brucellosis is a zoonotic disease mostly transmitted to humans through consumption of unpasteurized dairy products and can lead to a systemic disease with any organ involvement . in this report , we describe a case of brucellosis - induced avascular necrosis of the hip .
brucellosis was diagnosed through serological tests , and avascular necrosis of the femoral head was confirmed by pelvic mri .
the patient was treated with a combination of antimicrobial treatments and referred to the orthopedic service for total hip arthroplasty .
brucellosis may present with unusual manifestations and should be always taken into consideration , particularly in endemic areas .
brucellosis is a zoonotic disease mostly transmitted to humans through consumption of unpasteurized dairy products of infected animals ( 1 ) .
it is a serious public health problem particularly in endemic areas , and is accompanied by .
the disease is endemic in iran and has a high prevalence in lorestan province , central iran ( 3 ) .
brucellosis is a systemic disease that may involve any organ in the body ( 4 ) .
osteoarticular involvements including arthritis , spondylitis , osteomyelitis , tendonitis , and bursitis occur frequently and are reported in 3085% of patients with brucellosis ( 5 ) .
the involvement of the large peripheral joints is usually manifested as monoarthritis ( 1 ) . although the hip joints involvement may happen in brucellosis , brucellosis - induced avascular necrosis of the hip
, we describe a case of brucellosis that complicated by avascular necrosis of the femoral head .
the patient was a 50-year - old rural farmer and rancher who presented with groin pain for six months before admission .
he reported no history of trauma , underlying diseases , and steroids and alcohol use . over the previous six months
, he had experienced symptoms including .fever , night sweats , weakness , fatigue , anorexia , and weight loss of 10 kg .
the patient was visited by a local therapist ; in addition there was a delay in timely referral due to his addiction to opium .
the groin pain was his most severe complaint on admission so that he could not bear his weight on the right leg .
the physical examinations on admission showed stable vital signs , there was no organomegaly , and the right hip was in flexion and external rotation position so that any active and passive motion increased the pain .
the results of laboratory study were as follows : complete blood count ( cbc ) : nl , liver function test ( lft ) : nl , rheamatic factor ( rf ) : neg , antinuclear antibody ( ana ) : neg , blood culture : neg , elevated erythrocyte sedimentation rate ( esr ) , c - reactive protein ( crp ) : positive , and standard agglutination test for brucellosis : positive ( table 1 ) .
pelvic radiography and magnetic resonance imaging ( mri ) were administered showing avascular necrosis of right femoral head ( fig . 1 , 2 ) .
the patient was subsequently treated with standard antibrucellosis regimen : streptomycine 1gr / d i m for three weeks , doxycycline 100mg / bid po , and rifampin 600mg / d po .
.despite the improvement in the patient s general condition and laboratory evidence showing infection control , the patient was suffered from right groin pain and limitation of motion in the hip joint .
although osteoarticular involvements , especially arthritis in the large peripheral joints , are among the most common manifestations of brucellosis , no joint destruction has been reported in many studies ( 5 ) . despite few reports on the permanent joint complications of brucellosis - induced peripheral joint arthritis , hip joints pyogenic infection has a poor prognosis , particularly if treatment is delayed ( 6 ) .
delays in diagnosis and treatment of brucellosis - induced hip arthritis could lead to complications including dislocation and avascular necrosis of the femoral head ( 4 ) .
although aspiration and examination of the joint fluid were not performed due to lack of synovial effusion on admission , considering the positive serological tests for brucellosis and concurrent avascular necrosis of the femoral head on mri , it seems that the delay in diagnosis and treatment of brucellosis in this patient had led to avascular necrosis of the femoral head .
finally , the following questions arise : was avascular necrosis caused by increased intra - articular pressure related to the infection or due to direct involvement of the femoral head by the organism ?
since brucellosis is a systemic infection with a broad clinical spectrum ranging from asymptomatic forms to deaths in severe cases , this disease should be taken into considerations when dealing with any patient with various and nonspecific symptoms in endemic areas with extension of the clinical signs of brucellosis .
moreover , early diagnosis and long - term treatment and follow - up are of great importance in brucellosis .
 backgroundbrucellosis is a zoonotic disease mostly transmitted to humans through consumption of unpasteurized dairy products and can lead to a systemic disease with any organ involvement . in this report , we describe a case of brucellosis - induced avascular necrosis of the hip . 
 brucellosis was diagnosed through serological tests , and avascular necrosis of the femoral head was confirmed by pelvic mri . 
 the patient was treated with a combination of antimicrobial treatments and referred to the orthopedic service for total hip arthroplasty . 
 brucellosis may present with unusual manifestations and should be always taken into consideration , particularly in endemic areas . 
Background
Introduction
Case presentation
Discussion
Conclusions and Recommendations
Ethical consideration