BRUCELLOSIS Meral SÖNMEZOĞLU, MD Yeditepe University Hospital Professor of Department of Infectious Diseases and Microbiology

Learning Objectives Appreciate the importance for our country and epidemiology Know clinical features of brucellosis Understand laboratory diagnosis of brucellosis Describe the treatment of brucellosis

BRUCELLOSIS Known as “undulant fever”, “Mediterranean fever” or “Malta fever” Is a zoonosis and the infection is almost invariably transmitted by direct or indirect contact with infected animals or their products. It affects people of all age groups and of both sexes.

There still remain regions where the infection persists in domestic animals and, consequently, transmission to the human population frequently occurs. It is an important human disease in many parts of the world especially in the Mediterranean countries of Europe, north and east Africa, the Middle East, south and central Asia and Central and South America

BRUCELLOSIS Brucellosis is probably the commonest anthropozoonotic infection worldwide A zoonotic infection of domesticated and wild animals, caused by organisms of the genus Brucella. Humans become infected by ingestion of animal food products, direct contact with infected animals, or inhalation of infectious aerosols.

Brucella melitensis remains the major cause of human disease worldwide, followed by B. abortus and B. suis, while rare but persisting cases of B.canis human infection

BRUCELLOSIS Humans, who are usually infected incidentally by contact with infected animals or ingestion of dairy foods, may develop numerous symptoms in addition to the usual ones of fever, malaise, and muscle pain. Disease frequently becomes chronic and may relapse, even with treatment

In an era of rapid emergence of antimicrobial resistance, controversies regarding the prolonged use of antibiotics with established activity against Brucella pose special problems. In some endemic regions, especially in the developing world, brucellosis and tuberculosis coexist in the same communities.

Microbiology Brucellae are small, nonmotile, nonsporulating, nontoxigenic, nonfermenting, aerobic, Gram-negative coccobacilli that may, based on DNA homology, represent a single species. Conventionally, however, they are classified into six species, each comprising several biovars

Brucella Species Animal Host Human Pathogenicity B suis Swine High B melitensis Sheep, goats B abortus Cattle, bison Intermediate B canis Dogs B ovis Sheep None B neotomae Rodents

Geographic Distribution The 7 Currently Recognized Brucella Species Organism Animal Reservoir Geographic Distribution B melitensis Goats, sheep, camels Mediterranean, Asia, Latin America, parts of Africa and some southern European countries B abortus Cows, buffalo, camels, yaks Worldwide B suis Pigs (biotype 1-3) South America, Southeast Asia, United States Brucella canis Canines Cosmopolitan Brucella ovis Sheep No known human cases Brucella neotomae Rodents Not known to cause human disease Brucella pinnipediae and Brucella cetaceae Marine animals, minke whales, dolphins, seals Recent case reports describing some human cases (mainly neurobrucellosis

Microbiology Brucellae grow best on trypticase, soy-based, or other enriched media with a typical doubling time of 2 hours. Most biovars of B abortus require incubation in an atmosphere of 5% to 10% carbon dioxide for growth. Brucellae may produce urease, oxidize nitrite to nitrate, and are oxidase and catalase positive. Species and biovars are differentiated by their carbon dioxide requirements

Microbiology The lipopolysaccharide (LPS) component of the outer cell membranes of brucellae is quite different— both structurally and functionally—from that of other Gram-negative organisms The complete sequencing of the B. melitensis was achieved in 2002. B. suis and abortus recently.

Pathogenesis Brucella species have a unique ability of invading both phagocytic and nonphagocytic cells and surviving in the intracellular environment by avoiding the immune system in different ways, explaining why brucellosis is a systemic disease and can involve almost every organ system

Pathogenesis Although humoral antibodies appear to play some role in resistance to infection, the principal mechanism of recovery from brucellosis is cell-mediated. Cellular immunity involves the development of specific cytotoxic T lymphocytes and activation of macrophages, enhancing their bactericidal activity, through the release of cytokines

Pathogenesis

Pathogenesis Cultured human monocyte-derived macrophage infected with Brucella melitensis. The bacteria, which replicate in phagolysosomes, have a coccobacillary appearance

Pathogenesis Brucella species have relatively low virulence, toxicity, and pyrogenicity, making them a poor inducer of some inflammatory cytokines such as tumor necrosis factor (TNF) and interferons After replication in the endoplasmic reticulum, the brucellae are released with the help of hemolysins and induced cell necrosis

Epidemiology Brucellosis causes more than 500,000 infections per year worldwide. The heaviest disease burden lies in countries of the Mediterranean basin and Arabian Peninsula, Also common in India, Mexico, and South and Central America Because of variable reporting, true estimates in endemic areas are unknown. Incidence rates of 1.2-70 cases per 100,000 people are reported.

