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Brucellosis

Brucelloses

Brucellosis is an infectious disease caused by any of several species of the Brucella genus: Brucella melitensis, Brucella abortus, Brucella suis and Brucella canis.


Presentation

Acute brucellosis may present with symptoms such as [7]:

Fever is typically undulant, i.e it comes, reaches a high peak particularly in the afternoon or evening and then goes away for a while. When fever breaks, the patient may experience cold sweats and chills. After a few hours, fever spikes again. The associating symptoms may or may not persist.

Splenomegaly
  • The most frequent admission symptoms and findings of the patients with pancytopenia were fever (75%), fatigue (50%), splenomegaly (75%), and hepatomegaly (41%).[ncbi.nlm.nih.gov]
  • Tender hepatomegaly or splenomegaly was striking in seven patients. Other characteristics included epistaxis, arthralgia, myalgia, and weight loss. Leukopenia and leukemoid reaction were found in five patients.[pediatrics.aappublications.org]
  • Typical symptoms for Bang’s Disease are periodically occuring fever, splenomegaly and swelling of lymph nodes. In some cases an inflammation of different joints and organs occurs. Malta Fever is caused by the epidemic type of brucellosis.[ibl-international.com]
Generalized Lymphadenopathy
  • One patient presented with generalized lymphadenopathy, and 1 patient presented with meningitis. Eight (21.6%) of 28 patients exhibited 1 extrapulmonary complication of brucellosis.[academic.oup.com]
Cough
  • All patients presented with fever and cough.[ncbi.nlm.nih.gov]
  • Cough was reported by 25 patients (67.6%). Ten (27%) of these patients reported productive cough with expectoration, and 15 (40.5%) reported dry cough. One patient presented with paroxysmal, pertussis-like dry cough.[academic.oup.com]
Fever
  • Finally, fever subsided, and he was discharged with good condition and normal platelet count.[ncbi.nlm.nih.gov]
  • […] undulant fever", "zoonosis" and "Iran" in Title/Abstract/Keywords fields.[ncbi.nlm.nih.gov]
  • It has many other names such as Crimean Fever, Malta Fever, Undulant Fever, Mediterranean Fever, etc. It comes under the category of zoonotic diseases which refers to the group of diseases caused by organisms associated with animal reservoirs.[symptoma.com]
  • Brucellosis is a systemic zoonotic infectious disease that may cause fever, fatigue, sweating, arthritis, hepatosplenomegaly, cytopenia, and lymphadenopathy. It continues to be an important health problem worldwide.[ncbi.nlm.nih.gov]
  • A case is reported here of a 33-year-old woman with symptoms of night sweats, fever and low back pain. Rose-Bengal test for brucellosis was positive and Brucella standard tube agglutination test was positive at a titre of 1/160.[ncbi.nlm.nih.gov]
Fatigue
  • Clinical symptoms include fever, fatigue, hyperhidrosis, and joint pain with common complication of osteoarticular involvement.[ncbi.nlm.nih.gov]
  • Brucellosis is a systemic zoonotic infectious disease that may cause fever, fatigue, sweating, arthritis, hepatosplenomegaly, cytopenia, and lymphadenopathy. It continues to be an important health problem worldwide.[ncbi.nlm.nih.gov]
  • A 49-year-old man was admitted to the hospital with complaints of fatigue, epistaxis and a skin rash.[ncbi.nlm.nih.gov]
  • The patient described fever, night sweats, widespread muscle pain and fatigue that had been going on for the last six days. Standard tube agglutination for Brucella was positive at a titre of 1/320.[ncbi.nlm.nih.gov]
  • A 75-year-old Hispanic man presented to a University Hospital in Chía, Colombia, with a complaint of 15 days of fatigue, weakness, decreased appetite, epigastric abdominal pain, jaundice, and 10 kg weight loss.[ncbi.nlm.nih.gov]
Weight Loss
  • The patient reported the loss of appetite, arthralgia and weight loss during previous five months. Finally, he was diagnosed with brucellosis by positive blood culture and high titer for Brucella agglutination test.[ncbi.nlm.nih.gov]
  • A 75-year-old Hispanic man presented to a University Hospital in Chía, Colombia, with a complaint of 15 days of fatigue, weakness, decreased appetite, epigastric abdominal pain, jaundice, and 10 kg weight loss.[ncbi.nlm.nih.gov]
