical spine involvement, 5 patients (3.0%) had thoracic spine involvement, 2 patients (1.2%) had sacral spine involvement, 2 patients (1.2%) had concurrent thoracic and lumbar spine involvement, and 1 patient (0.6%) was involved of the cervical, thoracic, and lumbar spine. The distribution across spinal segments is as follows: C3/4 (1.2%), C4/5 (3.6%), C5/6 (4.2%), C6/7 (3.0%), C7/T1 (1.2%), T1/2 (1.2%), T4/5 (0.6%), T9/10 (0.6%), T10/11 (0.6%), T11/12 (0.6%), T12/L1 (1.8%), L1/2 (5.4%), L2/3 (16.8%), L3/4 (26.3%), L4/5 (41.3%), L5/S1 (16.2%), and S1 (1.2%) (Figure 2). Notably, 31 patients (18.6%) exhibited involvement of multiple spinal segments, hence the percentages for each segment are calculated independently. (Table 4) treatment results Among the 167 patients, 70 (41.9%) received conservative treatment, while 97 (58.1%) underwent surgery. All patients underwent six months of chemotherapy, with treatment discontinued only after rechecking SAT titers to ensure they were less than 1:50. Among the 97 surgical patients, 32 (33.0%) experienced postoperative fever, and 39 (40.2%) reported persistent or worsened limb numbness postoperatively. Five patients (3.0%) experienced recurrence after treatment, all from the conservative treatment group, and achieved satisfactory outcomes following subsequent surgical intervention. Discussion Gansu Province stands as a significant endemic area for brucellosis in China, characterized by numerous local pastures and a substantial population engaged in animal husbandry. However, inadequate local supervision has led to a lack of awareness among the populace regarding brucellosis, compounded by insufficient public health education efforts. Consequently, the incidence of brucellosis has been steadily rising. BS, a severe complication of brucellosis, poses considerable health risks to local residents and impedes the rapid economic development of Gansu Province. Hence, a comprehensive understanding of the clinical manifestations, laboratory examinations, and epidemiology of BS is imperative to curbing the disease's spread and alleviating patient suffering. In this study, a higher prevalence of brucellosis (BS) was observed among middle-aged men, with a male-to-female ratio of 4.39:1. The average age of the patients was 52.29 ± 9.46 years (range: 20–73 years), with 66.5% (111 patients) aged between 41 and 60 years, consistent with previous research[ 9 , 10 , 11 ]. This demographic trend can be attributed to the occupational exposure of men to physically demanding labor involving close contact with livestock, whereas women participate less in such agricultural activities, thereby reducing their exposure. This gender-based division of labor significantly increases the incidence of BS among men compared to women. Moreover, widespread educational initiatives by the Chinese government have encouraged younger individuals to migrate to economically developed regions rather than remain in rural areas where livestock handling is common. Consequently, older generations continue to manage livestock at home, contributing to the higher incidence of BS among middle-aged individuals. In analyzing the epidemiological history of the patients, it was found that 143 individuals (85.6%) had long-term residence in rural areas, where the incidence of BS is significantly higher compared to urban areas. This trend can be attributed to the extensive pasturelands in rural areas, which are conducive to cattle and sheep farming, major sources of Brucella infection. Among the 167 patients surveyed, 128 (76.6%) reported close contact with cattle and sheep[ 12 ], confirming this contact as a primary risk factor for the disease in the local rural population where livestock farming is prevalent[ 13 ]. Regarding symptom onset analysis, 63 patients experienced symptoms in spring, while others showed initial symptoms evenly distributed across summer, autumn, and winter. The higher incidence in spring can be attributed to seasonal calving and lambing periods, which increase contact with potentially infected animals. Throughout the year, residents consume beef, mutton, and related products, contributing to similar incidence rates in summer, autumn, and winter. Patients were classified into acute (31.7%), subacute (24.0%), and chronic (44.3%) categories based on disease duration. Although chronic cases predominated in data analysis, medical history inquiries revealed that some patients delayed seeking medical attention until neurological symptoms appeared, leading many cases to progress from acute to chronic stages. All 167 patients presented clinical symptoms associated with BS during their initial consultation. The most common manifestations included fever (81.4%), excessive sweating (61.1%), fatigue (69.5%), back pain (88.6%), and anorexia (65.3%), consistent with previous research findings [ 14 , 15 ]. Furthermore, during medical history inquiries and physical examinations, patients frequently displayed heightened pain levels, low pain tolerance, poor compliance, and significant anxiety during verbal communication. In clinical practice, it is advisable for healthcare providers to prioritize patients' emotional health, actively engage in communication, and implement measures to prevent a cascade of adverse events resulting from exacerbated emotional distress. In this study, among the 167 patients, 158 tested positives for RBT and SAT, resulting in a positivity rate of 94.6%. However, blood culture, considered the gold standard, was positive in only 13 patients, yielding a positivity rate of 7.8%. This finding corroborates previous studies, such as those by Feng et al[ 16 ]. Using these diagnostic criteria, 161 patients received definitive diagnoses, while 6 were classified as suspected cases. The suspected cases showed significant symptom improvement after treatment with brucellosis-specific medications, confirming their eventual diagnosis as brucellosis cases. Based on our data analysis, we conclude that widespread use of RBT and SAT testing in poor endemic areas provides satisfactory diagnostic results for brucellosis. In contrast, due to its low positivity rate and longer detection time, blood culture is not recommended as the preferred diagnostic method. Similarly, tests like Coombs' test, which are expensive and require sophisticated laboratory settings, should not be considered primary diagnostic methods. Upon admission, we analyzed the results of initial hematological examinations for each patient. We observed that 30 individuals (18.0%) had platelet counts > 300×10^9/L, which contrasts with previous studies that primarily focus on platelet reduction, with minimal mention of platelet elevation[ 17 , 18 ]. Regarding electrolyte levels, we observed a deviation from previous research, with 39 patients (23.4%) having K + levels < 3.5mmol/L. After discussion, we concluded that this phenomenon is likely due to anorexia and other factors that arise following infection with BS. Additionally, the prevalence of elevated ESR and CRP levels is higher compared with previous literature[ 1 , 18 ], which predominantly examines ESR and CRP in brucellosis rather than BS. This led us to hypothesize that ESR and CRP levels might be more likely to elevate in cases involving brucellosis-related spinal conditions. And, upon comparative analysis, we found no positive correlation between symptom severity, vertebral invasion observed on MRI, abscess size, and ESR and CRP levels. Consequently, we concluded that the degree of ESR and CRP elevation does not correlate with disease severity in these patients. Furthermore, based on the limited sample size, we concluded that there is no associated susceptibility between Brucella and hepatitis B, hepatitis C, syphilis, tuberculosis, and HIV. Imaging examinations of 167 patients revealed that lumbar spine involvement, particularly at the L4/5 level, was predominant, representing 41.3% (69 cases). This contrasts with the findings of Turan et al.[ 19 ] and Bozgeyik et al.