Brucellosis

2. Brucellosis Done by Dr/Abdullah Mohd. Jan King Abdulaziz University Hospital MBBS, Intern

3. 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 basin and Arabian Peninsula.

4. 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.

5. Classifications The traditional classification of Brucella species is based largely on the preferred hosts.

6. Causes • Ingestion of unpasteurized milk and related dairy products. • Aerosolizationof 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.

7. Clinical Presentation • Subclinical brucellosis • Acute or subacute brucellosis • Chronic brucellosis • Localized brucellosis. • Relapsing brucellosis

8. Symptoms • Fever is the most common symptom which is associated with chills. • Constitutional symptoms of brucellosis including anorexia, asthenia, fatigue, weakness, and malaise (>90% of cases). • Bone and joint symptoms include arthralgias, low back pain, spine and joint pain, and, rarely, joint swelling.

9. 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.

10. Symptoms • Cough and dyspnea develop in up to 19% of persons with brucellosis; however, these symptoms are rarely associated with active pulmonary involvement.

11. 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).

12. 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

13. 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.

14. Signs • Ocular findings can include uveitis, keratoconjunctivitis, optic neuritis or cataract.

15. DDx • Ankylosing Spondylitis and Undifferentiated Spondyloarthropathy • Cryptococcosis • Hepatitis, Viral • Histoplasmosis • Infectious Mononucleosis • Infective Endocarditis • Leptospirosis

16. DDx • Tuberculosis • Influenza • Tuberculosis of the Genitourinary System • Malaria • Typhoid Fever

17. Work up • CBC shows leukopenia, relative lymphocytosis or pancytopenia. • LFT shows slight elevation • Blood culture has sensitivity of 60% and subcultures are still adviced for at least 4 weeks. • Bone marrow culture has sensitivity of 80-90%.

18. Work up • Serology • Serum tube agglutination test. • 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.

19. Work up • ELISA it measures IgM,IgG and IgA allowing for better interpretation. • PCR it is used for rapid and accurate diagnosis of brucellosis.

20. Work up • Histological findings: it include mixed inflammatory infiltrates with lymphocytic predominance and granulomas (in up to 55% of cases) with necrosis.

21. Management • The World Health Organization recommends the following for adults and children older than 8 years: • Doxycycline 100 mg PO bid andrifampin 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.

22. 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.

23. 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.

24. Management • Surgical Care The role of surgery in patients with brucellosis lies in the treatment of endocarditis or drainage of focal abscesses.

25. Management • Consultations Infectious disease specialist Cardiothoracic surgery specialist if endocarditis is suspected or documented