brucellosis

2. By Dr / Mohammed Basiony

3. The Many Names of Brucellosis
Malta Fever
Undulant Fever ?
Why its important?

4. Brucellosis.
Br. Melitensis → Goats , Sheep & Camels.
Br. Abortus (?) → Cattle.
Br. Suis → Pigs.
Br. Canis → Dogs
Commonest classical zoonotic disease
of worldwide distribution.
Reservoir:

5. Causative organism:
Brucella sp.
small .
Aerobic .
non motile.
non capsulated.
non spore forming
gram –ve coccobacilli.
facultative intracellular bacteria.

6. Survival time
Cheese at 4c : 180 days
Water at 25c : 50 days
Meat and salted meat : 65 days.
Killed by:
boiling, pasteurization.
Not killed by freezing.

7. - Orally by ingestion of untreated milk & its
products ,raw meat,liver,spleen&bone marrow
[main route in non endemic areas]
Mode of transmission
- Skin direct contact of abraded skin with
infected meat or animals common in
veterinaries & slaughter men
- Inhalation through direct contact with
animals. mainly children,farm workers & lab.
workers.

8. Mode of transmission
-Conjunctiva, accidental splashing during animal
vaccination with live attenuated vaccine.
- Uncommon routes include blood transfusion&
bone m.transpl.
- Unproved routes trnsplacental,sexual&breast
milk feeding
N.B
( no man to man transmission )
Eating meat does not transmit brucellosis, except
if eaten raw and has been externally
contaminated

9. Who is at Risk?
 Occupational Disease
 dairy farmers
 Veterinarians
 Abattoir workers
 Meat inspectors
 Lab workers
 Hunters
 Travelers
 Consumers of unpasteurized dairy
products

10. Pathogenesis

11. classification
Acute < 3 months
Subacute 3 – 12 months
Chronic > 1 year

12. Onset :
may be sudden [1-2days] or
gradual [1 week or more]
It presnts as febrile illness
with or without localization.
Clinical picture
I.P: 1-3 weeks.
Divided into acute, chronic &with complications

13. Acute Brucellosis:
Symptoms:
Fever Prolonged fever [FUO]: recurrent
prolonged bouts of fever that is worse at night.
If specific treatment is not given, undulating
patterns of fever may last for several weeks (3-
4wks), followed by an afebrile period and then
relapse
Rigors,
Sweating ,
Headache . Malaise . Anorexia .wt loss
Generalized body aches specially low
backache.

14. Signs:
May be lacking.
Temp. is always high.(high afternoon fever)
Undulating pattern if specific ttt is not given
Hepatosplenomegaly
Splenomegaly reflects severe infection
Lymphadenopathy, specially in Br. Abortus.

15. Signs (cont)
Lassitude may be present and may
continue after successful ttt.
Full recovery is likely, in spite of the
severity, by proper therapy.
Relapse may occurs after ttt.
precipitated by new infection,
trauma, surgery or stress.

16. Relapse
Defined as a further episode of brucellosis
occurring < 6 months after the first
The cause is antibiotic incompliance
rather than drug resistance

17. Signs:
Temp. may be normal.(low grade fever)
The appearance may reflect a serious disease or
may be normal .
Moderate Splenomegaly may be in the minority of
cases , not reflecting the severity of infection &
may persist after treatment.
Lymphadenopathy.
Chronic brucellosis:
Symptoms:
Onset is insidious ,Commonly there is a story of
recurrent flu with lassitude ,headache , pain & sweat.
Low backache is common.
Long standing infection leads to depression.

19. Children
 Fever
 Joint pain
 single joint typically ( hip or knee )
 Rule out RH –fever
 Rule out septic arthritis

20. 1: Skeletal system (bones & joint)
Occurs in about 10-80% of cases.
a- Arthritis:
large weight-bearing joints (hips and knees)
- Reactive: mainly due to synovitis, polyarticular,
migratory resembles rheumatic fever
-Septic: monoarticular-- either blood born or
extension from osteomyelitis.
Complications:
May occur with acute or chronic &may be
the presenting picture.

21. Complications:
b- Spondylitis:
Average is 40 ys, rare in children.
affect single or mult.sites,
L4 is the commonnest site
C- sacroiliitis
in young patient
local tenderness on movement of the
sacroiliac joints .
d- Osteomyelitis:
Rare, affecting long bones femur, tibia,
hum.