[ 20 ], who indicated that L5/S1 is the most commonly affected segment. Additionally, we noted that BS predominantly manifests as single-level lesions, with only 31 patients (18.6%) exhibiting involvement across multiple segments. Moreover, most patients displayed mild vertebral body destruction, with severe damage primarily confined to the upper and lower endplates, anterior aspect of the vertebral body, and intervertebral discs[ 21 , 22 ]. In cases of BS, early signs include the formation of marginal osteophytes on the vertebral edges. As the condition progresses, it gradually invades the intervertebral discs and endplates, resulting in narrowing of the intervertebral spaces. However, compared to tuberculosis, brucellosis typically causes less severe damage to the vertebral bodies. Extensive collapse or widespread destruction of the vertebrae, commonly observed in tuberculosis cases where the entire vertebral body can be affected, is rare in BS patients[ 23 ]. Following confirmation of BS, all patients underwent a 6-month course of anti-Brucella therapy, with regular liver function tests performed until the SAT titers dropped below 1:50, indicating treatment cessation. Due to the neurological symptoms observed in most patients at initial consultation, a significant number underwent surgical intervention in this study (97 patients)[ 24 , 25 ]. Among them, 32 experienced post-operative fever, with temperatures peaking at 39°C; their condition gradually normalized after continuing anti-Brucella medication for 5 days. After discussion, we thought it might be caused by a small number of bacteria flowing back into the blood during surgical removal. After several days of drug treatment, the drug concentration in the blood reached the target and the body temperature gradually recovered. Furthermore, 39 patients reported persistent or worsening limb numbness post-surgery, likely due to transient nerve edema following abscess clearance. Follow-up indicated gradual relief of limb numbness starting approximately 3 months post-surgery. During follow-up, 5 cases of relapse were observed in the conservative treatment group, while none occurred in the surgical group, resulting in an overall relapse rate of 3.0%. These relapsed patients subsequently underwent surgery without serious complications and exhibited satisfactory treatment outcomes during follow-up, with no recurrence. Based on our observations in this study, surgical intervention appears more effective than conservative treatment for BS patients suffering from severe symptoms, particularly intense lumbar pain and limb numbness due to neurological impairment. Furthermore, we emphasize the importance of monitoring patients' psychological well-being, as severe pain can induce anxiety and potentially worsen compliance with treatment, thereby exacerbating the condition. Conclusion This study presents the epidemiological and clinical features of 167 cases of BS at the 940th Hospital of Joint Logistics Support Force of Chinese PLA. In endemic regions, the occurrence of back pain and unexplained fever should prompt suspicion of BS. Positive results from combined RBT and SAT testing should prompt early MRI examination to confirm the diagnosis and facilitate early intervention to prevent neurological complications. This study enhances clinicians' comprehension of BS characteristics and establishes a robust theoretical foundation for disease prevention and monitoring. Declarations Acknowledgments The authors would like to thank the Health Commission of Gansu Province and the Key Science and Technology Foundation of Gansu Province for their funding. The authors also thank Elsevier language services (http://webshop.elsevier.com/language editing/) for editing and reviewing this manuscript for English language. Author contributions Funding acquisition: Song-Kai Li Investigation: Tao Zhang, Yi-zhe Wang, Da-shuai Huang, Xing-guo Tan Methodology: Tao Zhang, Long Chen Resources: Qian-xi Cheng Visualization: Da-shuai Huang, Xing-guo Tan Writing – original draft: Yan-peng Lu, Wei-qi Qiu Writing – review & editing: Song-Kai Li Conflicts of Interest and Source of Funding Conflict of interest The authors report no conflicts of interest. Funding Key Science and Technology Foundation of Gansu Province（21YF1FA179）. The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the funding agency. Compliance with Ethical Standards Informed consent All patients were informed about the purpose and methods of the study and signed a written informed consent to participate in this study. Ethical approval The study was approved by the institutional research ethics committee of the 940th hospital. Device Status/Drug Statement The Manuscript submitted does not contain information about medical device(s)/drug(s). Data availability The datasets used and/or analysed during the current study available from the corresponding author on reasonable request. References Franco MP, Mulder M, Gilman RH, Smits HL. Human brucellosis. Lancet Infect Dis . 2007;7(12):775-86. Qureshi KA, Parvez A, Fahmy NA, et al. Brucellosis: epidemiology, pathogenesis, diagnosis and treatment-a comprehensive review. Ann Med . 2023;55(2):2295398. Sun GQ, Li MT, Zhang J, Zhang W, Pei X, Jin Z. Transmission dynamics of brucellosis: Mathematical modelling and applications in China. 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Tables Table 1Demographic and epidemiological characteristics with BS Variable No. (%) Sex Male 136 (81.4%) Female 31 (18.6%) Residence Urban 24 (14.4%) Rural 143 (85.6%) Age group Mean age 52.29±9.46 0-20 years 1 (0.6%) 21-40 years 14 (8.4%) 41-60 years 111 (66.5%) 61-80 years 41 (24.5%) Medical history History of contact with cattle or sheep 128 (76.6%) Consumed unpasteurized cattle or sheep meat and raw milk 13 (7.8%) Unknow 26 (15.6%) Incidence season spring 63 (37.7%) summer 37 (22.2%) autumn 33 (19.7%) winter 34 (20.4%) Staging Acute 53 (31.7%) Subacute 40 (24.0%) Chronic 74 (44.3%) Table 2 Clinical characteristics and complications with BS Variable No. (%) Symptoms Fever 136 (81.4%) Sweating 102 (61.1%) Fatigue 116 (69.5%) Back pain 148 (88.6%) Anorexia 109 (65.3%) Hepatomegaly 26 (15.6%) Splenomegaly 7 (4.2%) complications Limb pain and numbness 113 (67.7%) Sensory loss 47 (28.1%) Restricted mobility 76 (45.5%) Table 3 Laboratory findings with BS Variable No. (%) Tested positive for both the RBT and SAT 158 (94.6%) Positive blood cultures 13 (7.8%) WBC count (×10^9/L) >9.5×10^9/L 16 (9.6%) 7×10^9/L 6 (3.6%) <2×10^9/L 14 (8.4%) Decrease in hemoglobin (male<130 g/L, female300×10^9/L 30 (18.0%) 15mm/h 147 (88.0%) CRP >0.8mg/dL 131 (78.4%) AST >40U/L 16 (9.6%) ALT >40U/L 31 (18.6%) K+ <3.5mmol/L 39 (23.4%) Infectious disease Hepatitis B 8 (4.8%) Hepatitis C 2 (1.2%) Syphilis 3 (1.8%) Tuberculosis 4 (2.4%) Table 4 Segment distribution with BS Variable No. (%) Segment distribution Lumbar spine 142 (85.0%) Cervical spine 15 (9.0%) Thoracic spine 5 (3.0%) Sacral spine 2 (1.2%) Thoracic and Lumbar spine 2 (1.2%) Cervical, Thoracic and Lumbar spine 1 (0.6%) Segment distribution of spine C3/4 2 (1.2%) C4/5 6 (3.6%) C5/6 7 (4.2%) C6/7 5 (3.0%) C7/T1 2 (1.2%) T1/2 2 (1.2%) T4/5 1 (0.6%) T9/10 1 (0.6%) T10/11 1 (0.6%) T11/12 1 (0.6%) T12/L1 3 (1.8%) L1/2 9 (5.4%) L2/3 28 (16.8%) L3/4 44 (26.3%) L4/5 69 (41.3%) L5/S1 27 (16.2%) S1 2 (1.2%) Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 01 Nov, 2024 Read the published version in Scientific Reports → Version 1 posted Editorial decision: Revision requested 09 Sep, 2024 Reviews received at journal 24 Aug, 2024 Reviews received at journal 23 Aug, 2024 Reviewers agreed at journal 20 Aug, 2024 Reviewers agreed at journal 20 Aug, 2024 Reviewers invited by journal 20 Aug, 2024 Editor assigned by journal 20 Aug, 2024 Editor invited by journal 05 Aug, 2024 Submission checks completed at journal 02 Aug, 2024 First submitted to journal 24 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4794081","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":344733129,"identity":"c07c663b-4491-4dc0-8b29-7c969f887c48","order_by":0,"name":"Yan-peng Lu","email":"","orcid":"","institution":"The 940th Hospital of Joint Logistics Support Force of Chinese PLA","correspondingAuthor":false,"prefix":"","firstName":"Yan-peng","middleName":"","lastName":"Lu","suffix":""},{"id":344733130,"identity":"ec4fb1ec-5bbc-4e79-9900-37a07fb23c7b","order_by":1,"name":"Wei-qi Qiu","email":"","orcid":"","institution":"The