OverviewDR. SATTI MOHD SALLEH
Overview                                           Organism                                               History       ...
Brucella spp.Gram negative, coccobacilli bacteria Facultative, intracellular organism Environmental persistence Tempera...
The Many Names ofBrucellosis    Human Disease                                           Animal Disease           Malta Fev...
Transmission to HumansConjunctiva or broken skin contacting infected tissuesBlood, urine, vaginal discharges, aborted fe...
Transmission to HumansInhalation of infectious aerosols Pens, stables, slaughter houses Inoculation with vaccines B. ab...
Human DiseaseCan affect any organ or organ system All patients have a cyclical fever Variability in clinical signs Head...
Human Disease20-60% of cases Osteoarticular complications Arthritis, spondylitis, osteomyelitis ○Hepatomegaly may occur ...
Human DiseaseNeurological Depression, mental fatigue Cardiovascular Endocarditis resulting in death Chronic brucellosi...
Human DiseaseCongenitally infected infants Low birth weight Failure to thrive Jaundice Hepatomegaly Splenomegaly Res...
DifferentialsTuberculosis Toxoplasmosis CMV HIV infection 
Brucella spp.Gram negative, coccobacilli bacteria Facultative, intracellular organism Environmental persistence Tempera...
MOST HUMAN INFECTIONCAUSED BY:BRUCELLA MELIENTESIS ( 3 bio Types) Sheep, Goat, Camel -Brucella Abortus ( Cattle ) 9Bio Ty...
B. melitensisLatin America, Middle East, Mediterranean, eastern Europe,Asia, and parts of AfricaAccounts for most human c...
Center for Food Security and Public Health, Iowa             State University, 2008
B. abortusWorldwide Some countries have eradicated itNotifiable disease in many countriesPoor surveillance and reportin...
B. suisBiovars 1 and 3 Worldwide problems where swine are raised Free United Kingdom, Canada Eradicated Holland, Denm...
B. canisPoorly understood 1-19% prevalence in United StatesRarely causes disease in humans              Center for Food...
intracellular Organisms – Incubation ; Weeks to Months
Human Acquire Infectionsfrom Ingesting Milk – Dairy Products ( Not Pasteurized )- Products of Abortion & Placenta (Infe...
---CLINICAL---Recurrent Prolonged Fever- Undulating Patterns- A febrile Period- Relapse- Musculoskeletal Symptoms – F...
MeningoEncephalitis- 5-10 % Orchitis- Dry cough- Epistaxis- Meletenesis more acute Onset 
Children              ( Fever,             Joint pain           single joint –         Rule out RH -fever 
Suis ( Deep tissue Abscess )-    10 % Lymphodenephathy)        25 % Spleenomegally-         Endocarditis less 1 % 
DIAGNOSISGENERAL Low WBC w/ Lymphophenia- Low platelets-Low Hag- Low Alkaline Phosphates- Low Transeminates- ESR- 
CULTUREBlood Culture 2/3 Meletenesis- 1 Week to 3 Weeks to 6 Weeks- ( Risk of Aerosol )- Bone marrow culture- Synovial...
SEROLOGY Standard Agglutination Test – Prozone Phenomenon ( False Negative   )-Increase Dilution – 1/640 – Fourfold Ri...
SEROLOGY Negative result does rule out - Antigen Used is Important- Mercaptoethanol ( Dissociate 1gm ).  Cross react -...
ImagingPatients with spine symptoms MRI examination to rule out spinal cordcompromise.Plain radiographs, radionuclide bo...
Radiology of Spine                        Brucellosis                 TuberculosisSite                    Lumbar          ...
Localized snowflake calcification in chronic hepatosplenic brucellosis only specificradiographic finding.
TREATMENT 3 Questions Guide Management once Diagnosis has been made #- Is the disease acute less than 1 month or Relap...
MANAGEMENT Adults =acute non focal disease, treatment 6 weeks.-Patients with focal disease and or chronic disease. Trea...
ANTIBIOTICS   At least 2 antibioticsSuspicious of TB Treat both Do not take REFAMPICINE OR STREPTOMYCINE             i...
5. Alternative Doxycycline             6 weeks          +                      or Rifampicin             3 months (rel...
Pregnant womenRifampicin alone or + Co – trimoxazole (avoid or add folic acid in 1st trimester
PregnancyPremature labour and fetal wastage Rifampin — 900 mg once daily for six weeksRifampin — 900 mg once daily plus ...