22. 2- Genitourinary:
May be the presenting feature,
include
unilat.or bilat. epididymo-orchitis in children
Should be distinguished from mumps,
prostatitis &seminal vesiculitis in adult
males.
urithritis may occur.

23. 3-Respiratory:rare
Airborne transmission is a problem in
abattoirs and laboratories.
4-G.Intestinal:
Usually mild ,rarely a presenting feature.
hepatitis with mild jaundice.
liver & splenic abscesses are rare.

24. 5- Ocular:
Conjunctivitis [accidental], keratitis, …..
6-haematological
Anemia, leukopenia, thrombocytopenia
Granulomas in the bone marrow in 75% of
cases..

25. Diagnosis:
The different and multiple clinical types and
manifestations especially the recurrence of
fever makes its diagnosis difficult

26. Diagnosis:
Depends on the History
Clinical features
Brucella agglutinins in the blood.
+ve blood or tissue culture
1- Culture:
+ve in about 50 -70% of cases
+ve in 7-21 day….6weeks in old techniques.
Lab worker should be informed that brucella is
suspected
Best from BM(highest concentration)>3 blood
Useful if blood culture is –ve (preceeding ab)

27. Diagnosis:
2-Standard aggl. Test:
a titre of 1/160 in non endemic areas &
1/320 in endemic areas are significant.
-False +ve in Tularaemia, cholera & E-Coli
infection
-high titre of old infection persist
-3y in risky & 1y in civilized
-False –ve in prozonephenom-10% of culture
+ve cases (seronegative brucellosis)- immune
sppressed - hypoprotenemia

28. Prozone phenomenon
rabiezahran@gawab.com

29. Diagnosis:
3-Compl. fixation t., Radio-I-Assay, ELISA t.:
-High IgM in acute infection.
- High IgG in chronic infection.
4-Blood picture: Non sp., but exclude
pyogenic inf. &tb
Leukocytosis is rare ..neutropenia common
Anemia 75%- thrombocytopenia 40%
5-liver enzymes Mild elevation of alt and ast.
6-Pcr can replace malta and cultre but
expensive and not 100% sensitive.

30. Imaging
Bone changes are seen later in the disease
Typically---
 erosions at the edge of joints or the end plates of
vertebrae, with associated sclerosis.
 Marked bony destruction is unusual and is more
suggestive of TB
 Patients with spine symptoms MRI examination
to rule out spinal cord compromise.
 Plain radiographs, radionuclide bone scintigraphy,
CT scanning, and joint sonography.

31. ‫المطلوبة‬ ‫الفحوصات‬
1-]‫عمل‬ ‫يتم‬brucella agglutination test‫للتشخيص‬Titre ≥ 160 or
320 [‫الحالة‬ ‫تصبح‬probable‫أسبوعين‬ ‫بعد‬ ‫التحليل‬ ‫إعادة‬ ‫ويتم‬ ‫العالج‬ ‫ونبدأ‬,
‫وجود‬ ‫حالة‬ ‫فى‬4 fold rise in the titre‫الحالة‬ ‫تصبح‬confirmed
2-‫مؤكدة‬ ‫حالة‬ ‫لكل‬ ‫البطن‬ ‫على‬ ‫سونار‬ ‫عمل‬ ‫يتم‬(‫لتشخيص‬ ‫مهمة‬HSM‫و‬hepatic
granuloma‫و‬abscesses)
3-‫عامة‬ ‫فحوصات‬:‫كاملة‬ ‫دم‬ ‫صورة‬,‫عشوائى‬ ‫سكر‬,‫كامل‬ ‫بول‬ ‫تحليل‬,‫صدر‬ ‫أشعة‬,‫وظائ‬‫ف‬
‫وكبد‬ ‫كلى‬]‫لعمل‬ ‫المصاحبة‬ ‫األمراض‬ ‫و‬ ‫الدرن‬ ‫إلستبعاد‬ ‫مهمة‬adjustment‫للعالج‬[
‫المضاعفات‬ ‫الستبعاد‬ ‫خاصة‬ ‫حاالت‬ ‫فى‬ ‫فحوصات‬:
1-‫طلب‬ ‫يتم‬ ‫بالمفاصل‬ ‫التهاب‬ ‫أو‬ ‫بالفقرات‬ ‫موضعى‬ ‫الم‬ ‫وجود‬ ‫حالة‬ ‫فى‬X-ray‫أو‬MRI
‫نحتاج‬ ‫وقد‬isotope bone scan‫المصاب‬ ‫للجزء‬
2-‫المخ‬ ‫إللتهاب‬ ‫تشير‬ ‫أعراض‬ ‫وجود‬ ‫حالة‬ ‫فى‬(‫الرقبة‬ ‫تصلب‬–‫غيبوبة‬-)..‫ع‬ ‫يتم‬‫مل‬LP
3-‫الى‬ ‫تشير‬ ‫اعراض‬ ‫وجود‬ ‫حالة‬ ‫فى‬ ‫دم‬ ‫ومزرعة‬ ‫القلب‬ ‫على‬ ‫ايكو‬ ‫عمل‬ ‫يتم‬endocarditis
‫مثل‬Tachycardia or any murmur
4-‫عينة‬ ‫عمل‬ ‫يتم‬Biopsy‫وجود‬ ‫حالة‬ ‫فى‬localized lesion‫اليمفاوية‬ ‫بالغدد‬ ‫تضخم‬ ‫مثل‬