First School of Clinical Medical of Gansu University of Chinese Medical","correspondingAuthor":false,"prefix":"","firstName":"Wei-qi","middleName":"","lastName":"Qiu","suffix":""},{"id":344733131,"identity":"0e995706-05c9-4597-b570-8b325fbb99af","order_by":2,"name":"Tao Zhang","email":"","orcid":"","institution":"The 940th Hospital of Joint Logistics Support Force of Chinese PLA","correspondingAuthor":false,"prefix":"","firstName":"Tao","middleName":"","lastName":"Zhang","suffix":""},{"id":344733133,"identity":"72346a12-7ed3-43b0-b2b9-0dc55facfa1c","order_by":3,"name":"Qian-xi Cheng","email":"","orcid":"","institution":"The First School of Clinical Medical of Gansu University of Chinese Medical","correspondingAuthor":false,"prefix":"","firstName":"Qian-xi","middleName":"","lastName":"Cheng","suffix":""},{"id":344733134,"identity":"e7fc6e86-526d-4974-aaba-a9ae2756703c","order_by":4,"name":"Yizhe Wang","email":"","orcid":"","institution":"The 940th Hospital of Joint Logistics Support Force of Chinese PLA","correspondingAuthor":false,"prefix":"","firstName":"Yizhe","middleName":"","lastName":"Wang","suffix":""},{"id":344733135,"identity":"0538ab3e-d0d2-4252-8af4-680945b0a6d1","order_by":5,"name":"Song-kai Li","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4klEQVRIiWNgGAWjYBACPmYwlcDAxsx84IBEBRFa2OBa2NkSH1icIUYLA1QLAz+PsUFlGzFa2NkfPi74lSYPdKGZxM151rIN7IePbsDvMB5j45l9OYZtzAxpkjO3pRs38KSl3SCghU2at6eCEajlmLTktsOJDRI8ZgS0sD8DabFvY2Zsk/47hygtDGbSPD9yEtuYmZkNJBuI0gL0C29DWnIbMxvjA4lj6cZthPzCz3/84WOeP8m28/vPfzggUWMt289++BheLWDAiIgOZkZiogYI/iBpaSBOyygYBaNgFIwgAAAHhUFSnYwBmAAAAABJRU5ErkJggg==","orcid":"","institution":"The 940th Hospital of Joint Logistics Support Force of Chinese PLA","correspondingAuthor":true,"prefix":"","firstName":"Song-kai","middleName":"","lastName":"Li","suffix":""},{"id":344733136,"identity":"1686155b-b0e8-43be-9238-67b9eb5ab515","order_by":6,"name":"Long Chen","email":"","orcid":"","institution":"The 940th Hospital of Joint Logistics Support Force of Chinese PLA","correspondingAuthor":false,"prefix":"","firstName":"Long","middleName":"","lastName":"Chen","suffix":""},{"id":344733137,"identity":"f7a1e68f-5b23-46bd-aca0-e1e6eb4059e2","order_by":7,"name":"Xingguo Tan","email":"","orcid":"","institution":"The 940th Hospital of Joint Logistics Support Force of Chinese PLA","correspondingAuthor":false,"prefix":"","firstName":"Xingguo","middleName":"","lastName":"Tan","suffix":""},{"id":344733138,"identity":"b43a69fe-8de2-47a3-98cd-2283208d8125","order_by":8,"name":"Dashuai Huang","email":"","orcid":"","institution":"The 940th Hospital of Joint Logistics Support Force of Chinese PLA","correspondingAuthor":false,"prefix":"","firstName":"Dashuai","middleName":"","lastName":"Huang","suffix":""}],"badges":[],"createdAt":"2024-07-24 09:23:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4794081/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4794081/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-024-77391-w","type":"published","date":"2024-11-01T16:20:03+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":64146928,"identity":"cfc61c43-2965-4a2d-a5bd-98300ef79bd9","added_by":"auto","created_at":"2024-09-08 20:03:40","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":52346,"visible":true,"origin":"","legend":"\u003cp\u003eNumber of sick people each year from 2014 to 2023\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4794081/v1/225b1fe1879ad27e60b9ff3c.png"},{"id":64146929,"identity":"1a2d586f-4c0c-4527-b8fe-a438697c0de7","added_by":"auto","created_at":"2024-09-08 20:03:40","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":47876,"visible":true,"origin":"","legend":"\u003cp\u003eThe number of patients affected by each segment of the lumbar spine\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4794081/v1/ceb30bfb1618b1b2c5fb6c32.png"},{"id":68207053,"identity":"73fa1a69-2944-4612-b7a4-5498f64d26f9","added_by":"auto","created_at":"2024-11-04 16:34:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":602886,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4794081/v1/a11f234f-3d97-475a-b512-60515129ae3e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Epidemiology and laboratory testing of Brucella spondylitis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBrucellosis, caused by bacteria belonging to the genus Brucella, is a prevalent zoonotic infectious disease[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. According to surveillance data from China, the overall incidence of brucellosis rose from 0.92 per 100,000 in 2004 to 4.2 per 100,000 in 2014. Subsequently, the incidence sharply declined in 2015 but began a steady increase in 2017, reaching 4.95 per 100,000 in 2021, surpassing the peak observed in 2014. The disease predominantly affects pastoral regions such as Northeast China, Northwest China, Inner Mongolia, and the Qinghai-Tibet Plateau. Recently, high-incidence areas have shown an expanding trend southward[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Presently, brucellosis prevalence continues to rise in previously affected regions, with new epidemic areas emerging gradually[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The primary factors contributing to this trend may include the growing demand for cattle and sheep due to economic development, resulting in an increase in the number of individuals involved in livestock farming and slaughtering. Moreover, inadequate supervision and epidemic prevention measures, coupled with low self-protection awareness, have led to a yearly increase in the incidence rate of brucellosis.\u003c/p\u003e \u003cp\u003eBS ranks among the most prevalent osteoarticular complications of brucellosis, affecting approximately 2\u0026ndash;77% of all brucellosis patients[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. It develops when infectious microorganisms invade the spine through various routes, including direct external bacterial inoculation, contiguous spread from adjacent infected sites, dissemination through the nutrient arteries of the vertebral body[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], or rarely, retrograde spread through the Batson venous plexus[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This condition predominantly affects the spine, particularly the lumbar vertebrae, manifesting as chronic back pain, fever, night sweats, and weight loss[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Given its symptomatology's resemblance to that of numerous other spinal diseases, diagnosing BS is frequently delayed or misinterpreted. This study analyzes the epidemiology, clinical manifestations, laboratory data, imaging findings, and treatment outcomes of 167 BS patients. Its aim is to provide healthcare providers in endemic areas with comprehensive BS data to facilitate prompt diagnosis and appropriate treatment selection. Furthermore, this research contributes robust data supporting national measures for brucellosis prevention and control.\u003c/p\u003e"},{"header":"Patients and methods","content":"\u003cp\u003e\u003cstrong\u003eEthics Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of the 940th Hospital of Joint Logistics Support Force of Chinese PLA and was conducted in accordance with the principles of the Helsinki Declaration. All patients admitted to the hospital signed informed consent forms for the use of their clinical data for scientific research.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient Population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study examined the medical records of patients diagnosed with BS who received hospitalization and treatment at the Department of Spine Surgery, The 940th Hospital of Joint Logistics Support Force of Chinese PLA, from 2014 to 2023. Following meticulous screening involving detailed laboratory and imaging examinations, 167 patients met the inclusion criteria for the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiagnosis of BS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFollowing the Chinese diagnostic criteria for brucellosis (Health Standard No. WS 269-2019):\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eEpidemiological History: This includes a history of close contact with livestock or animal products suspected of Brucella infection, consumption of raw cattle or sheep milk and meat products, residing in brucellosis endemic areas, or involvement in Brucella culture, testing, or vaccine production and use.