1. Brucellosis MOHAMMAD TALAFHA Dr.T.V.Rao MD1

2. Brucellosis an Important Zoonotic Disease Dr.T.V.Rao MD2

3. Brucellosis, Brucellosis, also called Bang's disease, Crimean fever, Gibraltar fever, Malta fever, Maltese fever, Mediterranean fever, rock fever, or undulant fever, is a highly contagious zoonosis caused by ingestion of unsterilized milk or meat from infected animals or close contact with their secretions. Dr.T.V.Rao MD3

4. Brucellosis Brucellosis is a zoonotic infection transmitted to humans contact with fluids from infected animals (sheep, cattle, goats, pigs, or other animals) derived food products such as unpasteurized milk and cheese. The disease is rarely, if ever, transmitted between humans. Dr.T.V.Rao MD4

5. Zoonosis Brucellosis : Disease of domestic and wild animals (zoonosis): Transmittable to humans. It has different non-specific symptoms and signs “ 1886, Bruce isolated Brucella Melitensis from spleens of malta fever victims. Dr.T.V.Rao MD5

6. Brucellosis in humans Brucellosis in humans is usually associated with the consumption of unpasteurized milk and soft cheeses made from the milk of infected animals, primarily goats, infected with Brucella melitensis and with occupational exposure of laboratory workers, veterinarians, and slaughterhouse workers. Dr.T.V.Rao MD6

7. Major Transmission of Brucellosis Dr.T.V.Rao MD7

8. Other names for Brucellosis Undulant fever Malta fever Gibraltar fever Mediterranean fever. Dr.T.V.Rao MD8

9. Bacteriology Gm - ve cocci, coccobacilli, bacilli. Strict aerobic, nonmotile, nonspore forming. B. ovis, B. abortus --CO2 supplementation. Grow in regular media -- prolonged incubation > 4 weeks. Dr.T.V.Rao MD9

10. Characteristics of Bacteria Brucella spp are small gram-negative aerobic coccobacilli lacking a capsule, flagella, endospores, or native plasmids. Oxidase and catalase tests are positive for most members of the genus Brucella. Some species require CO2 enrichment for primary isolation in the laboratory. Dr.T.V.Rao MD10

11. Identification of Bacteria Other methods for the identification and speciation of Brucella include:  production of urease and H2S  sensitivity to dyes, basic fuchsin, thionin, and thionin blue  use of specific antiser a Dr.T.V.Rao MD11

12. Dr.T.V.Rao MD12

13. Brucella melitensis* Principal hosts - goats and sheep Most pathogenic in humans Sporadic cases in humans in the U.S. occur related to consumption of unpasteurized dairy products from countries where the disease is present. Dr.T.V.Rao MD13

14. Brucella abortus Principal host - cattle Eradication of B. abortus from cattle is nearly complete in the U.S., but the disease still occurs in some wild bison and elk herds in the western U.S. Dr.T.V.Rao MD14

15. Brucella suis Principal host - swine Since B. suis is normally found in pigs, wild hog (feral swine) hunters are at risk of becoming infected when they field dress infected pigs. Dr.T.V.Rao MD15

16. Brucella canis Principal host - dog Individuals who are in close contact with dogs, or breeders/veterinary staff who assist with birthing are at risk of becoming infected. CDC does not currently perform serological testing for Brucella canis Dr.T.V.Rao MD16

17. Epidemiology Brucellosis occurs worldwide; major endemic areas include countries of the Mediterranean basin, Arabian Gulf, the Indian subcontinent, and parts of Mexico, Central and South America Human Infection. melitensis is the species that infects humans most frequently. The incubation period ranges from a few days to a few months. The disease is manifested as fever accompanied by a wide array of other symptoms. Dr.T.V.Rao MD17

