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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
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Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


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Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Case report
Year : 2024 | Month : March | Volume : 18 | Issue : 3 | Page : DD01 - DD04 Full Version

A Case Report on the Rare Presentation of Brucellosis-induced Spondylitis


Published: March 1, 2024 | DOI: https://doi.org/10.7860/JCDR/2024/68135.19138
Nivetha Manivannan Raj, Priya Periaiah, Senita Samuel, Vengadakrishnan Krishnamoorthy

1. Postgraduate Student, Department of Microbiology, Sri Ramachandra Medical College and Research Institute, Chennai, Tamil Nadu, India. 2. Postgraduate Student, Department of Microbiology, Sri Ramachandra Medical College and Research Institute, Chennai, Tamil Nadu, India. 3. Associate Professor, Department of Microbiology, Sri Ramachandra Medical College and Research Institute, Chennai, Tamil Nadu, India. 4. Senior Consultant, Department of General Medicine, Sri Ramachandra Medical College and Research Institute, Chennai, Tamil Nadu, India.

Correspondence Address :
Dr. Nivetha Manivannan Raj,
Postgraduate Student, Department of Microbiology, Sri Ramachandra Medical College and Research Institute, Sriher, Porur, Chennai-600116, Tamil Nadu, India.
E-mail: dr.rmnivetha1527@gmail.com

Abstract

Human brucellosis is a zoonosis with a global distribution that can affect several organs and tissues. The most frequent brucellosis consequence, osteoarticular arthritis, has been reported in 10-85% of patients. Arthritis (most common), bursitis, tenosynovitis, sacroiliitis, spondylitis, and osteomyelitis are among the range of bone and joint disorders. The age of the patient and the Brucella species involved both have an impact on the type of skeletal involvement. The most common and significant clinical type of osteoarticular involvement in adults with Brucella species infection is spondylitis. The diagnosis of spondylitis may be challenging, and it may be made more difficult by potentially fatal neurological or vascular problems. In most cases, spinal arthritis is the most common presentation which emerges a few weeks following the initial Brucella infection and can impact any segment of the spine (especially lumbar region). Unlike in this case, a 54-year-old male with a history of remittent fever presented with complications where uncommon complication of sacroiliac joints are involved. Managing the infection involves a combination of antibiotics and stabilising the affected joints. Nonetheless, the therapeutic process could extend over several months, and there’s a possibility of infection recurrence if not treated appropriately.

Keywords

Arthritis, Brucella, Emerging infection, Zoonosis

Case Report

A 54-year-old male, milkman by occupation, had a previous history of fever with chills, headache, nausea, myalgia and polyarthralgia for the past four months for which he was treated on and off with Cap. doxycycline 100 mg OD for various durations at various private clinics in his native. Currently, for the past three days he was on treatment with Tablet amoxicillin clavulanate 625 mg twice a day and Intravenous doxycycline 100 mg once daily due to the increasing intensity of the symptoms. Since the patient’s condition did not improve and he developed fever, he was referred to another centre for further management. Patient presented to the referral’s centre emergency department with chief complaints of fever associated with breathlessness, nausea, polyarthralgia. On physical examination he was febrile. On auscultation decreased bilateral air entry present and no other significant signs were elicited. On palpation abdomen was soft and hepatomegaly was present. No was splenomegaly. Written informed consent was obtained from the patient. During the admission, his blood picture showed normal haemogram with elevated liver enzymes (Table/Fig 1).

Routine urinalysis and Stool routine were normal. As part of the routine fever panel tests blood culture, urine culture, Enzyme Linked Immune Sorbent Assay (ELISA) for Dengue IgM, IgG, Leptospira IGM and scrub typhus IgM were performed of which scrub typhus alone was positive which was later considered as false positive. Blood culture was negative. Urine culture and sensitivity showed no growth. His peripheral smear was normal, no haemoparasites Chest X-ray and High-Resolution Computed Tomography (HRCT) thorax scan unveiled enlarged pretracheal node, bilateral subpleural parenchymal bands on lower lobes, right mild fibrosis was also noted. Considering the chronic presentations with the above given pulmonary findings, and negative blood culture the patient was started on Antitubercular therapy (T. rifampicin, T. isoniazid, T. pyrazinamide, T. ethambutol) empirically for seven days till brucellosis was identified and sputum for acid fast staining and culture for Mycobacterium tuberculosis were sent.