\u003c/li\u003e\n \u003cli\u003eClinical Manifestations: Symptoms comprise fever lasting several days to weeks (including low-grade fever), excessive sweating, fatigue, muscle, and joint pain.\u003c/li\u003e\n \u003cli\u003eLaboratory Initial Screening:\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003ea) Positive RBT\u003c/p\u003e\n\u003cp\u003eb) Positive Colloidal Gold Immunochromatography Assay (GICA)\u003c/p\u003e\n\u003cp\u003ec) Positive Enzyme-Linked Immunosorbent Assay (ELISA)\u003c/p\u003e\n\u003cp\u003ed) Brucella culture smear indicating suspected Brucella on Gram staining.\u003c/p\u003e\n\u003col start=\"4\"\u003e\n \u003cli\u003eLaboratory Confirmatory Diagnosis:\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003ea) Isolation of Brucella from the patient\u0026apos;s blood, bone marrow, other body fluids, or excretions\u003c/p\u003e\n\u003cp\u003eb) SAT titer of 1:100++ or higher, or 1:50++ or higher if clinical symptoms persist for over a year\u003c/p\u003e\n\u003cp\u003ec) Complement Fixation Test (CFT) titer of 1:10++ or higher\u003c/p\u003e\n\u003cp\u003ed) Coomb\u0026rsquo;s Test titer of 1:400++ or higher\u003c/p\u003e\n\u003cp\u003ePatients meeting criteria 1 and 2 are considered suspected cases, those meeting criterion 3 are clinically diagnosed, and those meeting criterion 4 are confirmed cases.\u003c/p\u003e\n\u003cp\u003eFor patients suspected of spinal involvement, MRI scans are employed to identify affected segments and assess the extent of involvement in vertebral bodies, endplates, intervertebral discs, paravertebral soft tissue, and the epidural space, thereby aiding BS diagnosis.\u003c/p\u003e\n\u003cp\u003eCases are categorized based on symptom duration: Acute (\u0026lt;3 months); Subacute (3-6 months), Chronic (\u0026gt;6 months).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResearch data on BS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUpon admission, all patients underwent combined RBT and SAT testing, along with blood cultures. A single researcher documented each patient\u0026apos;s demographics, clinical manifestations, and epidemiological history, encompassing gender, age, consultation timing, place of residence, season of symptom onset, illness duration, history of close contact with cattle and sheep, and consumption of raw beef, lamb, and dairy products. Initial laboratory test results at admission were also recorded, including complete blood count, blood biochemistry, liver and kidney function tests, ESR, CRP, and screenings for infectious diseases (syphilis, HIV, hepatitis B, hepatitis C, and tuberculosis).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTreatment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAccording to the treatment guidelines issued by the Chinese Center for Disease Control and Prevention, the principles of Brucellosis treatment emphasize early initiation, combination therapy, adequate dosage, and sufficient duration of medication, with potential extension to prevent recurrence and chronicity. Common regimens typically involve doxycycline in combination with rifampicin or streptomycin. Patients presenting with complications may also receive third-generation cephalosporins or quinolone antibiotics.\u003c/p\u003e\n\u003cp\u003eIn this study, patients received Brucella-specific treatment adhering to these guidelines, which included intravenous ceftriaxone (2 grams daily), oral doxycycline (0.2 grams daily), oral rifampicin (0.1 grams daily), and hepatoprotective drugs (0.6 grams daily). For patients experiencing relapse (characterized by unexplained pain, fever, night sweats, weight loss, elevated ESR and CRP, new vertebral lesions, or increasing SAT titers) and those with spinal involvement, treatment was extended beyond six months until SAT titers dropped below 1:50 upon reevaluation.\u003c/p\u003e\n\u003cp\u003ePatients suffering severe pain or significant neurological impairment that affected daily life underwent aggressive surgical intervention. Surgical indications included: 1) persistent back pain after \u0026gt;3 courses of drug therapy or stubborn lumbar pain due to intervertebral disc damage; 2) large, difficult-to-absorb paraspinal/psoas abscesses; 3) vertebral lesions \u0026ge;1 cm, facet joint destruction, pathological fractures affecting spinal stability; 4) intraspinal abscesses, inflammatory granulomas, necrotic intervertebral discs causing compression of the spinal cord, cauda equina, or nerve roots. Patients meeting these criteria underwent a 5-day course of Brucella-specific antibiotic treatment before surgery. Surgery proceeded once liver and kidney function normalized, ESR was \u0026lt; 45 mm/h, and anemia and malnutrition were corrected. Early surgical intervention was crucial for cases where neurological symptoms progressively worsened to preserve nerve function.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eContinuous, discrete, and rating variables are presented as mean standard deviation (SD), and categorical variables are expressed as frequencies or percentages. All statistical analyses were performed using SPSS version 29.0 statistical software (SPSS Inc.,Chicago, IL, USA).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eDemographic and epidemiological characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study included a total of 167 patients. The data indicates a predominant male incidence, comprising 81.4% (136) of the total patients, with females constituting only 18.6% (31). Moreover, the patients\u0026apos; average age was 52.29\u0026plusmn;9.46 years, with 66.5% (111) falling within the 41-60 age range. The peak number of patients treated at our hospital was in 2015, with 35 (21.0%) admissions (Figure 1). While patient numbers have fluctuated over time, an overall slow increasing trend is observed. Epidemiological data reveal that 143 (85.6%) patients resided in rural areas, with the remaining 24 (14.4%) residing in urban areas. Of these, 128 (76.6%) patients had a documented history of contact with cattle or sheep, 13 (7.8%) had consumed unpasteurized cattle and sheep meat or raw milk, and the cause of disease in 26 (15.6%) patients remained unknown. In patients experiencing symptoms for the first time, the seasonal distribution was as follows: 63 patients (37.7%) in spring, 37 patients (22.2%) in summer, 33 patients (19.7%) in autumn, and 34 patients (20.4%) in winter. Cases were classified based on symptom duration into acute (31.7% [53]), subacute (24.0% [40]), and chronic (44.3% [74]). (Table 1)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical characteristics and complications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients presented clinical symptoms associated with BS upon admission, including fever (81.4%), excessive sweating (61.1%), fatigue (69.5%), back pain (88.6%), anorexia (65.3%), hepatomegaly (15.6%), and splenomegaly (4.2%). Additionally, some patients presented with neurological symptoms upon initial diagnosis, including limb pain and numbness (67.7%), sensory loss (28.1%), and restricted mobility (45.5%). (Table 2)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLaboratory findings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong the 167 patients, 158 (94.6%) tested positive for both RBT and SAT, whereas 13 patients (7.8%) tested positive via blood culture. Abnormal hematological findings included: WBC count \u0026gt;9.5\u0026times;10^9/L (9.6%) or \u0026lt;3.5\u0026times;10^9/L (6.6%), neutrophil count \u0026gt;7\u0026times;10^9/L (3.6%) or \u0026lt;2\u0026times;10^9/L (8.4%), decrease in hemoglobin\u0026nbsp;(male\u0026lt;130 g/L, female\u0026lt;110 g/L)) (18.0%), platelet count \u0026gt;300\u0026times;10^9/L (18.0%) or \u0026lt;100\u0026times;10^9/L (1.8%), ESR \u0026gt;15mm/h (88.0%), CRP \u0026gt;0.8mg/dL (78.4%), Aspartate aminotransferase (AST) \u0026gt;40U/L (9.6%), ALT \u0026gt;40U/L (18.6%), and K\u003csup\u003e+\u003c/sup\u003e \u0026lt;3.5mmol/L (23.4%). Infectious disease tests revealed that 4.8% (8) of patients had hepatitis B, 1.2% (2) had hepatitis C, 1.8% (3) had syphilis, and 2.4% (4) had tuberculosis, with no patients testing positive for HIV. (Table 3)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImaging findings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter admission, all patients underwent MRI examinations, revealing involvement of various spinal segments: 142 patients (85.0%) had lumbar spine involvement, 15 patients (9.0%) had cervical spine involvement, 5 patients (3.0%) had thoracic spine involvement, 2 patients (1.2%) had sacral spine involvement, 2 patients (1.2%) had concurrent thoracic and lumbar spine involvement, and 1 patient (0.6%) was involved of the cervical, thoracic, and lumbar spine. The distribution across spinal segments is as follows: C3/4 (1.2%), C4/5 (3.6%), C5/6 (4.2%), C6/7 (3.0%), C7/T1 (1.2%), T1/2 (1.2%), T4/5 (0.6%), T9/10 (0.6%), T10/11 (0.6%), T11/12 (0.6%), T12/L1 (1.8%), L1/2 (5.4%), L2/3 (16.8%), L3/4 (26.3%), L4/5 (41.3%), L5/S1 (16.2%), and S1 (1.2%) (Figure 2). Notably, 31 patients (18.6%) exhibited involvement of multiple spinal segments, hence the percentages for each segment are calculated independently. (Table 4)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003etreatment results\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong the 167 patients, 70 (41.9%) received conservative treatment, while 97 (58.1%) underwent surgery. All patients underwent six months of chemotherapy, with treatment discontinued only after rechecking SAT titers to ensure they were less than 1:50. Among the 97 surgical patients, 32 (33.0%) experienced postoperative fever, and 39 (40.2%) reported persistent or worsened limb numbness postoperatively. Five patients (3.0%) experienced recurrence after treatment, all from the conservative treatment group, and achieved satisfactory outcomes following subsequent surgical intervention.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eGansu Province stands as a significant endemic area for brucellosis in China, characterized by numerous local pastures and a substantial population engaged in animal husbandry. However, inadequate local supervision has led to a lack of awareness among the populace regarding brucellosis, compounded by insufficient public health education efforts. Consequently, the incidence of brucellosis has been steadily rising. BS, a severe complication of brucellosis, poses considerable health risks to local residents and impedes the rapid economic development of Gansu Province. Hence, a comprehensive understanding of the clinical manifestations, laboratory examinations, and epidemiology of BS is imperative to curbing the disease's spread and alleviating patient suffering.\u003c/p\u003e \u003cp\u003eIn this study, a higher prevalence of brucellosis (BS) was observed among middle-aged men, with a male-to-female ratio of 4.39:1. The average age of the patients was 52.29\u0026thinsp;\u0026plusmn;\u0026thinsp;9.46 years (range: 20\u0026ndash;73 years), with 66.5% (111 patients) aged between 41 and 60 years, consistent with previous research[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. This demographic trend can be attributed to the occupational exposure of men to physically demanding labor involving close contact with livestock, whereas women participate less in such agricultural activities, thereby reducing their exposure. This gender-based division of labor significantly increases the incidence of BS among men compared to women. Moreover, widespread educational initiatives by the Chinese government have encouraged younger individuals to migrate to economically developed regions rather than remain in rural areas where livestock handling is common. Consequently, older generations continue to manage livestock at home, contributing to the higher incidence of BS among middle-aged individuals.\u003c/p\u003e \u003cp\u003eIn analyzing the epidemiological history of the patients, it was found that 143 individuals (85.6%) had long-term residence in rural areas, where the incidence of BS is significantly higher compared to urban areas. This trend can be attributed to the extensive pasturelands in rural areas, which are conducive to cattle and sheep farming, major sources of Brucella infection. Among the 167 patients surveyed, 128 (76.6%) reported close contact with cattle and sheep[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], confirming this contact as a primary risk factor for the disease in the local rural population where livestock farming is prevalent[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRegarding symptom onset analysis, 63 patients experienced symptoms in spring, while others showed initial symptoms evenly distributed across summer, autumn, and winter. The higher incidence in spring can be attributed to seasonal calving and lambing periods, which increase contact with potentially infected animals. Throughout the year, residents consume beef, mutton, and related products, contributing to similar incidence rates in summer, autumn, and winter.\u003c/p\u003e \u003cp\u003ePatients were classified into acute (31.7%), subacute (24.0%), and chronic (44.3%) categories based on disease duration. Although chronic cases predominated in data analysis, medical history inquiries revealed that some patients delayed seeking medical attention until neurological symptoms appeared, leading many cases to progress from acute to chronic stages.\u003c/p\u003e \u003cp\u003eAll 167 patients presented clinical symptoms associated with BS during their initial consultation. The most common manifestations included fever (81.4%), excessive sweating (61.1%), fatigue (69.5%), back pain (88.6%), and anorexia (65.3%), consistent with previous research findings [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Furthermore, during medical history inquiries and physical examinations, patients frequently displayed heightened pain levels, low pain tolerance, poor compliance, and significant anxiety during verbal communication. In clinical practice, it is advisable for healthcare providers to prioritize patients' emotional health, actively engage in communication, and implement measures to prevent a cascade of adverse events resulting from exacerbated emotional distress.\u003c/p\u003e \u003cp\u003eIn this study, among the 167 patients, 158 tested positives for RBT and SAT, resulting in a positivity rate of 94.6%. However, blood culture, considered the gold standard, was positive in only 13 patients, yielding a positivity rate of 7.8%. This finding corroborates previous studies, such as those by Feng et al[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Using these diagnostic criteria, 161 patients received definitive diagnoses, while 6 were classified as suspected cases. The suspected cases showed significant symptom improvement after treatment with brucellosis-specific medications, confirming their eventual diagnosis as brucellosis cases. Based on our data analysis, we conclude that widespread use of RBT and SAT testing in poor endemic areas provides satisfactory diagnostic results for brucellosis. In contrast, due to its low positivity rate and longer detection time, blood culture is not recommended as the preferred diagnostic method. Similarly, tests like Coombs' test, which are expensive and require sophisticated laboratory settings, should not be considered primary diagnostic methods.\u003c/p\u003e \u003cp\u003eUpon admission, we analyzed the results of initial hematological examinations for each patient. We observed that 30 individuals (18.0%) had platelet counts\u0026thinsp;\u0026gt;\u0026thinsp;300\u0026times;10^9/L, which contrasts with previous studies that primarily focus on platelet reduction, with minimal mention of platelet elevation[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Regarding electrolyte levels, we observed a deviation from previous research, with 39 patients (23.4%) having K\u003csup\u003e+\u003c/sup\u003e levels\u0026thinsp;\u0026lt;\u0026thinsp;3.5mmol/L. After discussion, we concluded that this phenomenon is likely due to anorexia and other factors that arise following infection with BS.