18. Methods of transmission Direct inoculation through cuts and skin abrasions from handling animal carcasses, placentas, or contact with animal vaginal secretions Direct Conjunctival inoculation Inhalation of infectious aerosols Ingestion of contaminated food such as raw milk, cheese made from unpasteurized (raw) milk, or raw meat Venereal transmission has been suggested, but the data are not conclusive Dr.T.V.Rao MD18

19. Incubation period Acute or sub acute disease follows an incubation period which can vary from 1 week to 6 or more months. In most patients for whom the time of exposure can be identified, the incubation period is between 2 and 6 weeks The length of the incubation period may be influenced by many factors – virulence of the infecting strain – size of the inoculum – route of infection – resistance of the host Dr.T.V.Rao MD19

20. Portals of entry Oral entry - most common route – Ingestion of contaminated animal products (often raw milk or its derivatives) – contact with contaminated fingers Aerosols – Inhalation of bacteria – Contamination of the conjunctivae Percutaneous infection through skin abrasions or by accidental inoculation Dr.T.V.Rao MD20

21. Pathophysiology #Brucellosis is a systemic disease and can involve almost any organ system in the host. #Brucella can gain entry into human Body through : Skin, Mucous membranes, Conjunctivae, RS & GIT. Sexual transmission has not been documented..

22. Pathogenesis 1- Initial replication of brucella takes place within cells of the lymph nodes draining the point of entry 2- Once the Brucellae enter circulation, the organisms quickly become intracellular pathogens ;contained within circulating PMNs and macrophages )), 3- Subsequent hematogenous spread may result in chronic localized infection at almost any site, although the reticuloendothelial system, musculoskeletal tissues, and genitourinary system are most frequently targeted. #Osteoarticular, hepatosplenic and genitourinary involvements are most common Complications. #No classical virulence factors, so the productions of inflammatory cytokine is low in early infections

23. Pathogenesis Both acute and chronic inflammatory responses develop in brucellosis, and the local tissue response may include granuloma formation with or without necrosis and cessation..Abscesses may also develop, especially in chronic localized infection So, hepatitis, osteomyelitis, cholecysitis and, bacterial peritonitis, spondylitis, meningitis may occur.

24. Virulence Factors #LPS is believed to play a role in: suppressing phagosome–lysosome fusion and diverting the internalized bacteria into vacuoles located in endoplasmic reticulum, where intracellular replication takes place. #Specific exotoxins have not been isolated, but a type IV secretion system (VirB) that regulates intracellular survival and trafficking has been identified. #Brucellae then produce acid-stable proteins that facilitate the organisms’ survival in phagosomes and may enhance their resistance to reactive oxygen intermediates. #A type III secretion system based on modified flagellar structures also has been inferred, although not yet confirmed. #Virulent brucellae produce a Cu-Zn superoxide dismutase that increases their resistance to reactive oxygen intermediates. #A hemolysin-like protein may trigger the release of brucellae from infected cells.

25. Histologically #Granulomatous nodules: epitheliod cells, giant cells, central necrosis and peripheral fibrosis, proliferation of mononuclear cells and exudation of fibrin.

26. Immunology Exposure to brucellosis elicits both humoral and cell-mediated immune responses. The response to infection and its outcome are influenced by the virulence, phase, and species of the infecting strain Brucella infection is primarily controlled by cell-mediated immunity rather than antibody activity. Antibodies promote clearance of extracellular brucellae by bactericidal action and by facilitation of phagocytosis by polymorphonuclear and mononuclear phagocytes; however, antibodies alone cannot eradicate infection. Organisms taken up by macrophages and other cells can establish persistent intracellular infections. The key target cell is the macrophage, and bacterial mechanisms for suppressing intracellular killing and apoptosis result in very large intracellular populations.

