Brucellosis

Aka: Mediterranean fever, Malta fever, gastric remittent fever, and undulant
fever.

*A new remerging zoonotic disease

- Brucellosis consists of 7 sp (but only 4 cause human brucellosis)

Brucellosis sp in human brucellosis:

Organism Animal Reservoir Geographic Distribution

B Goats, Mediterranean, Asia, Latin America,

melitensis sheep, parts of and some southern
(highest camels European countries
pathogenici
ty)
B abortus Cows, buffalo, Worldwide
(moderate camels, yaks
pathogenici
ty)
B suis Pigs (biotype 1-3) South America, Southeast Asia,
(high United States
pathogenici
ty)
Brucella Canines Cosmopolitan
canis
 (moderate
pathogenici
ty)

Characteristics of brucella sp:

small (0.4-0.8 0.5-1.5m),

non motile.
non capsulated,
non spore forming ,
gram ve coccobacilli.
Aerobic ,
facultative intracellular bacteria.
All strains grow best in a medium
enrich with animal serum and glucose
& 5-10% carbon dioxide
Bacteria is excreted in genital secretions (including semen), milk,
colostrum.

Survival time:
Cheese at 4oC: up to 180 days !!!
Water at 25oC: - 50 days.
Meat and salted meat: 65 days.
Manure at 12oC: 250 days !!!!

Killed by:
boiling,
pasteurization,
lactic acid,
strong salts.
Not killed by freezing.
Mode of transmission:

1. Oral route:
- ingestion of untreated milk & its products, raw meat, liver ,spleen
& bone marrow
[main route in non endemic areas]

2. Inhalation:
- through direct contact with animals &pollution of the atmosphere
in endemic areas mainly children, farm workers & lab. workers.
3. Skin:
- direct contact of abraded or intact skin with infected meat or
animals
- common in veterinaries & abattoir worker
4. Conjunctiva
- accidental splashing during animal vaccination with live
attenuated vaccine.

5. Uncommon routes
- include blood transfusion& bone marrow transplant

6. Unproved routes,
- transplacental, sexual & breast milk feeding.

Pathophysiology:

- Possess a unique ability to invade both phagocytic and nonphagocytic

cells and to survive in the intracellular environment by finding ways to
avoid the immune system. This ability helps explain why brucellosis is a
systemic disease and can involve almost every organ system.
Case definition:

PROBABLE CASE :
- A CLINICALLY COMPATIBLE CASE THAT IS EPIDEMIOLOGICALLY LINKED TO
A CONFIRMED CASE
OR
THAT HAS SUPPORTIVE SEROLOGY
(I.E., BRUCELLA AGGLUTINATION TITER OF 1:160)

CONFIRMED CASE:
A CLINICALLY COMPATIBLE CASE THAT IS LABORATORY CONFIRMED

Clinical features:

1.Incubation Period:

- 1-3 weeks , may extend to several months.

- It may resemble other febrile illness [non specific]
- May be short and trivial without sequelae

2. Onset:

- may be sudden [1-2days] or gradual (1 week or more)

3. Features:

- Acute or chronic &with complications

Acute Brucellosis:

Symptoms:

- Fever (+ relative bradycardia), chills, Rigors, Sweating ,Headache &

- generalized body aches specially low backache, Bone and joint
symptoms include arthralgias, low back pain, spine and joint pain, and,
rarely, joint swelling.
- Constitutional symptoms of brucellosis include anorexia, asthenia
(abnormal physical weakness), fatigue, weakness, and malaise, and
weight loss and are very common (> 90% of cases).

- A significant percentage (approximately 50%) of patients have

gastrointestinal (GI) complaints, primarily dyspepsia, though abdominal
pain from hepatic abscesses may occur.