As there was no symptomatic improvement in the patient and arthritic joint pains intensified especially the back pain and the

acid-fast stain for tubercle bacilli was negative (Table/Fig 2). In view of all these findings extended blood cultures were done to rule out pyrexia of unknown origin.

Further ultrasound abdomen revealed hepatomegaly with grade 1 fatty changes and splenomegaly. X-ray pelvis revealed right sacroiliac joint spondylitis (Table/Fig 3),(Table/Fig 4),(Table/Fig 5). Conventional blood culture in Bactec bottles incubated at 37°C with periodic subcultures on every alternative day was performed. On day 7 extended blood culture grew gram negative coccobacilli (Table/Fig 6),(Table/Fig 7),(Table/Fig 8) which was identified as Brucella spp. by Matrix Associated Laser Desorption/Ionisation (MALDI TOF) with 99.1% confidence interval and finally diagnosed as brucellar spondylitis. When furthermore history was elicited, he was found to be a milkman by occupation also consumed unpasteurised milk which was supportive to the findings. Later 16 s RNA sequencing was done and was confirmed to be Brucella millitensis (Accession number: OR646656).

In view of the clinical picture and prolonged fever patient was started on a combination of streptomycin and rifampicin. The reason for this was that similar symptoms in conditions such as melioidosis, making it a differential diagnosis. After confirmation definitive therapy was started and the patient was started on combination of Inj. streptomycin 1g twice a day and T.rifampicin 600-900 mg once daily for five days. The patient improved symptomatically and got discharged with maintenance therapy of oral Cap Doxycycline 100 mg once daily along with Tab. Rifampicin 600-900 mg once daily for six weeks. The patient was contacted after four months, and he had recovered from his symptoms. Repeat X-ray after six weeks was found to be improved.

Discussion

Brucellosis affects primarily animals, particularly domestic livestock such as cattle, goats, sheep, and pigs. However, it can also be transmitted to humans through direct contact with infected animals or consumption of contaminated meat and dairy products. In humans, while brucellosis is rarely fatal, it can also cause chronic illness with debilitating symptoms if not properly treated. B. melitensis, B. abortus, B. suis, and B. canis are the four Brucella species that cause human brucellosis (1). As already known Brucella infection leads to non specific symptoms along with involvement of joints which makes it difficult to differentiate from other infectious spondylitis diseases (1). Joint involvement can manifest as arthralgia, enthesopathy, osteomyelitis, arthritis, bursitis, tendonitis, and tenosynovitis involving the knee, hip, sacroiliac, and ankle (2). In India the recent study in the period of 2019-2021 was by Kumari R et al., in a tertiary care centre in northern India revealed 19 (9.5%) and 23 (11.5%) positive results by anti-Brucella IgM ELISA and anti-Brucella IgG, respectively (3). In a recent study by Khoshnood S et al., from Iran 15.53% was the estimated pooled estimate for the prevalence of brucellosis and it seems to be increasing (4).

The patient in this case visited the hospital with respiratory symptoms as one of his complaints which were commonly encountered respiratory illnesses by the physicians. This has made the physicians to overlook the significant articular symptoms which were also present as minor complaint at the time of admission making it is more challenging to diagnose brucellosis and in the process the patient’s condition deteriorated. Therefore, in the differential diagnosis of back pain with fever, brucellar spondylitis should be considered. Due to the lack of specificity in its symptoms and signs, it is challenging to diagnose. Therefore, in cases with suspicion of Brucellosis, Magnetic Resonance Imaging (MRI) blood cultures, tissue biopsies, and cultures are advised. When furthermore history was elicited from the patient, he was found to be a milkman by occupation and consumes unpasteurised milk which was a very important supportive history. Overall, brucellosis remains an important public health concern, even now in India the prevalence being around 9.9-13.3% by various methods as mentioned by Mangalgi SS et al., and is on raising trend (5). Clinical manifestations and the isolation of Brucella species from blood or bone marrow cultures are required for the diagnosis of brucellosis (1).

Brucella responds favourably to a variety of treatment approaches. However, single-antibiotic therapy is ineffective for treating brucellosis because it results in disease relapse as well as prolonged treatment does not produce satisfactory results. In addition to providing rapid symptom relief, treatment should focus on avoiding illness relapse and future problems (such as arthritis, spondylitis, sacroiliitis, etc.,). Therapy for Brucella infections is more successful when two antibiotics are given in combination than when used alone (6). World Health Organisation (WHO) insists on combination therapy for Brucellosis as Monotherapy is not recommended (7). As seen in this case patient was on doxycycline monotherapy and rifampicin as a part of empirical ATT over weeks but the patient had no clinical improvement in fact the condition of the patient continued to deteriorate. In our institute, combination therapy of streptomycin and rifampicin were started and the patient improved later he was discharged with advice of rifampicin and doxycycline combination for six weeks and asked to come for review after 15 days.

