20: Anthrax and Brucellosis

Brown
5-1-17
B. anthracis
I. Epidemiology
I. Transmission: Anthrax in US is rare
I. in 20 years only 7 cases reported
II. Most were occupational associated transmissions (farmers, vets, etc.)
III. Most infections are non-invasive cutaneous anthrax
IV. In 2001, 22 cases reported as bioterrorism (US mail)
I. 5 people died—all who died had respiratory anthrax
V. Anthrax in heroin users—47 confirmed cases, 35 probable, and 37 possibleAnthrax
contaminated soil got in heroin in Scotland Most had soft tissue infection, 53% with GI
II. Diseases caused
I. Anthracis is the major cause of serious disease in humans/animals
II. cereus is less virulent and associated w/ food poisoning
III. Laboratory identification
I. Gram + rods
II. do not sporulate in tissue but will on culture plates
III. biosafety level 3—do not culture because it is very dangerous
IV. non-motile—catalase positive—y-hemolyic (non hemolytic)
V. Diagnosis: gram stain, culture, nucleic acid amplification test, antigen detection assays (most of which are
not available in labs because they will expire since they are used so rarely)—just send that shit out
VI. Vaccine: required for lots of military personnel—works against the PA part—no PA = no working EF or
LF
Brucella spp
I. Epidemiology: In countries when brucellosis in farm animals is not controlled w/ vaccination—US
vaccinates
II. Diseases caused
a. B. abortus: cattle, bison elk, humans (more self limited)
b. B. melitensis: goats, sheep, humans (more serious)
c. B. suis: pigs, European hares, reindeer, humans (also serious)
d. B. canis: dogs, humans (mild)
III. Laboratory identification
IV. DIAGNOSIS: Immunological rxns (serology, Brucellergin DTH skin test—kind of like the TB test, and
culture)
V. PREVENTION: live attenuated vaccine for animal immunization, assessment of dairy hers, pasteurization of
dairy products, gloves and protective clothing!!!

Checkpoints!
1) How are Clostridium spp. similar to Bacillus species? How are they different (spore morphology)?
a) Both are aerobic Gram + rods
b) Heat stable endospores
i) bacillus-aerobic (obligate or facultative)
(1) Central endospores in middle of rod
ii) Clostridium-anaerobic
(1) Terminal endospores at end of vegetative rod—drumstick

2) Where are Bacillus spp. commonly found?

a) Soil, water, dust—in nature!

3) What are the main virulence factors of B. anthracis?

a) Capsule
i) D-glutamic acid
b) Exotoxins
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20: Anthrax and Brucellosis
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c) *not seen in any other bacillus species
4) How is the capsule of B. anthracis similar to the capsule of Y. pestis?
a) polypeptide polymer
i) They are both protein based capsules (Y.pestis is glycoprotein)
ii) most others are polysaccharides
b) Antiphagocytic

5) Describe the function of EF, LF, and PA in B. anthracis infections.

a) Exotoxins – consists of 3 proteins (EF, LF, and PA), toxic only in two toxic combinations
i) Edema factor (EF)
(1) adenylate cyclase causing ↑cAMP active on many cell
types in the body
(2) Causes massive edema.
ii) Lethal factor (LF)
(1) protease that cleaves MAP kinases, disrupts signal
transduction, triggers apoptosis of many cell types
iii) Protective antigen (PA)
(1) binds to host cell membrane receptor
(2) facilitates entry of EF and LF into cells
(3) Immunogenic

b) Toxic combinations
i) EF + PA = edema
ii) LF + PA = death/necrotic center

6) What are the three main clinical manifestations of B. anthracis? Which clinical cases are seen predominantly in
patients who work around farm animals?
a) Cutaneous Anthrax
i) seen in pts who work around farm animals
ii) most common form
iii) spores enter break in skin (hands, forearms, face)
iv) skin lesion develops as site of entry
v) begins as small painless papuleturns into black eschar
vi) Bloodstream invasion is rare
vii) Low fatality (20% w/o treatment)
b) Pulmonary (inhalation) anthrax
i) See below
c) Meningitis
d) Intestinal anthrax
i) Eat spores from undercooked meatGI bleedingfluid filled vesicles form in infection
ii) very high death rate even if treated w/ ABX

7) What does the lesion of cutaneous anthrax look like?

a) Eschar
b) Necrotic center (PA+LF) that dips down surrounded by swollen tissue (EDEMA)

