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BRUCELLOSIS& PREGNANCY

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Aboubakr Elnashar

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BRUCELLOSIS& PREGNANCY

  1. 1. BRUCELLOSIS& PREGNANCY Prof. Aboubakr Elnashar Benha University Hospital, Egypt Aboubakr Elnashar
  2. 2. Other names for Brucellosis  Undulant fever  Malta fever  Mediterranean fever. Brucellosis remains a neglected disease in the developing world (Franc et al, 2018) Aboubakr Elnashar
  3. 3. CONTENTS 1. CAUSATIVE ORGANISM 2. EPIDEMIOLOGY 3. TRANSMISSION TO HUMAN 4. CLINICAL MANIFESTATION 5. INVESTIGATIONS 6. TREATMENT 7. PREVENTION  CONCLUSION Aboubakr Elnashar
  4. 4. 1. CAUSATIVE ORGANISM Brucella Coccobacillus, gram negative, non-sporing Non-motile aerobic bacterium Hosts: mostly animals. Four species:  Melitensis: most frequent human infection  Abortus  Suis  Canis Aboubakr Elnashar
  5. 5. 2. EPIDEMIOLOGY  Major zoonotic disease.  Worldwide  Major endemic areas:  Mediterranean basin  Arabian Gulf  Indian subcontinent  Parts of Mexico  Central & South America Aboubakr Elnashar
  6. 6. Aboubakr Elnashar Incidence  The highest incidence of human brucellosis  Syria (1,603.4 cases per1,000,000 individuals),  Mongolia (391.0)  Tajikistan (211.9).  Animal brucellosis  Mexico had the largest number of reported outbreaks, 5,514 in 2014  China (2,138)  Greece (1,268)  Brazil (1,142). (Lancet, 2006)
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  8. 8. Aboubakr Elnashar  In Egypt:  Seroprevalence of Brucella antibodies in  Cattle: 23.8%  Human: 21%.  Milk samples using PCR: 6.3% were positive for B. abortus biovar 1 • This study documented the endemic status of brucellosis in Egypt. (Eldiasty et al, 2016)
  9. 9. Aboubakr Elnashar  In Egypt  Brucellosis is still an endemic disease  The high prevalence of brucellosis in Minia governorate considered it as an epidemic area with this disease. (Ashraf et al, 2019)
  10. 10.  The incidence of bacteriological isolation from different collected samples of sheep, goat & human (Ashraf et al, 2019)
  11. 11. In Egypt: Among pregnant women 3.5% {Sherif et al.2003] 12 .2 % (Alshamy & Ahmed, 2008) Aboubakr Elnashar
  12. 12. In Saudi Arabia Endemic National prevalence: 15% 1. Persistence of domestic animal reservoirs for Brucella species 2. Human consumption of unpasteurized products Aboubakr Elnashar
  13. 13. Risk factors 1. Family history of brucellosis 2. Stockbreeding ( ‫الماشيه‬ ‫)تربيه‬ 3. Ingestion of non-pasteurized dairy products: most common source of transmission.  Occupational status & family history of brucellosis should be obtained during prenatal care in at-risk areas. # Aboubakr Elnashar
  14. 14. Aboubakr Elnashar Musallam et al, 2016
  15. 15. Aboubakr Elnashar  In Egypt: Risk factors of human infection 1. Consumption of unpasteurized dairy products 2. Eating ice cream from street sellers 3. Occupational contact with animals 4. No knowledge about the disease (Eldiasty et al, 2016)
  16. 16. 3. METHODS OF TRANSMISSION 1. Direct 1. Inoculation through cuts & skin abrasions from handling animal carcasses ‫الجثث‬ , placentas, or contact with animal vaginal secretions 2. Direct conjunctival inoculation 2. Inhalation of infectious aerosols 3. Ingestion of contaminated food: raw milk, cheese made from unpasteurized (raw) milk, or raw meatAboubakr Elnashar
  17. 17. Aboubakr Elnashar  The most common form of transmision  Contaminated food or  Direct contact with infected animals.  Human-to-human transmission by  Placental barrier  Lactation  Sexual  Tissues such as blood & bone marrow. (Tuon et al, 2017)
  18. 18.  Types of transmission 1. Consumption of: 1. Unpasteurized milk 2. Soft cheeses made from the milk of infected animals, primarily goats, infected with B melitensis 2. Occupational 1. Laboratory workers 2. Veterinarians 3. Slaughterhouse workers. Aboubakr Elnashar
  19. 19. Aboubakr Elnashar  In Egypt:  This lack of knowledge regarding disease transmission:  Assisting parturition without protective measures  Throwing aborted material into water canals  Reluctance to remove animals that had aborted from the flock.‫القطيع‬ (Hegazy et al, 2016)
  20. 20. Incubation period  Few days to a few months.  In most patients  2 and 6 w  Duration depend on:  Virulence of the infecting strain  Size of the inoculum  Route of infection  Resistance of the host Aboubakr Elnashar
  21. 21. Portals of entry  Oral entry  Most common route  Ingestion of contaminated animal products (often raw milk or its derivatives)  Contact with contaminated fingers  Aerosols  Inhalation of bacteria  Contamination of the conjunctivae  Per cutaneous through  skin abrasions or  accidental inoculation Aboubakr Elnashar
  22. 22. 4. CLINICAL MANIFESTATION  Usually Acute febrile illness  Accompanied by a wide array of other symptoms  Night sweats  Malaise  Anorexia  Arthralgia  Fatigue  Weight loss  Depression. Aboubakr Elnashar