  • This condition is characterized by fever, weakness, malaise, and weight loss.[ncbi.nlm.nih.gov]
  • This condition is characterized by Fever, weakness, malaise, and Weight Loss. 0 0 A Disease of Cattle caused by Bacteria of the genus Brucella leading to abortion in late Pregnancy.[dictionary.university]
  • Symptoms include abortions, infertility, decreased milk production, weight loss, and lameness. Brucellosis is also the most common bacterial disease that is transmitted from animals to humans, with approximately 500 000 new human cases each year.[ncbi.nlm.nih.gov]
Chills
  • The patients with this disease are typically present with chills, fever, asthenia and sweating. This paper describes a patient with brucellosis and skin rashes on the leg. A 41-year-old man presented with fever, ataxia, and dysarthria.[ncbi.nlm.nih.gov]
  • Symptoms Symptoms include fever with chills and rigors, fatigue, headache, abdominal pain, muscular pain, sweating and sometimes it may be accompanied with skin rashes, eye infections and CNS disorders.[symptoma.com]
  • B. melitensis is also the most virulent Brucella species for humans, responsible for a severely debilitating and disabling illness that results in high morbidity with intermittent fever, chills, sweats, weakness, myalgia, abortion, osteoarticular complications[ncbi.nlm.nih.gov]
  • Brucellosis is a bacterial disease that may affect various organs of the body, producing a wide variety of signs and symptoms such as intermittent fever of variable duration, headache, weakness, swollen lymph nodes, profuse sweating, chills, weight loss[dhs.wisconsin.gov]
  • BRUCELLOSIS SYMPTOMS Symptoms of Brucellosis include an undulating fever , which rises and falls throughout the day reaching over 104 degrees Fahrenheit in the late afternoon, fatigue, joint and bone pain, weakness, chills, muscle pain , back, pain, severe[medicalook.com]
Veterinarian
  • A total of 1050 sera samples were collected from animal handlers, veterinarians, veterinary students, para-veterinarians and persons engaged in artificial insemination of animals.[ncbi.nlm.nih.gov]
  • Greater knowledge about the disease was observed among people with a higher educational level, veterinarians, livestock farmers/traders and men.[ncbi.nlm.nih.gov]
  • In endemic areas, certain occupations such as veterinarians, butchers, and slaughterhouse workers are considered high risk regarding brucellosis.[ncbi.nlm.nih.gov]
  • The objective of the study was to develop and test a method for evaluating, in an innovative way, some farmers' and veterinarians' management practices in relation to brucellosis and to assess the vaccination campaign and coverage.[ncbi.nlm.nih.gov]
  • If you need advice on a cattle health problem please contact your local veterinarian.[cattletoday.info]
Vomiting
  • He began to feel myalgia, arthralgia, malaise, shortness of breath, abdominal pain, vomiting, diarrhoea and lost weight eight months after initial symptoms occured. Because symptoms progressed he was admitted to our hospital in February 2009.[ncbi.nlm.nih.gov]
  • For the past month, he has had general malaise, daily fevers, and some nausea and vomiting. On physical exam, he has a low-grade fever but otherwise a normal physical exam.[medbullets.com]
  • Gastrointestinal symptoms occur in 70% of cases and include nausea , vomiting , decreased appetite , unintentional weight loss, abdominal pain, constipation , diarrhea , an enlarged liver , liver inflammation , liver abscess , and an enlarged spleen .[en.wikipedia.org]
Nausea
  • For the past month, he has had general malaise, daily fevers, and some nausea and vomiting. On physical exam, he has a low-grade fever but otherwise a normal physical exam.[medbullets.com]
  • Gastrointestinal symptoms occur in 70% of cases and include nausea , vomiting , decreased appetite , unintentional weight loss, abdominal pain, constipation , diarrhea , an enlarged liver , liver inflammation , liver abscess , and an enlarged spleen .[en.wikipedia.org]
Loss of Appetite
  • The patient reported the loss of appetite, arthralgia and weight loss during previous five months. Finally, he was diagnosed with brucellosis by positive blood culture and high titer for Brucella agglutination test.[ncbi.nlm.nih.gov]
