Zoonotic infections Case-Based Session

Zoonotic Infections
Case Based Session
Abdullatif Sami Al Rashed
Microbiology Resident
Teaching Assistant, Department of Microbiology,
College of Medicine, Imam Abdulrahman Bin Faisal
University
Dammam, Saudi Arabia

Objectives
• Introduction.
– Definition.
– Mood of Transmission.
– List of Zoonotic Infection
• Three Cases.
• Resources for Zoonotic Infections.
• References.

Definition
• A zoonotic infection is an animal disease that is
transmissible to humans.
• Humans are usually an accidental host that acquires
disease through close contact with an infected animal
that may or may not be symptomatic.
• The most common route of infection related to animal
contact is through bites, especially in children
• Patients at higher risk for serious illness with zoonotic
infections:
– Children under 5 years old, immunosuppression, adults >
65 years old & pregnant women.
https://www.cdc.gov/healthypets/specific-groups/healthcare-providers.html

https://www.gov.uk/g
overnment/publicatio
ns/list-of-zoonotic-
diseases/list-of-
zoonotic-diseases
UK List of
Zoonotic
Diseases:

CASE 1
• A 22-year-old Chinese pregnant female was
admitted to Shanxi Grand Hospital, Shanxi
Province, China, on July 16, 2015 because of
one day of vaginal bleeding and three days of
abdominal distension accompanied by fever
after five months of amenorrhea.
• This patient had a history of regular
menstruation, and her last menstrual period
had been on February 20, 2015.
Yang HX, Feng JJ, Zhang QX, Hao RE, Yao SX, Zhao R, Piao DR, Cui BY, Jiang H. A case report of spontaneous
abortion caused by Brucella melitensis biovar 3. Infectious diseases of poverty. 2018 Dec;7(1):31.

CASE 1
• The patient had no fever during early pregnancy
and did not have a history of exposure to toxic,
harmful, or radioactive materials.
• Down’s syndrome screening performed as part of
a regular second-semester prenatal checkup
showed no obvious fetal abnormality.
• The patient had abdominal distension with fever
and received anti-infective treatment at a local
hospital three days before coming to Shanxi
Grand Hospital.

CASE 1
• Physical Examination:
– Temp: 39 °C, PP: 120 beats/min, RR: 21 breaths/min,
and BP: 90/53 mmHg,
– No cardiopulmonary or abdominal abnormalities.
• Ob/Gyne examinations showed:
– Minor abdominal swelling, irregular contraction of the
uterus palpable at two fingers under the uterus and
umbilicus, and a small amount of vaginal bleeding.
– The fetal membrane was slightly ruptured, and the
fetal heart rate was 170–180 beats/min.

CASE 1
• A CBC showed:
– 16.6 × 109/L white blood cells:
• 78.4% neutrophils, 16.5% lymphocytes, 4.9%
monocytes.
– RBCs 3.63 × 1012/L
– Hemoglobin 106 g/L
– Platelets 202.1 × 109 g/L
• C-reactive protein was 102.16 mg/L

CASE 1
• The patient had miscarriage and vaginal
delivery of a female fetus on July 19.
• Despite the delivery, the patient’s
temperature continued to fluctuate after
admission, increasing to 39.3.
Yang HX, Feng JJ, Zhang QX, Hao RE, Yao SX, Zhao R, Piao DR, Cui BY, Jiang H. A case report of spontaneous abortion
caused by Brucella melitensis biovar 3. Infectious diseases of poverty. 2018 Dec;7(1):31.
What would you consider
and investigate if you were
in the doctor place?

CASE 1
• Further questions about the patient’s medical
history showed that this patient had sheep at
home but never came into direct contact with
them.
• On further questioning, she had begun to
drink unpasteurized goat milk during her
fourth month of pregnancy.

• What investigations you want to order?

https://www-uptodate-com.library.iau.edu.sa/contents/brucellosis-epidemiology-microbiology-clinical-manifestations-
and-diagnosis?source=history_widget

Manual of clinical microbiology, eleventh edition citation

CASE 1
•A serum tube
agglutination test (SAT) for
brucellosis:
•1:800
•Blood culture were
immediately performed:
• Result is not documented in the
report

Case 1
• She was given antibiotic treatment for three
consecutive days and discharged from the when
the fever stopped.
• At the time of discharge, she was prescribed oral
doxycycline (100 mg/dose, BID) and rifampicin
(600 mg/dose, OD) for 6 weeks as recommended
by the World Health Organization (WHO).
• No recurrence was observed during the six
months of follow-up after the cessation of
antibiotic treatment.