The Global Incidence of Human Brucellosis

Morbidity and Mortality Human brucellosis carries a low mortality rate (< 5%), mostly secondary to endocarditis, which is a rare complication of brucellosis. However, brucellosis can cause chronic debilitating illness with extensive morbidity. Worldwide, brucellosis is more common in males than in females, with a ratio of 5:2-3 in endemic areas Persons in their third to fifth decades of life were most commonly affected.

Clinical Presentation Fever is the most common symptom and sign of brucellosis, occurring in 80-100% of cases. It is intermittent in 60% of patients with acute and chronic brucellosis and undulant in 60% of patients with subacute brucellosis. Fever can be associated with a relative bradycardia

Clinical Presentation Constitutional symptoms of brucellosis include anorexia, asthenia, fatigue, weakness, and malaise and are very common (>90% of cases). Bone and joint symptoms include arthralgias, low back pain, spine and joint pain, and, rarely, joint swelling. These symptoms affect as many as 55-80% of patients

Physical The most common findings include hepatosplenomegaly (or isolated hepatomegaly or splenomegaly) and osteoarticular involvement.

Physical Osteoarticular findings can include tenderness and swelling over affected joints, bursitis, decreased range of motion, and joint effusion (rare). Maneuvers that isolate the sacroiliac joint may cause pain

Symptoms and Signs of Brucellosis Study Total Number of Patients Fever or Chills Arthralgia or Arthritis Sweating Constitutional symptomsa Hepatomegaly Splenomegaly Memish et al (2000)[5] 160 146 (91.3%) 105 (65.6%) 30 (18.8%) 70 (43.8%) 9 (5.6%) 11 (6.9%) Kokoglu et al (2006)[6] 138 108 (78.3%) 107 (77.5%) 100 (72.5%) 98 (71%) 37 (26.8%) 50 (36.2%) Mantur et al (2006)[7] 495 417 (84.2%) 117 (23.6%) 19 (3.8%) 6 (1.2%) 56 (11.3%) 95 (19.2%) Ruiz-Mesa et al (2005)[8] 711 702 (98.7%) 353 (49.6%) 597 (84%) 533 (75%) 250 (35.2%) 148 (20.8%) Barroso Garcia et al (2002)[9] 565 441 (78.1%) 248 (43.9%) 483 (85.5%) 472 (83.5%) 422 (74.7%) 152 (26.9%) Hasanjani Roushan et al (2004)[10] 469 314 (67%) 252 (53.7%) 357 (76.1%) ... 27 (5.8%) Pappas et al (2005)[11] 100 91 (91%) 44 (44%) .. 26 (26%) 7 (7%) 16 (16%) Troy et al (2005)[12] 28 25 (89%) 15 (54%) 13 (46%) 8 (29%) 5 (18%) Andriopoulos et al (2007)[13] 144 144 (100%) 125 (86.8%) 138 (95.8%) 140 (97.2%) 74 (51.4%) Giannakopoulos et al (2006)[14] 52 42 (81%) 43 (83%) 8 (15%) 7 (13%) Mantur et al (2004)[15] 93 49 (53%) 19 (20%) Tsolia et al (2002)[16] 39 27 (69%) 8 (21%) 13 (33%)

Complications Osteoarticular complications Bone and joint involvement are the most frequent complications of brucellosis, occurring in up to 40% of cases Gastrointestinal complications Foodborne brucellosis resembles typhoid fever, in that systemic symptoms predominate over gastrointestinal complaints Hepatobiliary complications The liver is commonly involved in brucellosis, although liver function tests can be normal or only mildly elevated Genitourinary complications Orchitis and epididymitis are the most frequent genitourinary complications of brucellosis in men

Complications Cardiovascular complications Neurological complications Infective endocarditis is the most common cardiovascular manifestation, and it is said to be the most common cause of death from brucellosis Aortic valve is involved more often than the mitral valve Neurological complications Neurobrucellosis refers to a variety of neurological complications associated with brucellosis, meningitis or meningoencephalitis are the most common manifestations. Cutaneous complications Opthalmic complications

Complications Cutaneous manifestations develop in 5-10% of patients, are transient and nonspecific, resolve with therapy, and do not alter the prognosis. Lesions reported in association with brucellosis are as follows:[17] Erythema nodosum, abscesses, and papulonodular eruptions (most common) Impetigo, psoriatic, eczematous, and pityriasis rosea –like lesions Macular, maculopapular, and scarlatiniform rashes Vasculitic lesions (eg, petechiae, purpura, thrombophlebitis) Ocular findings can include the following:[18] Uveitis[19] Keratoconjunctivitis Iridocyclitis Nummular keratitis Choroiditis Optic neuritis[20] Metastatic endophthalmitis Cataracts

