Brucella prosthetic joint infection following total knee arthroplasty: a rare case report

Brucellosis is a zoonotic infection with a high prevalence in endemic regions and a strong predilection for osteoarticular involvement. Brucella prosthetic joint infection (PJI) is an exceptionally rare but challenging complication of total knee arthroplasty (TKA), often characterized by delayed presentation, indolent symptoms, and diagnostic difficulty. There is no consensus regarding optimal management, particularly concerning surgical strategy and duration of antimicrobial therapy.

A narrative literature review was conducted using PubMed and Scopus, searched on 1 March 2026 to identify reported cases of Brucella PJI following TKA. Cases were included based on microbiological or serological confirmation of Brucella infection. The screening process, exclusion criteria, and handling of duplicate reports are described in the Methods, and the selection process is summarized in a flow diagram.

We report the case of a 67-year-old male farmer who keeps sheep and presented four years after bilateral TKA with a three-week history of progressive pain and swelling of the right knee, without systemic symptoms. Laboratory evaluation revealed a markedly elevated C-reactive protein with a normal leukocyte count. Ultrasound-guided joint aspiration and subsequent intraoperative cultures confirmed Brucella species infection, supported by a positive Rose Bengal test and a standard agglutination titre above 1:160. Imaging demonstrated loosening of the tibial component with scintigraphic findings suggestive of PJI. The patient was treated with prolonged anti-brucellosis therapy followed by first-stage revision arthroplasty, including complete implant removal, extensive debridement, and insertion of an antibiotic-loaded articulating cement spacer. Postoperatively, he received combination doxycycline and rifampin therapy with an uncomplicated clinical course. Brucella was still recovered from the intraoperative cultures despite a completed three-month preoperative course, and a second three-month course was given. Second-stage reimplantation was performed on November 19, 2025, with negative intraoperative cultures. At the most recent review on May 11, 2026, approximately six months after reimplantation, he was pain free with a range of motion of 0° to 120°, a normal C-reactive protein, and no evidence of recurrence.

Forty cases of Brucella PJI after TKA were identified. Most presented years after index surgery with non-specific symptoms. Management strategies varied, with implant stability guiding the choice between medical therapy alone and surgical revision, most commonly a two-stage approach.

Brucella PJI should be considered in painful arthroplasties in endemic settings. Successful management requires a high index of suspicion, appropriate microbiological diagnosis, prolonged combination antimicrobial therapy, and individualized surgical intervention based on implant stability. Persistence of Brucella in intraoperative cultures despite three months of appropriate systemic therapy, as seen here, argues that implant retention is inadequate once components are radiographically loose.