https://data.gov.sa/Data/en/dataset/eported_cases_and_incidence_rates_of_cert
ain_notifiable_communicable__diseases_during_1435_and_1439h
Brucellosis In KSA

2010 CDC Case Definition of Brucella
Infection
• Clinical Description:
• An illness characterized by acute or insidious onset of
fever and one or more of the following:
– Night sweats, arthralgia, headache, fatigue, anorexia,
myalgia, weight loss, arthritis/spondylitis, meningitis, or
focal organ involvement (endocarditis,
orchitis/epididymitis, hepatomegaly, splenomegaly).
https://wwwn.cdc.gov/nndss/conditions/brucellosis/case-definition/2010/

Infection
• Laboratory Criteria for Diagnosis
• Definitive
– Culture and identification of Brucella spp. from clinical
specimens
– Evidence of a fourfold or greater rise in Brucella antibody
titer between acute- and convalescent-phase serum
specimens obtained greater than or equal to 2 weeks
apart.

Infection
• Laboratory Criteria for Diagnosis
• Presumptive
– Brucella total antibody titer of greater than or equal to 160
by standard tube agglutination test (SAT)
or Brucella microagglutination test (BMAT) in one or more
serum specimens obtained after onset of symptoms
– Detection of Brucella DNA in a clinical specimen by PCR
assay

Treatment
• The goal of brucellosis therapy is to control
the illness and prevent complications,
relapses, and sequelae.
• Important principles of brucellosis treatment
include use of antibiotics with activity in the
acidic intracellular environment (doxycycline,
Rifampicin), use of combination regimens, and
prolonged duration of treatment.

Non-Pregnant Adult with
Uncomplicated Brucellosis
Major
Regimens
Doxycycline 100 mg orally twice daily for six weeks +
Streptomycin 1 g intramuscularly once daily for the first 14 to
21 days. (Gentamicin may be substituted for streptomycin;
equal efficacy has been demonstrated)
Doxycycline 100 mg orally twice daily + Rifampicin 600 to 900
mg (15 mg/kg) orally once daily. Both drugs for 6 weeks
Alternativ
e Regimen
Fluoroquinolones (ciprofloxacin 500 mg twice daily) have
good in vitro activity against Brucella spp and can be used in
combination with Doxycycline or Rifampicin. They may be
useful in the setting of drug resistance, antimicrobial toxicity,
and some cases of relapse
Uncomplicated brucellosis (eg, not having spondylitis, neurobrucellosis, or
endocarditis)

Non-Pregnant Adult with
Uncomplicated Brucellosis
Major
Regimens
Doxycycline 100 mg orally twice daily for six weeks +
Streptomycin 1 g intramuscularly once daily for the first 14 to
21 days. (Gentamicin may be substituted for streptomycin;
equal efficacy has been demonstrated)
Doxycycline 100 mg orally twice daily + Rifampicin 600 to 900
mg (15 mg/kg) orally once daily. Both drugs for 6 weeks
Alternativ
e Regimen
Fluoroquinolones (ciprofloxacin 500 mg twice daily) have
good in vitro activity against Brucella spp and can be used in
combination with Doxycycline or Rifampicin. They may be
useful in the setting of drug resistance, antimicrobial toxicity,
and some cases of relapse
Uncomplicated brucellosis (eg, not having spondylitis, neurobrucellosis, or
endocarditis)
Monotherapy and regimens shorter
than six weeks are not accepted
treatment strategies for brucellosis

Learning Points
• History is the key for diagnosis of Brucellosis.
• Keeping in mind all types of complications of
Brucellosis.

CASE 2
• 40 y/o Philippino man living in Al Khobar, was
brought by his friend to our ER complaining of
decrease LOC, hypersalivation , intense fear
and behavioral change for 4 days of duration.
• One month back his friend noticed changes in
his behavior.
• The patient is a known case of hypertension
on antihypertensive medications.

YOUR DDx?
Differential diagnoses
Non-
Infectious
CNS vasculitis
toxic or metabolic
encephalopathy
Stroke
Drug overdose
Infectious
herpes simplex encephalitis
Rabies encephalitis
West Nile virus encephalitis

CASE 2
• 40 y/o Philippino man living in Al Khobar, was
brought by his friend to our ER complaining of
decrease LOC, hypersalivation , intense fear
and behavioral change for 4 days of duration.
• One month back his friend noticed changes in
his behavior.
• The patient is a known case of hypertension
on antihypertensive medications.
What other points to be asked ?

