Introduction

Brucellosis is a worldwide zoonosis caused by infection

with the bacterial genus Brucella.

It causes more than 500,000 infections per year

worldwide.

The heaviest disease burden lies in countries of the

Mediterranean and Arabian area
Introduction
The annual number of reported cases in United States
(now approximately 100 cases) has dropped
significantly because of aggressive animal vaccination
programs and milk pasteurization.

Human brucellosis carries a low mortality rate (<5%),

mostly secondary to endocarditis, which is a rare
complication of brucellosis.
Classifications
The traditional classification of Brucella species is
based largely on the preferred hosts.
Geographic Animal Reservoir Organism
Distribution

Mediterranean, Asia,
Latin America, parts of
Africa and some Goats, sheep, camels B melitensis
southern European
countries

Worldwide Cows, buffalo, camels, B abortus

South America,
Southeast Asia, United Pigs (biotype 1-3) B suis
States
Causes
• Ingestion of unpasteurized milk and related dairy
products.
• Aerosolization of fluids, contamination of skin abrasions,
and splashing of mucous membranes among
slaughterhouse workers , farmers and shepherds.
• Veterinarians are usually infected by inadvertent
inoculation of animal vaccines against B abortus and B
melitensis.
• Laboratory workers (microbiologists) are exposed by
processing specimens (aerosols) without special
precautions.
pathogenesis
 The genus Brucella consists of very small, non motile,
aerobic gram negative, coccobacilli that grow poorly on
ordinary media and have little or no fermentative powers.

 They are strict parasites of animals and may also infect

humans.

 Infectious diseases transmitted from animals to human

beings are called ZOONOSES.

Infection with any Brucella species, including attenuated

vaccine strains can cause serious human disease.

Br.melitensis is the most virulent of all the species.

Once these organisms gain entry into the body: PMNs are
attracted to inoculation site by chemotaxis.
Normal human serum has limited bactericidal
activity against brucellae, but it effectively opsonizes
bacteria for phagocytosis by PMNs.
Brucellae are facultative intracellular, slowly dividing
pathogens with capacity to survive and multiply
within host phagocytic cells.
o PMNs act as “taxicabs” and carry these organisms to
various lymphatic tissues.
o Hallmark of brucellosis is formation of
granulomas within lymphatic tissues.
o Multiplication of brucellae within macrophages fills
and destroys these cells and patients develop
bacteremia
If the cell mediated immune response that develops during
this stage is insufficient, the liver, spleen, bone marrow and
lymph nodes may become extensively infected.

Caseation necrosis may be seen in granulomas caused

by Br.suis.

In patients with chronic brucellosis, granulomas form in

the kidneys, central nervous system, subcutaneous tissues,
testes and ovaries.
Clinical Presentation
Subclinical brucellosis
Acute or subacute brucellosis
Chronic brucellosis
Localized brucellosis.
Relapsing brucellosis
Symptoms
• Fever is the most common symptom which is
associated with chills.

• Constitutional symptoms of brucellosis including

anorexia, asthenia, fatigue, weakness, sweating, and
malaise (>90% of cases).

• Bone and joint symptoms include arthralgias, low back

pain, spine and joint pain, and, rarely, joint swelling.
Symptoms
• Neuropsychiatric symptoms of brucellosis are common
including Headache, depression, and fatigue.

• Gastrointestinal symptoms include abdominal pain,

constipation, diarrhea, and vomiting.

Neurologic symptoms of brucellosis can include

weakness, dizziness, unsteadiness of gait and urinary
retention.
Symptoms
Cough and dyspnea develop in up to 19% of persons
with brucellosis; however, these symptoms are rarely
associated with active pulmonary involvement.
Signs
Fever which is associated with relative bradycardia.
Hepatosplenomegaly (or isolated hepatomegaly or
splenomegaly).
Osteoarticular findings can include tenderness and
swelling over affected joints, bursitis, decreased range
of motion, and joint effusion (rare).
Signs
Neurologic findings vary according to the
presentation of neurologic disease, as follows:
Acute meningoencephalitis (most common
neurological manifestation) - Depressed level of
consciousness, meningeal irritation, cranial nerve
involvement, coma, seizure, and respiratory depression
Peripheral polyradiculoneuropathy - Hypotonia and
areflexia in most cases, paraparesis, and an absence of
sensory involvement
Signs
- Diffuse CNS involvement - Spasticity, hyperreflexia,
clonus, extensor plantar response, sensorineural hearing
loss, cranial nerve involvement, and cerebellar signs.

• Cutaneous manifestations including erythema nodosum,

papulonodular eruption, impetigo or vasculitic lesions.
Signs
Ocular findings can include uveitis,
keratoconjunctivitis, optic neuritis or cataract.
DDx
Cryptococcosis
Histoplasmosis
Infectious Mononucleosis
Infective Endocarditis
Leptospirosis
Tuberculosis
Malaria
Typhoid Fever
Work up
CBC shows leukopenia, relative lymphocytosis or
pancytopenia.
LFT shows slight elevation in liver enzymes
Blood culture has sensitivity of 60% and subcultures
are still adviced for at least 4 weeks.
Bone marrow culture has sensitivity of 80-90%.
Work up
• Serology
1. Serum tube agglutination test.
2. Tray agglutination test
titers of more than 1:160 in conjunction with
compatible clinical presentation is considered highly
suggestive of infection. Titers of more than 1:320 are
considered to be more specific, especially in endemic
areas.
Work up
3. ELISA
it measures IgM,IgG and IgA allowing for better
interpretation.
4. PCR
it is used for rapid and accurate diagnosis of
brucellosis.
Work up
Histological findings:
it include mixed inflammatory infiltrates with
lymphocytic predominance and granulomas (in up to
55% of cases) with necrosis.
Management
• The World Health Organization recommends the
following for adults and children older than 8 years:
– Doxycycline 100 mg PO bid and rifampin 600-900 mg/d
PO: Both drugs are to be given for 6 weeks (more
convenient but probably increases the risk of relapse).
– Doxycycline 100 mg PO bid for 6 weeks and
streptomycin 1 g/d IM daily for 2-3 weeks: This regimen
is believed to be more effective, mainly in preventing
relapse.
Management
Gentamicin can be used as a substitute for
streptomycin and has shown equal efficacy.

Ciprofloxacin-based regimens have shown equal

efficacy to doxycycline-based regimens.
Management
Children younger than 8 years:
The use of rifampin and trimethoprim-
sulfamethoxazole (TMP-SMX) for 6 weeks is the
therapy of choice. Relapse rate appears to be
approximately 5% or less.
Management
Surgical Care
The role of surgery in patients with brucellosis lies in
the treatment of endocarditis or drainage of focal
abscesses.
Management
Consultations
Infectious disease specialist
Cardiothoracic surgery specialist if endocarditis is
suspected or documented