\u003c/p\u003e \u003cp\u003eAdditionally, the prevalence of elevated ESR and CRP levels is higher compared with previous literature[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], which predominantly examines ESR and CRP in brucellosis rather than BS. This led us to hypothesize that ESR and CRP levels might be more likely to elevate in cases involving brucellosis-related spinal conditions. And, upon comparative analysis, we found no positive correlation between symptom severity, vertebral invasion observed on MRI, abscess size, and ESR and CRP levels. Consequently, we concluded that the degree of ESR and CRP elevation does not correlate with disease severity in these patients.\u003c/p\u003e \u003cp\u003eFurthermore, based on the limited sample size, we concluded that there is no associated susceptibility between Brucella and hepatitis B, hepatitis C, syphilis, tuberculosis, and HIV.\u003c/p\u003e \u003cp\u003eImaging examinations of 167 patients revealed that lumbar spine involvement, particularly at the L4/5 level, was predominant, representing 41.3% (69 cases). This contrasts with the findings of Turan et al.[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] and Bozgeyik et al.[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], who indicated that L5/S1 is the most commonly affected segment. Additionally, we noted that BS predominantly manifests as single-level lesions, with only 31 patients (18.6%) exhibiting involvement across multiple segments. Moreover, most patients displayed mild vertebral body destruction, with severe damage primarily confined to the upper and lower endplates, anterior aspect of the vertebral body, and intervertebral discs[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In cases of BS, early signs include the formation of marginal osteophytes on the vertebral edges. As the condition progresses, it gradually invades the intervertebral discs and endplates, resulting in narrowing of the intervertebral spaces. However, compared to tuberculosis, brucellosis typically causes less severe damage to the vertebral bodies. Extensive collapse or widespread destruction of the vertebrae, commonly observed in tuberculosis cases where the entire vertebral body can be affected, is rare in BS patients[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFollowing confirmation of BS, all patients underwent a 6-month course of anti-Brucella therapy, with regular liver function tests performed until the SAT titers dropped below 1:50, indicating treatment cessation. Due to the neurological symptoms observed in most patients at initial consultation, a significant number underwent surgical intervention in this study (97 patients)[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Among them, 32 experienced post-operative fever, with temperatures peaking at 39\u0026deg;C; their condition gradually normalized after continuing anti-Brucella medication for 5 days. After discussion, we thought it might be caused by a small number of bacteria flowing back into the blood during surgical removal. After several days of drug treatment, the drug concentration in the blood reached the target and the body temperature gradually recovered. Furthermore, 39 patients reported persistent or worsening limb numbness post-surgery, likely due to transient nerve edema following abscess clearance. Follow-up indicated gradual relief of limb numbness starting approximately 3 months post-surgery. During follow-up, 5 cases of relapse were observed in the conservative treatment group, while none occurred in the surgical group, resulting in an overall relapse rate of 3.0%. These relapsed patients subsequently underwent surgery without serious complications and exhibited satisfactory treatment outcomes during follow-up, with no recurrence.\u003c/p\u003e \u003cp\u003eBased on our observations in this study, surgical intervention appears more effective than conservative treatment for BS patients suffering from severe symptoms, particularly intense lumbar pain and limb numbness due to neurological impairment. Furthermore, we emphasize the importance of monitoring patients' psychological well-being, as severe pain can induce anxiety and potentially worsen compliance with treatment, thereby exacerbating the condition.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study presents the epidemiological and clinical features of 167 cases of BS at the 940th Hospital of Joint Logistics Support Force of Chinese PLA. In endemic regions, the occurrence of back pain and unexplained fever should prompt suspicion of BS. Positive results from combined RBT and SAT testing should prompt early MRI examination to confirm the diagnosis and facilitate early intervention to prevent neurological complications. This study enhances clinicians' comprehension of BS characteristics and establishes a robust theoretical foundation for disease prevention and monitoring.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the Health Commission of Gansu Province and the Key Science and Technology Foundation of Gansu Province for their funding. The authors also thank Elsevier language services (http://webshop.elsevier.com/language editing/) for editing and reviewing this manuscript for English language.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFunding acquisition: Song-Kai Li\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInvestigation: Tao Zhang, Yi-zhe Wang, Da-shuai Huang, Xing-guo Tan\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMethodology: Tao Zhang, Long Chen\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResources: Qian-xi Cheng\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eVisualization: Da-shuai Huang, Xing-guo Tan\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWriting \u0026ndash; original draft: Yan-peng Lu, Wei-qi Qiu\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWriting \u0026ndash; review \u0026amp; editing: Song-Kai Li\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest and Source of Funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors report no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKey Science and Technology Foundation of Gansu Province（21YF1FA179）. The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the funding agency.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompliance with Ethical Standards\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients were informed about the purpose and methods of the study and signed a written informed consent to participate in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the institutional research ethics committee of the 940th hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDevice Status/Drug Statement\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Manuscript submitted does not contain information about medical device(s)/drug(s).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eFranco MP, Mulder M, Gilman RH, Smits HL. Human brucellosis. \u003cem\u003eLancet Infect Dis\u003c/em\u003e. 2007;7(12):775-86.\u003c/li\u003e\n\u003cli\u003eQureshi KA, Parvez A, Fahmy NA, et al. Brucellosis: epidemiology, pathogenesis, diagnosis and treatment-a comprehensive review. \u003cem\u003eAnn Med\u003c/em\u003e. 2023;55(2):2295398.\u003c/li\u003e\n\u003cli\u003eSun GQ, Li MT, Zhang J, Zhang W, Pei X, Jin Z. Transmission dynamics of brucellosis: Mathematical modelling and applications in China. \u003cem\u003eComput Struct Biotechnol J\u003c/em\u003e. 2020;18:3843-60.\u003c/li\u003e\n\u003cli\u003eMoriy\u0026oacute;n I, Blasco JM, Letesson JJ, De Massis F, Moreno E. Brucellosis and One Health: Inherited and Future Challenges. \u003cem\u003eMicroorganisms\u003c/em\u003e. 2023;11(8).\u003c/li\u003e\n\u003cli\u003eJin M, Fan Z, Gao R, Li X, Gao Z, Wang Z. Research progress on complications of Brucellosis. \u003cem\u003eFront Cell Infect Microbiol\u003c/em\u003e. 2023;13:1136674.\u003c/li\u003e\n\u003cli\u003eMorales H. Infectious Spondylitis Mimics: Mechanisms of Disease and Imaging Findings. \u003cem\u003eSemin Ultrasound CT MR\u003c/em\u003e. 2018;39(6):587-604.\u003c/li\u003e\n\u003cli\u003eSpernovasilis N, Karantanas A, Markaki I, et al. Brucella Spondylitis: Current Knowledge and Recent Advances. \u003cem\u003eJ Clin Med\u003c/em\u003e. 2024;13(2).