Hepatosplenomegaly
  • Brucellosis is a systemic zoonotic infectious disease that may cause fever, fatigue, sweating, arthritis, hepatosplenomegaly, cytopenia, and lymphadenopathy. It continues to be an important health problem worldwide.[ncbi.nlm.nih.gov]
  • The diagnostic criteria include fever, hepatosplenomegaly, bicytopenia, high serum ferritin level, decreased natural killer cell activity, elevated soluble CD25 level, high serum fasting triglyceride level or low fibrinogen level, and hemophagocytosis[ncbi.nlm.nih.gov]
  • On examination in an emergency room, abdomen palpation was normal with hepatosplenomegaly and the results of a liver function test were elevated.[ncbi.nlm.nih.gov]
  • Common clinical features included fever (83%), arthralgias or arthritis (67%), and hepatosplenomegaly (61%). Positive blood cultures were more frequently reported among children than adults (83% vs 33%, P 0.03).[ncbi.nlm.nih.gov]
  • Pediatricians caring for patients in areas where consumption of unpasteurized milk products is likely would do well to consider brucellosis in a child with obscure fever or toxic hepatosplenomegaly. Received March 5, 1974. Accepted August 12, 1974.[pediatrics.aappublications.org]
Hepatomegaly
  • Physical examination of the patient revealed massive hepatomegaly. Abdominal ultrasonography and computerised tomography showed a single large cystic lesion of the liver. The echinococcus indirect haemagglutination was positive at a titre of 1/1280.[ncbi.nlm.nih.gov]
  • Brucellosis is a multisystem infection found worldwide that has a broad range of characteristics, which range from acute fever and hepatomegaly to chronic infections that most commonly affect the central nervous system, cardiovascular system, or skeletal[ncbi.nlm.nih.gov]
  • The most frequent admission symptoms and findings of the patients with pancytopenia were fever (75%), fatigue (50%), splenomegaly (75%), and hepatomegaly (41%).[ncbi.nlm.nih.gov]
  • Tender hepatomegaly or splenomegaly was striking in seven patients. Other characteristics included epistaxis, arthralgia, myalgia, and weight loss. Leukopenia and leukemoid reaction were found in five patients.[pediatrics.aappublications.org]
Night Sweats
  • The patient described fever, night sweats, widespread muscle pain and fatigue that had been going on for the last six days. Standard tube agglutination for Brucella was positive at a titre of 1/320.[ncbi.nlm.nih.gov]
  • A case is reported here of a 33-year-old woman with symptoms of night sweats, fever and low back pain. Rose-Bengal test for brucellosis was positive and Brucella standard tube agglutination test was positive at a titre of 1/160.[ncbi.nlm.nih.gov]
  • An Egyptian female with night sweats, headache, and back pain was diagnosed with acute brucellosis one week after returning from a North African country.[ncbi.nlm.nih.gov]
  • Myalgia, fatigue, back pain, joint pain, night sweats, fever, malaise, and headache were common symptoms in seropositive cases. Moreover, 20.6% of the seropositive participants were asymptomatic.[ncbi.nlm.nih.gov]
  • The signs and symptoms associated with brucellosis may include fever, night sweats, chills, weakness, malaise, headache, and anorexia. The physical examination may reveal lymphadenopathy and hepatosplenomegaly.[mayomedicallaboratories.com]
Arthritis
  • When the patients were divided into groups as arthritis positive and arthritis negative and compared to the control group; we found that the NLR is more significant in between the arthritis positive and control group (p 0.013).[ncbi.nlm.nih.gov]
  • The musculoskeletal system involvement is frequent and, rarely, arthritis can be the only clinical feature of the disease. We report a case of monoarthritis caused by Brucella melitensis.[ncbi.nlm.nih.gov]
  • Brucellosis is a systemic zoonotic infectious disease that may cause fever, fatigue, sweating, arthritis, hepatosplenomegaly, cytopenia, and lymphadenopathy. It continues to be an important health problem worldwide.[ncbi.nlm.nih.gov]
  • The musculoskeletal system is frequently affected, and the disease can exhibit clinical involvements such as arthritis, spondylitis, spondylodiscitis, osteomyelitis, tenosynovitis and bursitis.[ncbi.nlm.nih.gov]