The main finding in this case was the uncommon occurrence of Brucella infection in the hip joint. As the symptoms of this disorder are like those of numerous other common illnesses, making early identification difficult. Various other factors should also be taken into consideration like the patient’s occupational history in present case. Overview of varied literature on Brucellosis briefly in (Table/Fig 9) (2),(8),(9),(10),(11).

Conclusion

The purpose of the article was to emphasise the importance of considering Brucella as one of the priority pathogens when a patient comes with fever with joint pain and the significance of initiating combination therapy to prevent further deterioration of the patient. Hence, it is for healthcare professionals to be vigilant about diagnosing and managing brucellosis to ensure timely and effective patient care.

References

1.
Lee HJ, Hur JW, Lee JW, Lee SR. Brucellar spondylitis. J Korean Neurosurg Soc. 2008;44(4):277. https://doi.org/10.3340/jkns.2008.44.4.277. [crossref][PubMed]
2.
Jahmani R, Obeidat O, Yusef D. Brucella septic hip arthritis: A case report. Am J Case Rep. 2021;22:e928592-1-e928592-5. https://doi.org/10.12659/ajcr.928592. [crossref][PubMed]
3.
Kumari R, Kumar KR, Asmat J, Amita J, Kumar P, Gupta KK, et al. Human Brucellosis: An observational study from a tertiary care centre in north India. Cureus. 2023;15(8):e42980. [crossref]
4.
Khoshnood S, Pakzad R, Koupaei M, Shirani M, Araghi A, Irani GM, et al. Prevalence, diagnosis, and manifestations of brucellosis: A systematic review and meta-analysis. Frontiers in Veterinary Science. 2022;9:976215. [crossref][PubMed]
5.
Mangalgi SS, Sajjan AG, Mohite ST, Kakade SV. Serological, clinical, and epidemiological profile of human brucellosis in rural India. Indian J Community Med. 2015;40(3):163-67. [crossref][PubMed]
6.
Glowacka P, Zakowska D, Naylor K, Niemcewicz M, Bielawska-Drózd A. Brucella- virulence factors, pathogenesis and treatment. Polish J Microbiol. 2018;67(2):151-61. https://doi.org/10.21307/pjm-2018-029. [crossref][PubMed]
7.
Young EJ. Brucella spp. Gillepsie SH, Hawkey PM. Principles and practice of clinical bacteriology. PUBLISHER John Wiley & Sons. 2006;2:265-71. [crossref]
8.
Kim EJ, Lee SJ, Ahn EY, Ryu DG, Choi YH, Kim TH. Relapsed brucellosis presenting as neurobrucellosis with cerebral vasculitis in a patient previously diagnosed with brucellar spondylitis: A case report. Infection & Chemotherapy. 2015;47(4):268. https://doi.org/10.3947/ic.2015.47.4.268. [crossref][PubMed]
9.
Chidambaram Y, Alagesan M, Dhas CJ. Human brucellosis in a non- susceptible host: A case report. Int J Adv Med. 2018;5(4):1072. https://doi. org/10.18203/2349-3933.ijam20183150. [crossref]
10.
Dash SK, Jena, L, Panigrahy R, Sahu S, Singh S. Brucella melitensis lurking threat in eastern part of Odisha-A case report. J Pure Appl Microbiol. 2022;16(4):2949-53. https://doi.org/10.22207/jpam.16.4.12. [crossref]
11.
Saj SM, Menon G, Rukhsar. A case report on Brucellosis. J Med Sci Clin Res. 2020;08(07):575-78. Doi: https://dx.doi.org/10.18535/jmscr/v8i7.94.[crossref]

DOI and Others

DOI: 10.7860/JCDR/2024/68135.19138

Date of Submission: Oct 17, 2023
Date of Peer Review: Nov 29, 2023
Date of Acceptance: Jan 25, 2024
Date of Publishing: Mar 01, 2024

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Oct 18, 2023
• Manual Googling: Dec 19, 2023
• iThenticate Software: Jan 23, 2024 (7%)

ETYMOLOGY: Author Origin

EMENDATIONS: 6

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