8. Triple Theraphy Doxy + Rifampicin + gentamycine Superior to double treatment Use for all infection with complication...
 Follow – up at 3 weeksEncourage adherence to therapy  Return of appetite Return of weight         Investigation WBC,...
 Follow – up at 3 weeksEncourage adherence to therapy  Return of appetite Return of weight         Investigation WBC,...
  Serology not very useful (variable   pattern for months or year)Relapse – define as further episode as further episode...
 Chronic Brucellosis difficult to define  serologicallyExclude chronic fatigue syndrome Depression Malignancy Immunity...
Indications for SurgeryEndocarditis where valve replacement or valve debridement is requiredDrainage or excision of absce...
Resection of mycotic aneurysms Procurement of tissue for diagnostic purposesChronic hepatosplenic suppurative brucellos...
Osteoarticular DiseasePatients with Brucella spondylitis appear to respond better to doxycycline-streptomycinor a three-d...
NeurobrucellosisDoxycycline, Rifampin Trimethoprim-sulfamethoxazole . The duration of therapy is generally prolonged ...
 Public    health aspectsEducation to people Commitment of all related deportation Control of infected hands flucks An...
Prevention and ControlEducation about risk of transmission Farmer, veterinarian, abattoir worker, butcher, consumer, hun...
Prevention and ControlImmunize in areas of high prevalenceYoung goats and sheep with Rev-1 Calves with RB51 No human va...
Prevention and ControlB. suis, B. ovis, and B. canis Venereal transmission Separate females at birthing to reduce trans...
RB51Approved for use February 1996 for calves Able to differentiate ―wild type‖ exposure from immunizationLacks LPS-O an...
U.S. Eradication ProgramU.S. Department of Agriculture 1934: Cooperative State-Federal Brucellosis Eradication ProgramRe...
U.S. Eradication ProgramTarget date for eradication                                                   was December 31, 19...
U.S. Eradication ProgramFiscal Year 2001 4.7 million calves vaccinated 9.9 million cattle tested under the Market Cattl...
http://www.aphis.usda.gov/vs/nahps/brucellosis/status_rpt/figure11.jpg           Center for Food Security and Public Healt...
http://www.aphis.usda.gov/vs/nahps/brucellosis/status_rpt/figure05.jpg           Center for Food Security and Public Healt...
Brucella                                                                  asa Biological WeaponAerosolized B. melitensis ...
Brucellosis dr. satti new
Brucellosis dr. satti new
Brucellosis dr. satti new
Brucellosis dr. satti new
Brucellosis dr. satti new
Brucellosis dr. satti new
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Brucellosis dr. satti new

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Lecture By Dr.Satti Moh'd Saleh

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  • The symptoms of congenital brucellosis are variable. Some congenitally infected infants are delivered prematurely, while others are born at full term. Common symptoms include low birth weight, fever, failure to thrive, jaundice, hepatomegaly, and splenomegaly. Some newborns with congenital brucellosis have respiratory difficulty or severe respiratory distress, hypotension, vomiting, and other signs of sepsis. Other infants may be asymptomatic or have only mild symptoms at birth. Whether brucellosis can lead to spontaneous abortion in humans is controversial.