27. Immunology Some immunity to reinfection is provided by serum immunoglobulins.

28. Classification #Subclinical : Disease is usually asymptomatic. Diagnosis is usually established incidentally after serologic screening of person at high risk exposure. #Acute and subacute : Disease can be mild\self-limited “ associated symptoms can develop 2-3 months before diagnosis e.g.: ( B abortus ) or fulminant with sever complications associated symptoms can.develop 3-12 months before diagnosis e.g.:( B melitensis ) #Chronic : Diagnosis it typically made after symptoms have persisted for one year or more, Low-grade temperature and neuropsychiatric symptoms predominate, results of serological and **cultures are often negatives.

29. Classification #Relapsing Brucellosis : Relapsing Brucellosis maybe difficult to distinguish from reinfection ; Presenting symptoms typically reflect the initial disease, however, these symptoms are more sever, symptoms typically develop 2-3 months after therapy completion. Culture results are typically positive and serologic studies may be difficult to interpret, ELISA may be helpful.

30. Medical history A careful history is the most helpful tool in the diagnosis of brucellosis. The history should include both assessment of any risk factors present and evaluation of any symptoms reported. Brucellosis should be considered in any patient whose place of residence or dietary, travel, or occupational\ Family history suggests a risk for the infection and who is experiencing any of the various known neurologic or nonneurologic complications of brucellosis. It must be put in mind that the latency period from infection to onset of symptoms of primary brucellosis may be as long as months, incubation period varies from one week to months.

31. Clinical Picture Fever is most common symptom and sign, occurring in 80-100% of cases : intermittent in 60% of acute and chronic infection and undulant in 60% of subacute infection Undulant fever where bouts of fever for several days are followed by several days of normal temperature. It is associated with profuse sweats especially at night, chills in 80% of cases and relative bradycardia.

32. Clinical Picture Two features recognized in the nineteenth century distinguish brucellosis from other tropical fevers, such as typhoid and malaria: (1) Left untreated, the fever of brucellosis shows an undulating pattern that persists for weeks before the commencement of an a febrile period that may be followed by relapse. (2) The fever of brucellosis is associated with musculoskeletal symptoms and signs in about one-half of all patients.

33. Clinical Picture The clinical syndromes caused by the different brucellae species are similar, although B. melitensis tends to be associated with a more acute and aggressive presentation and B. suis with focal abscess induction. B. abortus infections may be more insidious in onset and more likely to become chronic. B. canis infections are reported to present frequently with acute gastrointestinal symptoms.

34. Clinical Picture Constitutional symptoms ( > 90% of cases ) : #Anorexia, #Weight loss,#Malaise, #Fatigue, #Weakness, #Asthenia #myalgia. Bone and joint symptoms : arthralgias, low back pain, spine and joint pain. Neuropsychiatric symptoms : Headache, fatigue, nervousness and depression, irritability. Neurologic symptoms : Weakness, Dizziness, unsteadiness gait and urinary retention. GU infections : Glomerulonephritis GN, orchitis, UTI. GI involvement ( ~ 50% of cases ) : primary dyspepsia, abdominal pain*, (constipation, diarrhea and vomiting may occur). #cough + #dyspnea

36. Physical Examination Physical findings with brucellosis vary and nonspecific. The most common finding is hepatosplenomegaly. ** Right upper quadrant pain and jaundice may be indicate hepatic abscess Minimal lymphodenopathy Cutaneous manifestations develop in 5-10% of cases are transient and nonspecific, resolve with therapy and do not alter the prognosis. Most common are Abscesses, arythema nodosum and papulonodular eruptions. Neurologic findings vary according to the presentation of neurologic disease and may include the following: Acute meningoencephalitis ( most common manifestation )

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39. An accurate history taking (including travel history, occupation, animal exposure, etc.) may be very helpful in raising the suspicion of brucellosis as a possible diagnosis. Physical Examination (search for signs).