Signs:

High fever
Hepato-splenomegaly (Splenomegaly reflects severe infection)
Lymphadenopathy , specially in Br. Abortus .
Tender spines - Spondyolitis , bursitis, Osteomyelitis, epidydemo-
orchitis , meningo -encephalitis & endocarditis may occur specially
in Br. Meltensis . Osteoarticular involvement is also common. Focal
infection of bones or joints may present with localized abnormal
physical findings (eg, swelling, tenderness, and limited motion) in
the affected areas.
Rarely, erythematous rash or erythema nodosum may occur.
Right upper quadrant pain + jaundice (hepatic abscess), peritonitis

Less common:
- chest pain ,
abdominal pain, U n d u l a n t fe v e r

palpitation,
constipation ,
3 9 .5
confusion & night
mares.
3 7 .0
Pattern of fever:
Undulant fever
 Chronic Brucellosis

Symptoms:

- Onset is insidious ,commonly there is a history of recurrent flu with

lassitude ,headache , pain & sweat. Low backache is common. Long
standing infection leads to depression.

Signs:

- Temp. may be normal. Patient may looks normal, or may reflect a severe
PUO .
Moderate Splenomegaly may be in the minority of cases & may persist
after treatment.

Complications:

Encephalitis, meningitis
Endocarditis
Hepatic impairment
Sponsylitis, osteomyelitis, sacro iliac ilitis
Arthritis
Pyelonephritis
Orchitis, epididymitis

Diagnosis of brucellosis:

- Definitive diagnosis of brucellosis is based on culture, serologic

techniques, or both. Clinically, identification to the genus level is sufficient
to warrant initiation of therapy. The particular Brucella species involved
does not affect the choice of therapeutic agents; however, speciation is
necessary for epidemiologic surveillance and requires more detailed
biochemical, metabolic, and immunologic testing.

- presence of clinical features + (+ve) blood or tissue culture

and/or detection of raised brucella agglutinins in the blood.

- Culture: +ve in about 50 -70% of cases .

- Bone marrow culture is thought to be the criterion standard, since the

reticuloendothelial system holds a high concentration of the organism.
Sensitivity is usually 80-90%.

- Recent advances: PCR test

Standard aggl. Test:

A titer of :

>1/160 in non endemic areas

>1/320 in endemic areas are significant.

-False +ve in:

Tularaemia, cholera & E-Coli infection.

-False ve in:

prozone phenom (may occur secondarily to hyperantigenemia,

which might result in a false-negative results, so routine dilution of
the serum beyond 1:320 would help to prevent such a problem.)

differential dx:

(consider: connective tissue disorder and chronic fatigue syndrome)

Anklosing Spodiolitis, Cryptococcosis, Hepatitis, Viral infections

Infections: Histoplasmosis Infectious Mononucleosis, Infective
Endocarditis, Influenza, Leptospirosis, Malaria, TB, Typhoid Fever
Treatment:

- The optimum antibiotic therapy is still unclear.

- recommended:

1. Adult without complications:

A course of 2-3 months is required.

1st Month:
- Doxycycline orally 100 mg BD
+
- IM Streptomycin 1 gm daily for patients less than 45 y. (in older 0.5
0.75 gm.)(advised For 2-3 weeks only).

2nd-3rd Month:
- Doxycycline orally 100 mg BD +
- Rifampicin orally 600-900 mg / day.

2. With complications:

- Endocarditis:
2-3 months of triple therapy.
Aminoglycoside + Rifampicin + Doxycycline

- Meningitis:
2-3 months of triple therapy.
Rifampicin must be used all the time .

- Renal impairment:
2-3 months of:
Doxycycline + Rifampicin or Co-Trimoxazole.
 Prevention

1. Strategies to fight brucella: 3) Test and slaughter method

2. 4) Quarantine
1) Collaboration among 5) Depopulation
laboratory, field and public 6) Vaccination Programme
health services 3.
2) Control the infection
4.
5. Control the infection: Movement of animals.
6. Natural service by bulls.
Source of Infection. Transmission by carnivores
Transmission of infection. animals and through milk .
7.
8. Test and slaughter method:
9.
No effective treatment, so diagnose, if +ve cull the animals until no
reactor animal for three consecutive tests, carried out at three-
month interval is found
10. (Mathur et. al., 1974)
Financial compensation to farmers
11.
12. Vaccination programme:
13.
Increases resistance and decreases the source of infection
Different vaccine against the B. abortus are
Live B. abortus Strain-19 vaccine
Killed adjuvant B. abortus 45/20 vaccine B.
abortus vaccine RB51
Make calf vaccination compulsory and avoid vaccination of adult
animals
14.
15.
16.
17.