Brucellosis

By
Dr. Mahmoud Saif
Objectives:
By the end of this lecturer the student
should be able to:
• Know the etiology and epidemiology of Malta
fever
• Diagnose Malta fever clinically and by
investigations
• Deal with the complications of Malta fever
• Give the proper and suitable treatment and
prevent the recurrence
• Learn how to offer the means for prophylaxis
• Explain to the patient means of transmission and
the prognosis
 ZOONOSIS
• A disease, primarily of animals, that can be
transmitted to humans as a result of direct or
indirect contact with the infected animal
population.

• Brucellosis: Disease of domestic and wild

animals (zoonosis): Transmittable to humans
 Brucella
• The genus Brucella consists of six species,
four of which cause human brucellosis:
Brucella melitensis , Brucella suis , Brucella
abortus , and Brucella canis .

• All are intracellular organisms

• Brucella are small , non-motile, non-

capasulated, gram-negative coccobacilli.
• The organism is
aerobic, and their
nutritional
requirements are
complex.
• All strains grow best
in a medium enrich
with animal serum
and glucose
Etiologic agents

Goats,
B.
sheep, ++++ 1 – 10
melitensis
Cattle, Swine

1,000 –
B. suis Swine, Cattle +++
10,000
B. abortus Cattle ++ 100,000

B. canis Dogs + 1,000,000

The Many Names of Brucellosis
Human Disease
• Malta Fever

• Undulant Fever

• Mediterranean Fever

• Gastric Fever
Epidemiology
Transmission to Humans
• Conjunctiva or broken skin contacting
infected tissues
• Blood, urine, vaginal discharges, aborted
fetuses, placentas

• Ingestion
• Raw milk & unpasteurized dairy products
• Rarely through undercooked meat
Transmission to Humans

• Inhalation of infectious aerosols

• Pens, stables, slaughter houses

• Person-to-person transmission is very

rare
• Meat products: rare source of infection

because: Meat is rarely eaten raw and

organisms are present in low number of

muscle tissue.

- Blood and bone marrow may transmit

disease when ingested in some cultures.

• Brucellosis not rare in children as
previously believed

• Brucellosis manifests similarly in:

Neonates, children and adults.
Who is at Risk?
• Occupational Disease
• Cattle ranchers/dairy farmers
• Veterinarians
• Abattoir workers
• Meat inspectors
• Lab workers
• Hunters
• Travelers
• Consumers of unpasteurized dairy products
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
• Percutaneous infection through skin
abrasions or by accidental inoculation
 Incubation period
• Acute or subacute 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

COURSE OF BRUCELLOSIS
• If the disease is not treated, the symptoms
may continue for 2 to 4 weeks
• Many patients will then recover
spontaneously
• Others may suffer a series of
exacerbations

• May produce an undulant fever in which the

intensity of fever and symptoms recur and
recede at about 10 day intervals.
 Undulant fever

39.5

37.0
• Most affected persons recover entirely
within 3 to 12 months

• Some will develop complications

– involvement of various organs,

– a few may enter an ill-defined chronic

syndrome.
PATHOGENESIS
▪ Skin abrasion, conjunctivae, inhalation
or ingestion

▪ Engulfed by neutrophils and

monocytes (resistant to killing)

▪ Localize regional lymph nodes

▪ Infect phagocytic cells in the RE

system and form granulomas within
organs rich in reticuloendothelial
system, e.g. liver, spleen and B.
marrow.
Spread of Brucella in the body
CLINICAL MANIFESTATION
• Can affect any organ.
• Onset: acute or insidious
• An “Undulant” fever pattern
• Night sweats, Some patients c/o malodorous,
drenching sweat and peculiar mouth taste.
• Malaise
• Anorexia
• Arthralgia
• Fatigue
• Weight loss
• Depression.
• Patients may have a multitude of complaints
without objective findings except fever.
Physical Examination
• Physical manifestations may be absent.
➢ If present,
Focal Features:
• Musculoskeletal pain
• Osteomyelitis
• Septic Arthritis
• Minimal lymphadenopathy
• Hepatosplenomegaly occasionally.
Complications

• Osteoarticular disease, especially sacroileitis

— 20 to 30 percent and vertebral spondylitis.
Large joints are affected most commonly in
children

• Genitourinary disease, especially epididymo-

orchitis — 2 to 40 percent of males
• Neurobrucellosis, usually presenting as
meningitis — 1 to 2 percent.

• Less common neurologic complications

include papilledema, optic neuropathy,
radiculopathy, stroke, and intracerebral
hemorrhage.

• Endocarditis — 1 %. Most cases of

endocarditis are left-sided, and about two-
thirds occur on previously damaged valves.
• - Hepatic abscess — 1 %

 - Other less common complications include

pneumonitis, pleural effusion, empyema,, or
abscess involving the spleen, thyroid, or
epidural space, uveitis.

 - A few cases of Brucella infection involving

prosthetic devices such as pacemaker wires
and prosthetic joints have been reported
 Osteomyelitis,
1. Skeletal
suppurative arthritis
Haemolytic anaemia,
2. Haematologic thrombocytopenia,
pancytopenia
3. Neurologic Meningitis, encephalitis
Keratitis, uveitis, optic
4. Ocular
neuritis
Pneumonia, chronic
5. Pulmonary
pulmonary granuloma
6. Cardiovascular Endocarditis, myocarditis
7. Genito-urinary Epididymitis, orchitis
Cholecystitis, sub-
8. Abdominal
diaphragmatic abscess
 Clinical forms

• Subclinical.

• Acute and subacute.

• Localizing disease and complications.

• Relapsing infection.

• Chronic brucellosis: >1 year after the onset.

low titre or –ve serology, -ve culture.

CLINICAL DIAGNOSIS
• Isolation of organism
• Blood, bone marrow, other tissues

• Serum agglutination test

• Four-fold or greater rise in titer
• Samples 2 weeks apart

• Immunofluorescence
• Organism in clinical specimens

• PCR
• X-ray in skeletal and joint affection,
✓ Loss of lumbar lordosis
✓ Marginal bone destruction.
✓ Degenerative disc changes,
✓ Narrow intervertebral spaces.
✓ New bone formation.

• LN biopsy.

• Splenic puncture.
TREATMENT OF CHOICE
• Combination therapy has the best efficacy
• Doxycycline for six weeks in combination
with streptomycin for 2-3 weeks or
rifampin for 6 weeks
• Tetracycline 1 gm/day for 3-6ws+
aminoglycosides for 1st 2 Ws.
• Trimethoprim-sulphamethoxazole (3-6 Ws).
• Quinolones (10 days)

• CNS cases treat 6-9 months

• Same for endocarditis cases plus surgical
replacement of valves
PROGNOSIS
• May last days, months, or years
• Recovery is common
• Disability is often pronounced
• About 5% of treated cases relapse
• Failure to complete the treatment
regimen
• Sequestered infection requiring surgical
drainage
• Case-fatality rate: <2% ( untreated)
• Endocarditis caused by B. melitensis