\u003c/li\u003e\n\u003cli\u003eEsmaeilnejad-Ganji SM, Esmaeilnejad-Ganji SMR. Osteoarticular manifestations of human brucellosis: A review. \u003cem\u003eWorld J Orthop\u003c/em\u003e. 2019;10(2):54-62.\u003c/li\u003e\n\u003cli\u003eLiang C, Wei W, Liang X, De E, Zheng B. Spinal brucellosis in Hulunbuir, China, 2011-2016. \u003cem\u003eInfect Drug Resist\u003c/em\u003e. 2019;12:1565-71.\u003c/li\u003e\n\u003cli\u003eJiang W, Chen J, Li Q, et al. Epidemiological characteristics, clinical manifestations and laboratory findings in 850 patients with brucellosis in Heilongjiang Province, China. \u003cem\u003eBMC Infect Dis\u003c/em\u003e. 2019;19(1):439.\u003c/li\u003e\n\u003cli\u003eBuzgan T, Karahocagil MK, Irmak H, et al. Clinical manifestations and complications in 1028 cases of brucellosis: a retrospective evaluation and review of the literature. \u003cem\u003eInt J Infect Dis\u003c/em\u003e. 2010;14(6):e469-78.\u003c/li\u003e\n\u003cli\u003eBosilkovski M, Krteva L, Caparoska S, Dimzova M. Osteoarticular involvement in brucellosis: study of 196 cases in the Republic of Macedonia. \u003cem\u003eCroat Med J\u003c/em\u003e. 2004;45(6):727-33.\u003c/li\u003e\n\u003cli\u003eG\u0026uuml;r A, Geyik MF, Dikici B, et al. 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Brucellosis. \u003cem\u003eN Engl J Med\u003c/em\u003e. 2005;352(22):2325-36.\u003c/li\u003e\n\u003cli\u003eChelli Bouaziz M, Ladeb MF, Chakroun M, Chaabane S. Spinal brucellosis: a review. \u003cem\u003eSkeletal Radiol\u003c/em\u003e. 2008;37(9):785-90.\u003c/li\u003e\n\u003cli\u003eTali ET, Koc AM, Oner AY. Spinal brucellosis. \u003cem\u003eNeuroimaging Clin N Am\u003c/em\u003e. 2015;25(2):233-45.\u003c/li\u003e\n\u003cli\u003eLuan H, Liu K, Deng X, et al. One-stage posterior surgery combined with anti-Brucella therapy in the management of lumbosacral brucellosis spondylitis: a retrospective study. \u003cem\u003eBMC Surg\u003c/em\u003e. 2022;22(1):394.\u003c/li\u003e\n\u003cli\u003eFeng Z, Wang X, Yin X, Han J, Tang W. Analysis of the Curative Effect of Posterior Approach on Lumbar Brucellar Spondylitis with Abscess through Magnetic Resonance Imaging under Improved Watershed Algorithm. \u003cem\u003eContrast Media Mol Imaging\u003c/em\u003e. 2021;2021:1933706.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable\u0026nbsp;1Demographic and epidemiological characteristics with BS\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003eNo. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e136 (81.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e31 (18.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003eResidence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Urban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e24 (14.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Rural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e143 (85.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003eAge group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Mean age\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e52.29\u0026plusmn;9.46\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 0-20 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e1 (0.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 21-40 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e14 (8.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 41-60 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e111 (66.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 61-80 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e41 (24.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003eMedical history\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; History of contact with cattle or sheep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e128 (76.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Consumed unpasteurized cattle or sheep meat and raw milk\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e13 (7.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Unknow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e26 (15.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003eIncidence season\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; spring\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e63 (37.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; summer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e37 (22.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; autumn\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e33 (19.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; winter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e34 (20.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003eStaging\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Acute\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e53 (31.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Subacute\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e40 (24.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Chronic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e74 (44.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;2 Clinical characteristics and complications with BS\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003eNo. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003eSymptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Fever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e136 (81.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Sweating\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 102 (61.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Fatigue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 116 (69.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Back pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 148 (88.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Anorexia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 109 (65.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Hepatomegaly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 26 (15.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Splenomegaly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 7 (4.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003ecomplications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Limb pain and numbness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 113 (67.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Sensory loss\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 47 (28.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Restricted mobility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 76 (45.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;3 Laboratory findings with BS\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003eNo. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003eTested positive for both the RBT and SAT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e158 (94.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003ePositive blood cultures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e13 (7.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003eWBC count (\u0026times;10^9/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026gt;9.5\u0026times;10^9/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 16 (9.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026lt;3.5\u0026times;10^9/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 11 (6.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003eNeutrophil count (\u0026times;10^9/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026gt;7\u0026times;10^9/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 6 (3.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;2\u0026times;10^9/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 14 (8.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003eDecrease in hemoglobin (male\u0026lt;130 g/L, female\u0026lt;110 g/L))\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 30 (18.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003ePlatelet count (\u0026times;10^9/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026gt;300\u0026times;10^9/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 30 (18.