32. treatment
Intracellular organism
granulomatous pathology
so
We need AB can penetrate the cell and
for long duration and in combination

33. treatment
3 questions guide the management
 Is the disease acute (duration < 1month)
or relapsing or chronic ( > 6 months)
 Is there focal disease of bone or joints or
other complications?
Has TB definitely been excluded?

34. treatment
Duration of treatment
 Adults with acute non-focal disease → 6
weeks
 Children < 12 yr with acute non-focal
disease → 6 weeks but 3 weeks may be
adequate
 Patients with focal disease and/or chronic
/ relapsing disease → 3 months

35. Treatment
Principles of treatment
 Monotherapy is avoided because,early
relapse occurs in > 30% of cases
 Combination of 2 antibiotics is the
preferred regimen
 Triple therapy in complicated cases
 In patients in whom TB has not been
excluded
 Use antimicrobials to which only
brucellosis responds or
 Treat both infections simultaneously

36. treatment
(A):standard regimen
 Doxycycline 100 mg twice daily for 6-12 week
+ streptomycin 1 g I.M. daily for 2-3 weeks
for patients under 45 y. if older 0.5 – 0.75 gm
[the long period for chronic cases]
 Relapse rate after this regimen only 5%
alternative regimen
 Doxycycline 100 mg twice daily + rifampicin
600 mg once daily before breakfast
 Relapse rate after this regimen > 10%

37. B: Children without complications:
A course of 6 weeks of:
-Rifampicin 10-20 mg/kgm b.wt. once daily orally +
Co-Trimoxazole 8-10mg/kg/day [max. TMP 480
mg/24hr] in 2 divided doses orally
OR Rifampicin + streptomycin or gentamycin
Relapse rate 5% or less
Treatment.

38. Treatment.
C: Pregnency:
 A course of 6 weeks of:
 Rifampicin alone in 1st trimester or
+ Co-Trimoxazole in 2nd and 3rd trimester
or ceftriaxone 1 igm / day for 3 weeks.
septrin in 3rd trimester leads to kernicterus
septrin is antifolate so CI in 1st trimester.
Azithromycin also can be used.

39. D: Spondylitis or sacroiliitis
 Doxycycline 100 mg twice daily + streptomycin
1 g I.M. daily for 3 weeks THEN Doxycycline 100 mg
twice daily + Rifampicin 600 mg daily up to the end of
the 6th month
‫يعطى‬ ‫االستربتومايسين‬ ‫توفر‬ ‫عدم‬ ‫حالة‬ ‫فى‬
 Gentamycin 5mg/kg/d IM or IV (240 mg for adults)
for 1-2wk
E: Endocarditis
 Gentamicin 5 mg/kg/ day for 2 weeks +
Doxycycline 100 mg twice daily & Rifampicin 600
mg daily up to the end of the 3rd month + ‫جراحة‬ ‫عرض‬
‫قلب‬

40. F: Neurobrucellosis
 Doxycycline 100 mg twice daily +
Rifampicin 600 mg daily +
Ceftriaxone 2g/12 hr i.v.
For 1 month
THEN
Doxycycline 100 mg twice daily +
Rifampicin 600 mg daily up to the end of the
4th month + steroids

41. G: Renal impairment
Doxycycline in usual dose
Rifampicin → should not exceeding 600 mg/d
& reduce the dose to 300 mg/d if creatinine
clearance < 10 ml/min
Co-trimoxazole → reduce to the half dose if
creatinine clearance < 30 ml/min
IF on hemodialysis → Rifampicin 300-600 mg
+ doxycycline 100-200 mg single dose after
dialysis session for 6 weeks