• No history of:
– Headache, fever, photophobia, hydrophobia,
numbness, seizure attacks, slurred speech, weakness
in any side of his body, increase bleeding tendency,
trauma, or previous psychiatric illness.
• Past medical and surgical:
– HTN.
• Medication history:
– Antihypertensive medications.
• Family history:
– Major depressive disorder.
• Social hx:
– Working in private company as a truck driver

Confused, not oriented to TPP, having
hypersalivation and behaving like a
child.
febrile
No meningeal signs, no Lymph
adenopathy
CNS, CVS, GI, RESP  normal
Local : healed large wound below the Rt knee
PhysicalExamination

On Further history
• There is history of a stray dog bite 2 months
ago for which irrigation and cleaning of the
wound was done and he received rabies,
tetanus toxoid vaccines and rabies
immunoglobulin

Lab Investigations
• WBC= 13X10^3 mm^3
• Plt= 319 10^3 mm^3
• Hb= 13 mg/dl
• CRP= 14.5
• LFT, RFT & metabolites= Normal

Radiology
• CT scan : no evidence of stroke
• MRI : light signal intensity in the basal ganglia
in T12 with edema

Lab Investigations
• CSF analysis:
– Colorless fluid, Glucose = 61, protein= 58.9
• CSF culture: No Growth
• Samples of saliva, serum, CSF, and skin
biopsies of hair follicles at the nape of the
neck were collected.

ICU
25 days
Intubated
2 weeks
Acyclovir Amantadine
Hospital Course

Progress
• One attack of seizure during intubation
• Extubation : Conscious, oriented to TPP
• Slow understanding and movement
• Febrile and hypotensive :
• Septic work up  MDR A.bumannii
• Shifted to MMW : quite, communicating, walking with assistance
and eating by him self with difficulty in opening his mouth, less
salivation
• Discharge

• Rabies virus belongs to Rhabdoviridae family
with a nonsegmented, negative-stranded
RNA genomes
https://www.cdc.gov/rabies/diagnosis/index.html

https://data.gov.sa/Data/en/dataset/eported_cases_and_incidence_rates_of_cert

Pre-exposure Prophylaxis
Pre-exposure prophylaxis should be targeted to
persons in high-risk groups, including:
• Veterinarians
• Laboratory workers working with rabies virus or
material and specimens that might contain
infectious rabies virus
• International travelers, who are likely to come
into contact with animals during stays in
countries where dog rabies is enzootic and rapid
access to medical care, particularly biologics, may
not be readily available

ANTIVIRAL SUSCEPTIBILITIES
- No biologics are licensed for rabies antiviral activity.
- Human antiviral treatment recommendations and treatment protocols
are dynamic.
- Antiviral drugs previously used in human treatment regimens include
Antiviral agents
Ketamine Amantadine Ribavirin
effective against RNA virus
infections,
is contraindicated
for rabies treatment due to
depression of the immune
responses.
Alpha
interferon
Toxicic
contraindicat
ed

Learning Points
• History is the key for diagnosis of Rabies.
• Indications of Pre and post exposure
prophylaxis of Rabies.

Case 3
• A 16-month-old child was admitted to the pediatrics
department of Amiens University hospital (France) for
diarrheal syndrome associated with rhinitis.
• He was born in France to French parents living in a rural
area who had never been outside of France. The child’s
father was a dairy farmer and his mother did not work on
the farm.
• The child did not have any particular family history, but had
a personal history of acute otitis media and
rhinopharyngitis.
• His immune status was not investigated, but on the basis of
this history of frequent rhinitis, a respiratory allergy was
suspected and treated with antihistamine.
Agnamey P, Djeddi D, Diallo A, Vanrenterghem A, Brahimi N, da Costa C, Totet A. Childhood
cryptosporidiosis: A case report. Journal of parasitology research. 2010;2010.

Case 3
• The child presented with a six-day history of
fever, rhinitis, vomiting, and profuse diarrhea.
• He experienced up to 7 episodes of nonbloody
watery diarrhea per day.
• He was moderately dehydrated with very
minor signs of dehydration such as weight
loss, deep-set eyes, but no disorders of
consciousness.