  • Brucellosis dr. satti new

    1. 1. OverviewDR. SATTI MOHD SALLEH
    2. 2. Overview Organism  History  Epidemiology  Transmission  Disease in Humans  Disease in Animals  Prevention and Control  Actions to Take  Center for Food Security and Public Health, Iowa State University, 2008
    3. 3. Brucella spp.Gram negative, coccobacilli bacteria Facultative, intracellular organism Environmental persistence Temperature, pH, humidity Frozen and aborted materials Multiple species  Center for Food Security and Public Health, Iowa State University, 2008
    4. 4. The Many Names ofBrucellosis Human Disease Animal Disease Malta Fever  Bang’s Disease  Undulant Fever  Enzootic Abortion  Mediterranean Fever  Epizootic Abortion Rock Fever of Gibraltar  Slinking of Calves  Gastric Fever  Ram Epididymitis  Contagious Abortion  Center for Food Security and Public Health, Iowa State University, 2008
    5. 5. Transmission to HumansConjunctiva or broken skin contacting infected tissuesBlood, urine, vaginal discharges, aborted fetuses, placentasIngestion Raw milk & unpasteurized dairy products Rarely through undercooked meat  Center for Food Security and Public Health, Iowa State University, 2008
    6. 6. Transmission to HumansInhalation of infectious aerosols Pens, stables, slaughter houses Inoculation with vaccines B. abortus strain 19, RB-51 B. melitensis Rev-1 Conjunctival splashes, injection Person-to-person transmission is very rare Incubation varies 5-21 days to three months  Center for Food Security and Public Health, Iowa State University, 2008
    7. 7. Human DiseaseCan affect any organ or organ system All patients have a cyclical fever Variability in clinical signs Headache, weakness, arthralgia, depression,weight loss, fatigue,liver dysfunction Center for Food Security and Public Health, Iowa State University, 2008
    8. 8. Human Disease20-60% of cases Osteoarticular complications Arthritis, spondylitis, osteomyelitis ○Hepatomegaly may occur Gastrointestinal complications 2-20% of cases Genitourinary involvement Orchitis and epididymitis most common ○ Center for Food Security and Public Health, Iowa State University, 2008
    9. 9. Human DiseaseNeurological Depression, mental fatigue Cardiovascular Endocarditis resulting in death Chronic brucellosis is hard to define Length, type and response to treatment variable Localized infection Blood donations of infected persons should not be accepted Center for Food Security and Public Health, Iowa State University, 2008
    10. 10. Human DiseaseCongenitally infected infants Low birth weight Failure to thrive Jaundice Hepatomegaly Splenomegaly Respiratory difficulty General signs of sepsis (fever, vomiting) Asymptomatic  Center for Food Security and Public Health, Iowa State University, 2008
    11. 11. DifferentialsTuberculosis Toxoplasmosis CMV HIV infection 
    12. 12. Brucella spp.Gram negative, coccobacilli bacteria Facultative, intracellular organism Environmental persistence Temperature, pH, humidity Frozen and aborted materials Multiple species  Center for Food Security and Public Health, Iowa State University, 2008
    13. 13. MOST HUMAN INFECTIONCAUSED BY:BRUCELLA MELIENTESIS ( 3 bio Types) Sheep, Goat, Camel -Brucella Abortus ( Cattle ) 9Bio Types - BRUCELLA SUIS– Pigs ( 5Bio types ) - Brucella CANIS – Dogs ( Rare ) 
    14. 14. B. melitensisLatin America, Middle East, Mediterranean, eastern Europe,Asia, and parts of AfricaAccounts for most human cases In the Mediterranean and Middle East Up to 78 cases/100,000 people/year ○Arabic Peninsula 20% seroprevalence ○Recent emergence in cattle on Middle Eastern intensive dairy farms Center for Food Security and Public Health, Iowa State University, 2008
    15. 15. Center for Food Security and Public Health, Iowa State University, 2008
    16. 16. B. abortusWorldwide Some countries have eradicated itNotifiable disease in many countriesPoor surveillance and reporting due to lack of recognitionFever of Unknown Origin (FUO)  Center for Food Security and Public Health, Iowa State University, 2008
    17. 17. B. suisBiovars 1 and 3 Worldwide problems where swine are raised Free United Kingdom, Canada Eradicated Holland, Denmark Low Incidence Middle East, North Africa ○ Center for Food Security and Public Health, Iowa State University, 2008
    18. 18. B. canisPoorly understood 1-19% prevalence in United StatesRarely causes disease in humans Center for Food Security and Public Health, Iowa State University, 2008
    19. 19. intracellular Organisms – Incubation ; Weeks to Months
    20. 20. Human Acquire Infectionsfrom Ingesting Milk – Dairy Products ( Not Pasteurized )- Products of Abortion & Placenta (Infected Animals, Farmers, VeterinarianBreast Milk ( Rare )- Sexual Transmission ( Rare )- Transfusion of Blood (Rare)- Only Raw Meat 
    21. 21. ---CLINICAL---Recurrent Prolonged Fever- Undulating Patterns- A febrile Period- Relapse- Musculoskeletal Symptoms – Fever Mostly at Night- Profuse sweating- Anorexia, Lethargy ,Depressions- Neuropsychiatric Manifestations 
    22. 22. MeningoEncephalitis- 5-10 % Orchitis- Dry cough- Epistaxis- Meletenesis more acute Onset 
    23. 23. Children  ( Fever,  Joint pain  single joint –  Rule out RH -fever 
    24. 24. Suis ( Deep tissue Abscess )-  10 % Lymphodenephathy)  25 % Spleenomegally-  Endocarditis less 1 % 
    25. 25. DIAGNOSISGENERAL Low WBC w/ Lymphophenia- Low platelets-Low Hag- Low Alkaline Phosphates- Low Transeminates- ESR- 
    26. 26. CULTUREBlood Culture 2/3 Meletenesis- 1 Week to 3 Weeks to 6 Weeks- ( Risk of Aerosol )- Bone marrow culture- Synovial fluid 
    27. 27. SEROLOGY Standard Agglutination Test – Prozone Phenomenon ( False Negative )-Increase Dilution – 1/640 – Fourfold Rise on Titer ( Acute & Convalescent Sample )- Previous Exposure ( Low Titer )- 
    28. 28. SEROLOGY Negative result does rule out - Antigen Used is Important- Mercaptoethanol ( Dissociate 1gm ).  Cross react -ve-Bacilli (Yersenia, Cholera)- EL Dipsticks-  PCR ( DNA ) sensitive-  Tissues ( Non Calcified Granuloma- Radiology ( differentiate from TB ) ISA –Specific IgG ,IGM Immuno essay- 
    29. 29. ImagingPatients with spine symptoms MRI examination to rule out spinal cordcompromise.Plain radiographs, radionuclide bone scintigraphy, CT scanning, and jointsonography.