  23. 23. Fever 1. Acute stages: high 2. Undulant stages: low grade and intermittent 3. Chronic stages: low grade or absent Aboubakr Elnashar
  24. 24.  Complications may affect any organ system 1. Osteoarticular disease most common complication (i.e., sacroiliitis and peripheral arthritis) 2. Genitourinary disease second most common complication. 3. Liver disease second most common medical complication in brucellosis are more susceptible to develop liver disease. Aboubakr Elnashar
  25. 25. 4. Hematological disease Anaemia: found in 72.3% {role of iron in the biology of Brucella} Leukopenia & lymphopenia (the latter considered a prognostic factor) Leukocytosis 23.1% Thrombocytopenia: occurs rarely : fatal CNS bleeding. Aboubakr Elnashar
  26. 26.  The disease may persist as  Relapse  Chronic localized infection  Delayed convalescence Aboubakr Elnashar
  27. 27. Brucellosis & pregnancy outcome: 1. Abortion.  The incidence: 27%  Statistically sign difference in abortion rates between  Patients with a titre ≥ 1/160 and  Those with a titre ≤ 1/160  Causes of spontaneous abortion & IUFD Maternal bacteremia Toxemia Acute febrile reaction DIC Aboubakr Elnashar
  28. 28.  Cases with unexplained spontaneous abortion should be investigated for brucellosis. (Vilchez et al, 2015) Brucellosis causes fewer spontaneous abortions in humans than it does in animals because of 1. Absence of erythritol in the human placenta which appears to be a preferentional medium and growth factor for Brucella in the placenta of animals. 2. Presence of anti-Brucella activity in human amniotic fluid Aboubakr Elnashar
  29. 29. 2. IUFD  More frequently than do other bacterial infections  12% 3. Chorioamnionitis 4. Preterm labour  10%.  The frequency of fetal loss among patients with brucellosis is very high. Aboubakr Elnashar
  30. 30. Aboubakr Elnashar 5. Congenital brucellosis  2% of infants exposed in-utero.  Brucellosis very rarely causing neonatal infection.  Prematurity is the prime cause of death in neonates with congenital brucellosis. (Alsaif et al, 2018)
  31. 31. 5. INVESTIGATIONS  CBC: Total counts: Normal/reduced Thrombocytopenia  ESR/CRP: Normal/Increased  CSF/Body fluid analysis: Lymphocytosis, low glucose levels, elevated ADA  Biopsied samples of lymph node, liver: non caveating granuloma without acid fast bacilli.Aboubakr Elnashar
  32. 32. Serological Tests  Main laboratory method of diagnosis  based on antibody detection  include:  Serum agglutination (standard tube agglutination) STA  ELISA Rose Bengal agglutination  Complement fixation  Indirect Coombs  Immunecapture-agglutination (Brucellacapt) Aboubakr Elnashar
  33. 33.  Serum agglutination test  most widely used  measures agglutination for IgG, IgM, IgA  Diagnostic level: 1 : 160 to 1 : 320 Aboubakr Elnashar
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  36. 36. 6. TREATMENT  Drugs against Brucella  Tetracycline's  Aminoglycosides  Streptomycin since 1947  Gentamicin  Netilmicin  Rifampicin  Quinolones - ciprofloxacin  ?3rd generation cephalosporins Aboubakr Elnashar
  37. 37. WHO recommends  Non pregnant:  Regimen A: Doxycycline 100 mg orally twice daily for 6 w + Gentamycin 5mg/kg daily for 1w more effective, mainly in preventing relapse.  Regimen B: Doxycycline 100 mg orally twice daily plus Rifampin 600 to 900 mg (15 mg/kg) orally once daily for 6 w. more convenient but probably increases the risk of relapse Aboubakr Elnashar
  38. 38. Pregnant  Rifampicin:  900 mg once daily for 6 w  mainstay of treatment of brucellosis during pregnancy OR  Rifampicin:  900 mg once daily plus  Trimethoprim-Sulphmethoxazole  5 mg/kg of the trimethoprim component twice daily for 4 w  Incidence of abortion was not different among patients who received TMP-SMX alone or received TMPSMX and rifampicin Aboubakr Elnashar
  39. 39. 7. PREVENTION Aboubakr Elnashar
  40. 40. Aboubakr Elnashar  In Egypt 1. Effective programs for the control of brucellosis in infected & reservoir animals 2. Raising awareness between whose in contact with animals especially sheep & goat 3. Educational programs to those sharing in milk byproduct production & handling. 4. Hygienic measures (Eldiasty et al, 2016; Ashraf et al, 2019)
  41. 41. CONCLUSION 1. Causative organism: Melitensis: most frequent human infection 2. Epidemiology: Among pregnant women 3.5%-12 .2 % 3. Transmission to human: direct, inhalation, ingestion 4. Clinical Manifestation:  Abortion  IUFD  Chorioamnionitis  PTL Aboubakr Elnashar
  42. 42. 5. Investigations: Serum agglutination test Diagnostic level:1 : 160: 6. Treatment: Rifampicin 7. Prevention: occupational and food hygiene Aboubakr Elnashar
  43. 43. Aboubakr Elnashar You can get this lecture from: 1.My scientific page on Face book: Aboubakr Elnashar Lectures. https://www.facebook.com/groups/2277448840913 51/ 2.Slide share web site 3.elnashar53@hotmail.com 4.My clinic: Elthwara St. Mansura

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