40. Investigations Blood/tissue cultures: (culture could be taken from blood, bone marrow, CNS) are positive in 75%-80% of infection caused by B.melitensis and 50% in those caused by B.abortus. Serum agglutination test (SAT): Most widely used to measure agglutination for IgG, IgM, IgA. The level of SAT: 1/160 in non endemic area 1/320 in endemic area

41. SAT its generally agreed that a titer >1/160 in the presence of the illness support the diagnose of brucellosis. Demonstration of a fourfold or greater increase or decrease in agglutinating Abs over 4 to 12 weeks provides a strong evidence for the diagnosis. Polymerase chain reaction (PCR): Shows promise for rabid diagnoses of Brucella spp in human blood specimens. Positive PCR at the completion of treatment is not predictive of subsequent relapse. PCR testing for fluid and tissue samples other than blood has also been

43. CSF culture: to reveal infections such as meningitis or encephalitis, Is positive in 30% of cases. CSF/Body fluid analysis: show high protein and low glucose levels. CBC: (anemia, thrombocytopenia, leukopenia, and lymphocytosis). LFT: (Mild elevation of aminotransferase). ELISA: second most common serologic method. (elevated IgG and IgM) An elevated serum lgG level is evidence of current or recent infection ; a negative test excludes chronic brucellosis.

44. To help detect complications of brucellosis, and in patients who complain of focal symptoms you may have additional tests, including: X-rays: to reveal changes in bones and joints. (CT) scan or magnetic resonance imaging (MRI): to identify inflammation or abscesses in brain, spine or other tissues. Echocardiography: to check for signs of infection or damage to the heart Results specific to imaging: Localized snowflake calcification in chronic hepatosplenic brucellosis  only specific radiographic finding.

46. Radiograph and CT with bilateral pulmonary nodules showing 3 on the right side and 2 on the left. Their sizes ranged from 2 to 3.5cm, with well-defined edges, concentric linear calcifications and in contact with the pleura.

47. Bones and joints: spondylitis and osteomyelitis. Cardiovascular: endocarditis, myocarditis, pericarditis. Central nervous system: Meningoencephalitis. Gastrointestinal: hepatitis, hepatic abscess, colitis. Genitourinary: orchitis Pulmonary: pneumonia Ocular: optic neuritis

48. The essential treatment for brucellosis is antibiotics. Because of the high relapse rate, the use of a multidrug (two or more) antibiotic regimen is recommended. The antimicrobials most commonly used include : doxycycline,streptomycin, rifampicin, gentamicin, and trimethoprim-sulfamethoxazole. Standard therapy in acute infection doxycycline 100 mg twice daily for 6 wks. with Streptomycin 1g IM daily for the 1 st 2 weeks. (relapse rate with this tt is 5%) Alternative oral therapy doxycycline 100 mg twice daily with Rifampicin 900 mg once daily for 6 wks. (failure and relapses are high especially with spondylitis)

49. Rifampicin and Co-Trimoxazole are potential agents to use in pregnancy. Endocarditis : almost always needs surgical intervention plus treated with 3 agents (doxycycline,rifampicin,streptomycin) Chronic illness or neurobrucellosis (Doxycycline, Rifampin, Trimethoprim sulfamethoxazole) should be treated for a minimum of 3 months- 6 months depending on the response. Patients with focal disease have a less favorable prognosis. relapse rates of the disease are still about 5%-10%, even with treatment. Most relapses occur within three months following therapy and almost all occur within six months. Risk factors for relapse include inadequate initial therapy, duration of the initial illness of less than 10 days, male sex, bacteremia, and thrombocytopenia

50. Rarely, surgical intervention may be needed for certain complications associated with brucellosis, such as abscess formation or heart-valve infection, infected foreign bodies (pacemaker wires, prosthetic joints)

51. Animal vaccination programs, animal testing, and the elimination of infected animals. preventive measures are aimed at reducing the risk of transmission to humans: Pasteurization of dairy products. Avoiding the consumption of undercooked meat. Using appropriate barrier precautions (goggles, gloves, masks, etc) to avoid exposure to aerosols and body fluids for those with an occupational risk for brucellosis. Warning laboratory workers about potentially infected specimens There is no human vaccine currently available.