    30. 30. Radiology of Spine Brucellosis TuberculosisSite Lumbar Dorso lumbarVertebrae Multiple,contigous ContigousDisctis Late EarlyBody Intact until late Morphology lost earlyCanal compression Rare commonEpiphysitis Antero Superior (Pedro- General + Lower Disc Pons’ –Sign ) region,Centre,subperiost rialOsteophyte Anterolateral Parrot beak unusualDeformity Wedging uncommon Anterior wedgingRecovery Sclerosis Of whole body VariableParavertebral abscess Small well localized Common discrete loss,transverse processPsoas Abscess Rare More likely
    31. 31. Localized snowflake calcification in chronic hepatosplenic brucellosis only specificradiographic finding.
    32. 32. TREATMENT 3 Questions Guide Management once Diagnosis has been made #- Is the disease acute less than 1 month or Relapsing or Chronic morethan 6 months ###- Is there disease ofbone or joints?-?-Has TB or other been Excluded?- 
    33. 33. MANAGEMENT Adults =acute non focal disease, treatment 6 weeks.-Patients with focal disease and or chronic disease. Treat for 3 months-No mono therapy ,early relapse, Increase 30 %Endocarditis 6 months 
    34. 34. ANTIBIOTICS At least 2 antibioticsSuspicious of TB Treat both Do not take REFAMPICINE OR STREPTOMYCINE if TB not excluded 3. Gold Standard Doxycline (6 – 12 weeks 100 mg / BID Stripmycine 1G (2-3 weeks)  4. Gentamycin 8 mg / kg may be substituted for streptomycinOptimum duration ?? WHO – 14 days 
    35. 35. 5. Alternative Doxycycline 6 weeks  + or Rifampicin 3 months (relapse is 10 % compared to 5 % with doxystriptomycin) 6. Co-trimoxazole High dose (3 tabs / BID) S/E drug rash &anemia,  supplement with folic acidFor adults (cotrimoxazole + doxycycline better than dcotrimoxazole + rifampicin)Children (3 weeks rather than 6 weeks) 
    36. 36. Pregnant womenRifampicin alone or + Co – trimoxazole (avoid or add folic acid in 1st trimester
    37. 37. PregnancyPremature labour and fetal wastage Rifampin — 900 mg once daily for six weeksRifampin — 900 mg once daily plus trimethoprim-sulfamethoxazole(TMP-SMX;5 mg/kg of the trimethoprim componenttwice daily) for four weeks
    38. 38. 8. Triple Theraphy Doxy + Rifampicin + gentamycine Superior to double treatment Use for all infection with complication ex. Spondylitis, meningitis,endocarditis(may need volume replacement)9. ? Ceftriaxone 
    39. 39.  Follow – up at 3 weeksEncourage adherence to therapy  Return of appetite Return of weight  Investigation WBC, HB, ESR, PLATELETES
    40. 40.  Follow – up at 3 weeksEncourage adherence to therapy  Return of appetite Return of weight  Investigation WBC, HB, ESR, PLATELETES
    41. 41.  Serology not very useful (variable pattern for months or year)Relapse – define as further episode as further episode 6monthsFailure to adequate treatment Treatment for 3 months – include streptomycin (to ensure compliance)
    42. 42.  Chronic Brucellosis difficult to define serologicallyExclude chronic fatigue syndrome Depression Malignancy Immunity not solid (repeated infection) 
    43. 43. Indications for SurgeryEndocarditis where valve replacement or valve debridement is requiredDrainage or excision of abscesses, especially those that have not respondedto antimicrobialsSpinal epidural abscess Removal of infected foreign bodies, eg, pacemaker wires, prosthetic joints
    44. 44. Resection of mycotic aneurysms Procurement of tissue for diagnostic purposesChronic hepatosplenic suppurative brucellosis may require surgery in additionto antibiotics to achieve cure
    45. 45. Osteoarticular DiseasePatients with Brucella spondylitis appear to respond better to doxycycline-streptomycinor a three-drug regimen (doxycycline-streptomycin-rifampin) than to doxycycline-rifampin.