  • MRI is a good method in differentiating those with symptoms of arthritis.[ncbi.nlm.nih.gov]
Arthralgia
  • A 15-year-old girl, who was evaluated for arthralgia of knees, was diagnosed as having brucellosis by serum agglutination and enzyme linked immunosorbent assay tests. Physical examination of the patient revealed massive hepatomegaly.[ncbi.nlm.nih.gov]
  • Initially, our patient, a 65 year-old man, had nonspecific manifestations of fever, malaise, headache, anorexia and arthralgia which are the classic symptoms of this disease.[ncbi.nlm.nih.gov]
  • Common clinical findings are usually nonspecific involving fever, arthralgia, myalgia, weakness and malaise. Since none of the symptoms of brucellosis is pathognomonic, it may have a similar course with various multisystemic diseases.[ncbi.nlm.nih.gov]
  • In this study, we discuss a 17 year old male patient who was admitted to our hospital due to fever, abdominal pain, arthralgia and rash on legs, diagnosed with brucellosis through brucellosis tube agglutination test and found to have splenic infarct upon[ncbi.nlm.nih.gov]
  • The patient reported the loss of appetite, arthralgia and weight loss during previous five months. Finally, he was diagnosed with brucellosis by positive blood culture and high titer for Brucella agglutination test.[ncbi.nlm.nih.gov]
Myalgia
  • Common clinical findings are usually nonspecific involving fever, arthralgia, myalgia, weakness and malaise. Since none of the symptoms of brucellosis is pathognomonic, it may have a similar course with various multisystemic diseases.[ncbi.nlm.nih.gov]
  • Myalgia, fatigue, back pain, joint pain, night sweats, fever, malaise, and headache were common symptoms in seropositive cases. Moreover, 20.6% of the seropositive participants were asymptomatic.[ncbi.nlm.nih.gov]
  • Brucellosis patients present various non-specific clinical symptoms, such as fever, fatigue, sweating, joint pain, arthritis, myalgia, and headache.[ncbi.nlm.nih.gov]
  • B. melitensis is also the most virulent Brucella species for humans, responsible for a severely debilitating and disabling illness that results in high morbidity with intermittent fever, chills, sweats, weakness, myalgia, abortion, osteoarticular complications[ncbi.nlm.nih.gov]
  • He began to feel myalgia, arthralgia, malaise, shortness of breath, abdominal pain, vomiting, diarrhoea and lost weight eight months after initial symptoms occured. Because symptoms progressed he was admitted to our hospital in February 2009.[ncbi.nlm.nih.gov]
Low Back Pain
  • A case is reported here of a 33-year-old woman with symptoms of night sweats, fever and low back pain. Rose-Bengal test for brucellosis was positive and Brucella standard tube agglutination test was positive at a titre of 1/160.[ncbi.nlm.nih.gov]
Headache
  • The patient also suffered from headache, partial seizures, changes of personality and static tremor of both upper limbs.[ncbi.nlm.nih.gov]
  • Initially, our patient, a 65 year-old man, had nonspecific manifestations of fever, malaise, headache, anorexia and arthralgia which are the classic symptoms of this disease.[ncbi.nlm.nih.gov]
  • An Egyptian female with night sweats, headache, and back pain was diagnosed with acute brucellosis one week after returning from a North African country.[ncbi.nlm.nih.gov]
  • Symptoms include recurring fevers, sweating, weakness, anorexia, headaches, depression and generalized aches and pains. Synonyms * undulant fever[wikidiff.com]
  • Myalgia, fatigue, back pain, joint pain, night sweats, fever, malaise, and headache were common symptoms in seropositive cases. Moreover, 20.6% of the seropositive participants were asymptomatic.[ncbi.nlm.nih.gov]
Confusion
  • Brucellosis can lead to haematological abnormalities including cytopenia confusing with haematological malignancies.[ncbi.nlm.nih.gov]
  • Cautions Discusses conditions that may cause diagnostic confusion, including improper specimen collection and handling, inappropriate test selection, and interfering substances Although Brucella species are relatively resistant to adverse environmental[mayomedicallaboratories.com]