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026lt;100\u0026times;10^9/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 3 (1.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003eESR \u0026gt;15mm/h\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 147 (88.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003eCRP \u0026gt;0.8mg/dL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 131 (78.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003eAST \u0026gt;40U/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 16 (9.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003eALT \u0026gt;40U/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 31 (18.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003eK+ \u0026lt;3.5mmol/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 39 (23.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003eInfectious disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Hepatitis B\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 8 (4.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Hepatitis C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 2 (1.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Syphilis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 3 (1.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Tuberculosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 4 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;4\u0026nbsp;Segment distribution with BS\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003eNo. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003eSegment distribution\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Lumbar spine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 142 (85.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Cervical spine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 15 (9.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Thoracic spine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 5 (3.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Sacral spine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 2 (1.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Thoracic and Lumbar spine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 2 (1.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Cervical, Thoracic and Lumbar spine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 1 (0.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003eSegment distribution of spine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; C3/4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 2 (1.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; C4/5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 6 (3.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; C5/6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 7 (4.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; C6/7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 5 (3.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; C7/T1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 2 (1.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; T1/2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 2 (1.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; T4/5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 1 (0.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; T9/10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 1 (0.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; T10/11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 1 (0.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; T11/12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 1 (0.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; T12/L1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 3 (1.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; L1/2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 9 (5.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; L2/3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 28 (16.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; L3/4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 44 (26.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; L4/5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 69 (41.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; L5/S1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 27 (16.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.28933092224231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; S1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 2 (1.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"brucella spondylitis, epidemiology, hematology, treatment","lastPublishedDoi":"10.21203/rs.3.rs-4794081/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4794081/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe average age of patients with BS was 52.29±9.46 years, comprising 136 males and 31 females. Risk factors for BS include close contact with cattle and sheep and consumption of unpasteurized food. The positive detection rate using combined Rose Bengal Test (RBT) and Standard Agglutination Test (SAT) was 94.6%, whereas the positive rate for blood culture was only 7.8%. The most common clinical manifestations were fever (81.4%), back pain (88.6%), sweating (61.1%), fatigue (69.5%), and anorexia (65.3%). Hematological examinations often revealed decreased hemoglobin (18.0%), increased platelets (18.0%), elevated erythrocyte sedimentation rate (ESR) (88.0%), elevated C-reactive protein (CRP) (78.4%), elevated Alanine aminotransferase (ALT) (18.6%), and decreased K+(23.4%). The imaging examinations revealed that the lumbar spine, particularly L4/5 (41.3%), is the most frequently affected vertebral level in BS. After treatment, the overall recurrence rate was 3.0%. In endemic areas, clinicians should be vigilant for BS in patients presenting with back pain and unexplained fever, particularly those with a history of close contact with cattle and sheep. The RBT and SAT tests show a high positivity rate of 94.6%, establishing them as the preferred diagnostic methods. This study enhances clinicians' comprehension of BS characteristics and lays a robust theoretical groundwork for disease prevention and monitoring.\u003c/p\u003e","manuscriptTitle":"Epidemiology and laboratory testing of Brucella spondylitis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-08 20:03:35","doi":"10.21203/rs.3.rs-4794081/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-09T05:58:55+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-24T06:20:25+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-23T08:37:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"78319493105976287658103199533791542442","date":"2024-08-20T14:05:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"197213445479779672470737730006932359453","date":"2024-08-20T11:00:08+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-20T07:44:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-20T06:58:15+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-08-05T17:30:12+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-02T14:11:59+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2024-07-24T09:22:10+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"041caabb-984d-4e93-9d09-28e237a7ecd3","owner":[],"postedDate":"September 8th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":36535831,"name":"Health sciences/Medical research/Epidemiology"},{"id":36535832,"name":"Health sciences/Medical research/Pre clinical studies"}],"tags":[],"updatedAt":"2024-11-04T16:24:53+00:00","versionOfRecord":{"articleIdentity":"rs-4794081","link":"https://doi.org/10.1038/s41598-024-77391-w","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2024-11-01 16:20:03","publishedOnDateReadable":"November 1st, 2024"},"versionCreatedAt":"2024-09-08 20:03:35","video":"","vorDoi":"10.1038/s41598-024-77391-w","vorDoiUrl":"https://doi.org/10.1038/s41598-024-77391-w","workflowStages":[]},"version":"v1","identity":"rs-4794081","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4794081","identity":"rs-4794081","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}