    46. 46. NeurobrucellosisDoxycycline, Rifampin Trimethoprim-sulfamethoxazole . The duration of therapy is generally prolonged individualized according toclinical signs and symptomsContinued until cerebrospinal fluid parameters have returned to normal
    47. 47.  Public health aspectsEducation to people Commitment of all related deportation Control of infected hands flucks Animal vaccination For infected animal test & slaughter Financial compliment 
    48. 48. Prevention and ControlEducation about risk of transmission Farmer, veterinarian, abattoir worker, butcher, consumer, hunter, publicWear proper attire if dealing with infected animals/ tissuesGloves, masks, goggles Avoid consumption of raw dairy products  Center for Food Security and Public Health, Iowa State University, 2008
    49. 49. Prevention and ControlImmunize in areas of high prevalenceYoung goats and sheep with Rev-1 Calves with RB51 No human vaccine Eradicate reservoir Identify, segregate, and/or cull infected animals Center for Food Security and Public Health, Iowa State University, 2008
    50. 50. Prevention and ControlB. suis, B. ovis, and B. canis Venereal transmission Separate females at birthing to reduce transmission on the farm or in kennel Center for Food Security and Public Health, Iowa State University, 2008
    51. 51. RB51Approved for use February 1996 for calves Able to differentiate ―wild type‖ exposure from immunizationLacks LPS-O antigen that causes antibody response on serologic or milk testsInfectious to humans Serologically negative upon testing post- exposureCDC registry of human exposures 32 documented exposures as of 1998  Center for Food Security and Public Health, Iowa State University, 2008
    52. 52. U.S. Eradication ProgramU.S. Department of Agriculture 1934: Cooperative State-Federal Brucellosis Eradication ProgramRemoval of diseased cattle due to drought ○1951: APHIS became involved 1957: 124,000 positive herds Approach Test, slaughter, trace back, investigate, and vaccinate Center for Food Security and Public Health, Iowa State University, 2008
    53. 53. U.S. Eradication ProgramTarget date for eradication was December 31, 1998Surveillance Brucellosis ring test Pooled milk ○Market Cattle Identification Blood test, individual ○Indemnity for whole herd depopulation $250 nonregistered cattle/bison $750 or 95% of value minus salvage value for registered cattle Center for Food Security and Public Health, Iowa State University, 2008
    54. 54. U.S. Eradication ProgramFiscal Year 2001 4.7 million calves vaccinated 9.9 million cattle tested under the Market Cattle Identification program3 brucellosis herds depopulated Indemnity paid = $211,153 ○An additional $47,700 for purchase of animals ○or diagnostic purposes Center for Food Security and Public Health, Iowa State University, 2008
    55. 55. http://www.aphis.usda.gov/vs/nahps/brucellosis/status_rpt/figure11.jpg Center for Food Security and Public Health, Iowa State University, 2008
    56. 56. http://www.aphis.usda.gov/vs/nahps/brucellosis/status_rpt/figure05.jpg Center for Food Security and Public Health, Iowa State University, 2008
    57. 57. Brucella asa Biological WeaponAerosolized B. melitensis City of 100,000 people Inhale 1,000 cells (2% decay per min) Case-fatality rate of 0.5% 50% hospitalized for 7 days Outpatients required 14 visits ○5% relapsed ○Results 82,500 cases requiring extended therapy 413 deaths $477.7 million economic impact  Center for Food Security and Public Health, Iowa State University, 2008
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