Case 3
• On initial physical examination:
– The patient was afebrile but presented
tachycardia of 124 bpm, a respiratory rate of
18/min, and blood pressure of 82/52 mmHg.
– Oxygen saturation on room air was 99%.
• Chest, cardiac, and abdominal examinations
were normal.
• The patient was placed on intravenous fluids
and oral cefpodoxime was started while
waiting for laboratory results

The Laboratory Work-up
• WBC:
– 10,200 cells/mm3 with 46% PMN, 41% lymphocytes,
10% monocytes, 3% eosinophils;
• HgB:
– 13.3 g/dL;
• PLT:
– 477,000/mm3
• Blood biochemistry showed:
– Hyponatremia (130 mmol/L) and decreased alkaline
reserve (19 mmol/L).

The Laboratory Work-up
• Stool specimens were also sent for routine
bacterial culture, rotavirus/adenovirus antigen,
Giardia antigen, Clostridium difficile antigen:
–All were negative.
• Routine stool examination for enteric parasites
including direct saline wet mount examination
and two concentration techniques with both a
fixative and a stain
– Were negative.

What to do next?
What further stool
Investigations in
Your mind?

• Modified Ziehl-Nielsen staining of a stool
smear
??

Modified Kinyoun acid-fast stain

Case 3
• Modified Ziehl-Nielsen staining of a stool
smear showed several Cryptosporidium
oocysts, up to 2,400 per gram of stool.
Is it Important to quantify ?

Case 3
• Cryptosporidium antigen was detected in stool
by the immunochromatographic method
(RIDA QUICK Cryptosporidium, R-biopharm
Diagnostic).
• Polymerase chain reaction-restriction
fragment length polymorphism (PCR/RFLP)
identified the species as Cryptosporidium
parvum.

https://www.aafp.org/afp/2014/0201/p180.ht
ml

Case 3
• Three-day treatment with nitazoxanide
suspension (100 mg twice daily) was then
initiated.
• The symptoms resolved on the day after the
last dose of nitazoxanide.

Is it recommended to do lab follow up or rely on
the clinical response alone ???

Case 3
• Oocysts were no longer detected in stool using
the modified Ziehl-Nielsen stain and
immunochromatographic methods, while PCR
detection was still weakly positive
• Eradication of oocyst excretion was observed
on the day-7 stool sample and PCR detection
was also negative

Cryptosporidiosis
• Cryptosporidiosis is a zoonotic disease (people
handling domestic animals are at high risk)
• Cryptosporidiosis may cause water-borne
outbreaks infection as it is highly resistant to
chemicals used to treat drinking water
• It has a World wide Distribution.
https://www.cdc.gov/parasites/crypto/index.html

Treatment
• In immunocompetent patients: usually no
need to start Antimicrobial therapy.
• In Immunocompromised patients or
immunocompetent with severe acute
symptoms:
• Nitazoxanide
– Adult: 500 mg/12 hours for 3 days.
– Children (1-3 years): 100 mg/12 hours for 3 days.
– Children (4-11 years): 200 mg/12 hours for 3 days.
If Nitazoxande is not tolerated, or if it is not
available, Paromomycin can be used.

Treatment
• Antidiarrheal agents —
–Loperamide is often used for control
of diarrhea.
–However, tincture of opium may be
more effective than loperamide.
• Fluid and electrolytes correction.

Learning Points
• Differential Diagnosis of Diarrheal Diseases.
• How to diagnose Cryptosporidiosis.

Recourses For More Information about
Zoonotic Infections
• https://www.cdc.gov/healthypets/specific-
groups/healthcare-providers.html
• https://www.who.int/topics/zoonoses/en/
• https://www.gov.uk/government/publicatio
ns/list-of-zoonotic-diseases/list-of-zoonotic-
diseases

References
• https://www.cdc.gov/healthypets/specific-groups/healthcare-providers.html
• Agnamey P, Djeddi D, Diallo A, Vanrenterghem A, Brahimi N, da Costa C, Totet A.
Childhood cryptosporidiosis: A case report. Journal of parasitology research.
2010;2010.
• Yang HX, Feng JJ, Zhang QX, Hao RE, Yao SX, Zhao R, Piao DR, Cui BY, Jiang H. A case
report of spontaneous abortion caused by Brucella melitensis biovar 3. Infectious
diseases of poverty. 2018 Dec;7(1):31.
• Manual Of Clinical Microbiology, 11th edition.
• https://www.aafp.org/afp/2014/0201/p180.html
• https://data.gov.sa/Data/en/dataset/eported_cases_and_incidence_rates_of_cert
• https://www-uptodate-com.library.iau.edu.sa/contents/brucellosis-epidemiology-
microbiology-clinical-manifestations-and-diagnosis?source=history_widget

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