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20: Anthrax and Brucellosis
Brown
5-1-17
8) What are some of the ways pulmonary anthrax occurs? Why does this make B. anthracis a great agent of
bioterrorism?
a) Inhalation of spores
b) Spores enter alveoli and phagocytosied by alveolar macrophages
c) macrophages migrate to mediastinal lymph nodes
d) intracellular bacteria replicate (germination) and lyse
macrophage
e) released extracellular bacteria w/ capsule and toxins
f) Why is it a good bioterrorism agent?
i) Symptoms start 1-40 days after exposure, depending on dose
ii) Initial symptoms are nonspecific (sore throat, mild fever, coughing, chest
discomfort)
iii) Severe local inflammation (mediastinitis) w/ massive edema and cell death from
toxins
iv) fluid accumulation and hemorrhage in the lungs
v) hemorrhagic mediastinitis common w or w/o necrotizing pneumonia
vi) Pulmonary anthrax has 92% mortality rate
g) This is all bad news but…. It gets worse!!!!
i) encapsulated extracellular bacteria and toxins spread to bloodstreamsepticemia, septic shock, meningitis!
ii) 90% mortality rate even WITH treatment

9) Describe the odd shape of B. anthracis colonies.

a) Medussa head appearance
i) Comma shaped projections from colony edges
b) Do not sporulate in tissues but do in culture

Brucella spp.
10) Why is brucellosis referred to as undulating fever?
a) Relapsing/remitting pattern of illness w/ fever (moving like a wave)
b) Pts had chronic debilitating disease w/ fever, malaise, profound muscular
weakness

11) What are the general characteristics of Brucella spp.?

a) No bipolar staining
b) nonsporulating
c) Small, weak staining Gram-neg coccobacilli
d) Facultative intracellular pathogen (can grow outside cells)
i) Replicates in macrophages!
ii) No extracellular phase!
e) Grows slowly on complex media w/ serum or blood
f) Growth of brucella stimulated by erythritol (found in high concentrations in animal uterus and placental tissue)
—especially B. abortus

12) Which type of animals carry Brucella spp.? What type of workers are at the highest risk of contracting brucellosis?
a) Animals—mostly domestic—some wild
i) B. abortus: cattle, bison elk, humans (more self limited)
ii) B. melitensis: goats, sheep, humans (more serious)
iii) B. suis: pigs, European hares, reindeer, humans (also serious)
iv) B. canis: dogs, humans (mild)
v) Transmission usually occurs from domestic animals!!
(1) Urine, milk, vaginal secretions, and placental tissue of infected animals
(2) B. spp are highly resistant to trying out!!!
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20: Anthrax and Brucellosis
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b) High risk
i) Farmers
ii) Vets
iii) Slaughterhouse workers
c) Transmission: direct contact w/ infected materials and a break in the
skin
i) NO LESION
ii) Injection of unpasteurized milk or cheese
iii) Inhalation of contaminated dust (also bioterroism threat)
iv) NO PERSON TO PERSON SPRED

13) Why is exposure to animal placental tissue a huge risk factor for contracting brucellosis?
a) infected pregnant animals have high rates of miscarriages—bacteria highly concentrated in placental tissue of
infected animals!!!!
b) Women who get infected also have higher rate of miscarriages

14) Why is brucellosis a good candidate as an agent of bioterrorism?

a) It can be dried out and still be pathogenic—can live for 6 weeks in dry environment!!!
i) Contaminated areas can have dust filled with bacteria
ii) Easy to aerosolize
iii) Farmers use cow poop as fertilizer and spray it over fields
b) It can live for 6 weeks in wet environments too!

15) What are the common clinical manifestations of brucellosis and how can the disease be contracted?
a) 1-4 wk to months incubation period
b) Chronic, febrile illness either with abrupt or indisious onset
i) insidious is more common
c) Symptoms severe and prolonged with B. melitensis, but mild and self-limited with B. abortus
d) Fever and malaise may persist for weeks – diagnosis difficult
e) May have a series of relapses (“undulant fever”) – Why?
i) Bacteria can infected phagocytes and block maturation of the phagolysosome, leading to persistent infections
in phagocytes (macrophages).
ii) Blocking phagosome maturation also prevents antigen presentation.
f) Target organs
i) lungs; if inhaled
ii) lymph nodes
iii) spleen
iv) liver
v) bone marrow
g) basically any organ system can be affected, but the three most common clinical presentations are….
i) A typhoid like-illness in a small child with fever and acute monoarthritis (hip or knee most common)
ii) Typhoid-like illness in the elderly with long-lasting fever, misery, and low-back or hip pain in an older man.
iii) In an endemic area (e.g., much of the Middle East), a patient with fever and difficulty walking into the clinic
would be regarded as having brucellosis until it was proven otherwise.

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