Differential diagnoses Ankylosing Spondylitis and Undifferentiated Spondyloarthropathy Cryptococcosis Hepatitis, Viral Histoplasmosis Infectious Mononucleosis Infective Endocarditis Influenza Leptospirosis Malaria Tuberculosis Tuberculosis of the Genitourinary System Typhoid Fever

Diagnosis Culture blood cultures with improved techniques such as the Castaneda bottles Subcultures are still advised for at least 4 weeks Bone marrow culture is thought to be the criterion standard Any fluid can be cultured (eg, synovial, pleural, cerebrospinal CSF evaluation

Culture

Diagnosis Serology Serological testing is the most commonly used method of brucellosis diagnosis. Serum tube agglutination test Tray agglutination (TAT) and modified TAT are also popular. Titers of more than 1:160 in conjunction with compatible clinical presentation is considered highly suggestive of infection ELISA: cytoplasmic proteins as antigens and measures IgM, IgG, and IgA, Polymerase chain reaction (PCR):

Imaging Chest radiography :hilar and paratracheal lymphadenopathy, pulmonary nodules, pleural thickening, and pleural effusion. Spinal radiography : sacroiliitis, the most commonly observed abnormalities include blurring of articular margins and widening of the sacroiliac spaces Spondylitis-related abnormalities include anterosuperior vertebral angle epiphysitis, spinal straightening, narrowing of the intervertebral disc spaces, end-plate sclerosis, and osteophytes Radionuclide scintigraphy

Histology Histologic findings in brucellosis usually include mixed inflammatory infiltrates with lymphocytic predominance and granulomas (in up to 55% of cases) with necrosis Well-formed hepatic granuloma from a patient with brucellosis

Treatment The goal of medical therapy in brucellosis is to control symptoms as quickly as possible to prevent complications and relapses. Multidrug antimicrobial regimens are the mainstay of therapy because of high relapse rates reported with monotherapeutic approaches. The risk of relapse is not well understood, as resistance is not a significant issue in treating brucellosis

Treatment A meta-analysis performed in 1995 evaluated the efficacy of the two WHO-recommended regimens and concluded that the efficacy of the doxycycline-streptomycin (DOX-STR) regimen was superior to that of the doxycycline-rifampicin (DOX-RIF) regimen, as already suggested by previous studies

Treatment In November 2006, a consensus meeting aimed at reaching a common specialist statement on the treatment of brucellosis was held in Ioannina, Greece under the auspices of the International Society of Chemotherapy and the Institute of Continuing Medical Education of Ioannina

Recommendations of Ioannina Concensus

Treatment

Treatment The essential element in the treatment of all forms of human brucellosis is the administration of effective antibiotics for an adequate length of time. Treatment of uncomplicated cases in adults and children eight years of age and older: Doxycycline 100 mg twice a day for six weeks + streptomycin 1 g daily for two to three weeks. OR Doxycycline 100 mg twice a day for six weeks + rifampicin 600– 900 mg daily for six weeks.

Treatment

Treatment Doxycycline Gentamicin Streptomycin Rifampin Trimethoprim-sulfamethoxazole (TMP-SMZ) Other agents with potential roles include the following: Chloramphenicol Imipenem-cilastatin Tigecycline Fluoroquinolones

Treatment Children younger than 8 years: The use of rifampin and trimethoprim-sulfamethoxazole (TMP-SMX) for 6 weeks Pregnant women: rifampin alone or in combination with TMP-SMX. However, TMP-SMX use associated with kernicterus Patients with meningoencephalitis may require doxycycline in combination with rifampin, TMP-SMX, or both Patients with endocarditis require aggressive therapy. Aminoglycoside therapy in conjunction with doxycycline, rifampin, and TMP-SMX for at least 4 weeks followed by at least 2-3 active agents for another 8-12 weeks is preferred.

Surgery The role of surgery in patients with brucellosis lies in the treatment of endocarditis or drainage of focal abscesses. Previously healthy native valves, diseased native valves, and prosthetic valvular structures have been involved in brucellosis. Valvular lesions are typically large and destructive, regardless of the organism involved

Follow-up Relapse rate %10, usualy occur in the first year after 1 infection Often milder in severity than initial Most cases of relapse are caused by inadequate treatment Can be treated by repeated course

KEY POINTS ON THE DISEASE IN HUMANS Human brucellosis usually presents as a febrile illness. Most cases are caused by B. melitensis. All age groups are affected. Complications may affect any organ system. The disease may persist as relapse, chronic localized infection or delayed convalescence

TUS 2012 Güneydoğu Anadolu’da yaşayan, 45 yaşında hayvancılıkla uğraşan bir hasta son bir aydır devam eden ateş, eklem ağrıları, gece terlemeleri, iştahsızlık ve hâlsizlik yakınmalarıyla başvuruyor. Yapılan fizik muayenede hepatosplenomegali ve radyolojik incelemelerde sakroileitis tespit ediliyor. Bu hastanın tedavisinde aşağıdaki ilaçlardan hangisi kullanılmaz? A) Tetrasiklin B) Amoksisilin / klavulanat C) Trimetoprim-sulfametoksazol D) Rifampisin E) Siprofloksasin