42. Treatment.
H: Hepatic patient :
a) Compansated cirrhosis :
*Fluorinated quinolones can be used
in its normal dose for 6-8 ws. With
monitoring of liver function.
*Azithromycine in its normal daily dose
for 6 days /then 6days rest/for 6-8 ws

43. treatment
B ) decompensated cirrhosis
Levofloxacin 500 mg daily for 4-6 weeks
Ceftriaxone 1gm daily for 3 weeks

44. Acute cases
→ 2 drugs for 6 weeks
Chronic or relapsing cases
→ 2 drugs for 3 months
Complicated cases
→ 3 drugs for 3 months

45. ‫المتابعة‬
‫بعد‬ ‫الحالة‬ ‫تتحسن‬4-14‫العالج‬ ‫بدء‬ ‫من‬ ‫يوم‬
‫بعد‬ ‫المريض‬ ‫متابعة‬ ‫يتم‬3‫و‬6‫على‬ ‫المواظبة‬ ‫لضمان‬ ‫العالج‬ ‫من‬ ‫أسابيع‬
‫عند‬ ‫ذلك‬ ‫بعد‬ ‫ثم‬ ‫العالج‬3‫و‬6‫و‬12‫شهر‬to detect relapse &
complications
‫الشهية‬ ‫وتحسن‬ ‫الوزن‬ ‫زيادة‬ ‫و‬ ‫السخونة‬ ‫زوال‬ ‫هى‬ ‫العالج‬ ‫نجاح‬ ‫عالمات‬
‫ا‬ ‫العالمات‬ ‫وزوال‬ ‫للمريض‬ ‫العامة‬ ‫والصحة‬ ‫المزاجية‬ ‫الحالة‬ ‫وتحسن‬ ‫لألكل‬‫لتى‬
‫والطحال‬ ‫الكبد‬ ‫تضخم‬ ‫مثل‬ ‫العالج‬ ‫قبل‬ ‫موجودة‬ ‫كانت‬‫اليمفاوية‬ ‫والغدد‬(‫تحليل‬
‫سنوات‬ ‫إلى‬ ‫شهور‬ ‫يستغرق‬ ‫النه‬ ‫المتابعة‬ ‫فى‬ ‫يستخدم‬ ‫ال‬ ‫البروسيال‬‫للرجوع‬
‫الطبيعى‬ ‫للمستوى‬)
‫كورس‬ ‫اتمام‬ ‫برغم‬ ‫مستمرة‬ ‫بصفة‬ ‫تكرارها‬ ‫أو‬ ‫االعراض‬ ‫استمرار‬ ‫حالة‬ ‫فى‬
‫عمل‬ ‫يتم‬ ‫العالج‬ ‫من‬ ‫كامل‬MRI‫عن‬ ‫للبحث‬ ‫والفقرات‬ ‫والحوض‬ ‫البطن‬ ‫على‬
localized suppurative lesions

46. ‫هامة‬ ‫ملحوظة‬:‫بالحمى‬ ‫اإلصابة‬ ‫إلى‬ ‫تشير‬ ‫أعراض‬ ‫وجود‬ ‫حالة‬ ‫فى‬
‫سلبى‬ ‫البروسيال‬ ‫تحليل‬ ‫لكن‬ ‫المالطية‬seronegative‫عمل‬ ‫يتم‬
‫اآلتى‬ ‫من‬ ‫واحد‬:
1-‫عمل‬Tuberculine test‫البدء‬ ‫ثم‬ ‫الدرن‬ ‫إلستبعاد‬ ‫صدر‬ ‫وأشعة‬
‫الكور‬ ‫إكمال‬ ‫يتم‬ ‫التحسن‬ ‫حالة‬ ‫وفى‬ ‫المعتاد‬ ‫البروسيال‬ ‫بعالج‬‫س‬.
2-‫ح‬ ‫وفى‬ ‫والكوترايموكسازول‬ ‫الدوكسيسيكلين‬ ‫استخدام‬ ‫يتم‬ ‫أو‬‫التحسن‬ ‫الة‬
‫الكورس‬ ‫إكمال‬ ‫يتم‬
3-‫عمل‬ ‫يتم‬ ‫أو‬Brucella Eliza‫دم‬ ‫مزرعة‬ ‫أو‬

47. prevention
 Education about risk of transmission
 Avoid consumption of raw dairy products
 Immunize in areas of high prevalence
 Wear protective ( Gloves, masks ……)
if dealing with infected animals/ tissues