TUS 2012 Güneydoğu Anadolu’da yaşayan, 45 yaşında hayvancılıkla uğraşan bir hasta son bir aydır devam eden ateş, eklem ağrıları, gece terlemeleri, iştahsızlık ve hâlsizlik yakınmalarıyla başvuruyor. Yapılan fizik muayenede hepatosplenomegali ve radyolojik incelemelerde sakroileitis tespit ediliyor. Bu hastanın tedavisinde aşağıdaki ilaçlardan hangisi kullanılmaz? A) Tetrasiklin B) Amoksisilin / klavulanat C) Trimetoprim-sulfametoksazol D) Rifampisin E) Siprofloksasin

TUS 2012 Aşağıdakilerden hangisi, bruselloz tedavisinde kullanılan antibiyotiklerden biri değildir? A) Doksisiklin  B) Streptomisin C) Rifampin  D) Trimetoprim-sulfametoksazol E) Fusidik asit

TUS 2012 Aşağıdakilerden hangisi, bruselloz tedavisinde kullanılan antibiyotiklerden biri değildir? A) Doksisiklin  B) Streptomisin C) Rifampin  D) Trimetoprim-sulfametoksazol E) Fusidik asit

TUS 2012 Hayvancılıkla uğraşan 40 yaşındaki bir erkek hasta, son 2 aydır devam eden ateş, bol terleme, kas ağrıları, sol dizinde ağrı ve şişlik yakınmalarıyla başvuruyor. Öyküsünden ateşinin aralıklarla geldiği; 7-10 gün ateşli dönemleri, 7-10 gün normal dönemlerin izlediği öğreniliyor. Fizik muayenesinde konjunktivada solukluk ve 6 cm splenomegali saptanıyor. Laboratuvar incelemelerinde hematokrit: % 30, lökosit: 6000/mm3 (% 60 parçalı, % 40 lenfosit) ve trombosit: 150.000/mm3 olarak bulunuyor. Bu hasta için en olası tanı aşağıdakilerden hangisidir? A) Tifo B) Sıtma C) Bruselloz D) Q ateşi E) Hodgkin hastalığı

TUS 2012 Hayvancılıkla uğraşan 40 yaşındaki bir erkek hasta, son 2 aydır devam eden ateş, bol terleme, kas ağrıları, sol dizinde ağrı ve şişlik yakınmalarıyla başvuruyor. Öyküsünden ateşinin aralıklarla geldiği; 7-10 gün ateşli dönemleri, 7-10 gün normal dönemlerin izlediği öğreniliyor. Fizik muayenesinde konjunktivada solukluk ve 6 cm splenomegali saptanıyor. Laboratuvar incelemelerinde hematokrit: % 30, lökosit: 6000/mm3 (% 60 parçalı, % 40 lenfosit) ve trombosit: 150.000/mm3 olarak bulunuyor. Bu hasta için en olası tanı aşağıdakilerden hangisidir? A) Tifo B) Sıtma C) Bruselloz D) Q ateşi E) Hodgkin hastalığı

TUS 2013 Mezbahada et kesimi ile uğrasan kişide eklem ağrısı var. katalaz ve oksidaz + üreme etkeni var. a) Brucella melitensis b) Listeria monocytogenesis c) Tuberculosis

TUS 2013 Brusellozda, aşağıdaki örneklerin hangisinden bakteri izolasyonu yapılmaz? A) Kan B) Kemik iliği C) İdrar D) Gaita E) Sinovyal sıvı

TUS 2013 Brusellozda, aşağıdaki örneklerin hangisinden bakteri izolasyonu yapılmaz? A) Kan B) Kemik iliği C) İdrar D) Gaita E) Sinovyal sıvı

TUS 2013 Sekiz yaşından büyük çocuklarda bruselloz tedavisinde kullanılan en etkili antibiyotik kombinasyonu aşağıdakilerden hangisidir? A) Sikloserin ve aminoglikozid B) 3. kuşak sefalosporin ve aminoglikozid C) Tetrasiklin ve 3. kuşak sefalosporin D) Doksisiklin ve aminoglikozid E) Kloramfenikol ve amoksisilin

TUS 2013 Sekiz yaşından büyük çocuklarda bruselloz tedavisinde kullanılan en etkili antibiyotik kombinasyonu aşağıdakilerden hangisidir? A) Sikloserin ve aminoglikozid B) 3. kuşak sefalosporin ve aminoglikozid C) Tetrasiklin ve 3. kuşak sefalosporin D) Doksisiklin ve aminoglikozid E) Kloramfenikol ve amoksisilin