Workup

Workup consists of a detailed history and physical examination.

Laboratory tests

  • Complete blood count
  • Liver function tests
  • Culture
  • Serology is unreliable. A four-fold rise in titre of agglutinating antibody, which detects IgM antibody, may be diagnostic but cross reactions are common [8]. 
  • Arthrocentesis: In patients with joint involvement to rule out septic arthritis
  • CSF culture: In patients with CNS involvement.
  • PCR 
  • Bone marrow biopsy
  • Urinalysis

Imaging

Imaging studies are conducted if systemic manifestations are present. They may include:

  • Chest X-ray if respiratory system seems to be involved. 
  • Spinal X-ray to examine vertebral involvement.
  • Radionuclide scintography [9]
  • CT scan
  • Echocardiography to rule out endocarditis

Test Results

Test results are enough to form a definitive diagnosis and treatment needs to be started immediately. An empiric antibody trial may be started if test results are awaited.

Brucella Abortus
  • In this case of neonatal brucellosis, Brucella abortus was isolated by blood culture from both the mother and the neonate. Serology was positive only in the mother.[ncbi.nlm.nih.gov]
  • In the study, blood samples were collected to screen for serum agglutinins reactive to stained antigen of Brucella abortus Standard tube titration was performed for reactive serum to determine the titer of the agglutinin.[ncbi.nlm.nih.gov]
  • In Albania, Brucella abortus and B. melitensis affect humans, cattle and small ruminants. In the United States, B. abortus affects cattle and wild ungulates in the Greater Yellowstone Area.[ncbi.nlm.nih.gov]
  • The species was Brucella melitensis in 35 cases, Brucella abortus in 3 cases and not documented in 6 cases. The diagnosis was based on a positive blood culture from the first day of life in 20 cases (45%).[ncbi.nlm.nih.gov]
  • Brucella abortus is the etiological agent of brucellosis, a zoonotic disease affecting cattle and humans. This disease has been partially controlled in cattle by immunization with live attenuated B. abortus S19 and RB51 strains.[ncbi.nlm.nih.gov]
Blood Culture Positive
  • A diagnosis of acute brucellosis was considered due to positive serological tests and a blood culture positive for Brucella spp.[ncbi.nlm.nih.gov]
  • Agglutination test showed 98.5% positive with 34% blood culture positive of Brucella.[ncbi.nlm.nih.gov]
  • Sera from this patient with chronic brucellosis recognized some of the same B. melitensis proteins as those recognized by sera from acute/subacute, blood culture-positive brucellosis patients but also recognized a distinct set of proteins.[ncbi.nlm.nih.gov]

Treatment

Antibiotics are the primary treatment. The most common and most efficacious of used agents include:

  • Streptomycin
  • Doxycycline 
  • Gentamycin
  • Rifampin
  • Cotrimoxazole
  • Ciprofloxacin

Of the currently existing alternative regimens, only the combination of doxycycline with gentamycin can be considered therapeutically adequate and cost-effective, the latter factor being a major obstacle in using quinolones for brucellosis [10].

Prognosis

Even though initial symptoms may appear to be debilitating, brucellosis has an excellent prognosis. With appropriate treatment for a few weeks to months, this disease can be cured with no lasting effects. Relapse may sometimes occur. It should be noted, however, that in patients with comorbidities such as congestive heart failure, prognosis can be negatively affected. Overall, mortality rate in uncomplicated cases is less than 2 to 5%.

Complications

Infection in pregnancy may result in abortion, congenital and neonatal infections, and infections of the delivery team [6]. Other complications include endocarditis, CNS disorders (neurobrucellosis), meningitis, skin lesions, ulcers and eye infections.

Etiology

The causative agent of brucellosis is an unencapsulated gram negative rod called Brucella. There are three main human pathogens of Brucella, each with their specific animal reservoirs:

  • Brucella melitensis (goats and sheep)
  • Brucella suis (pigs)
  • Brucella abortus (cattle)

Brucella canis (dogs) may also infect humans but it is rare and clinically indistinguishable from B. abortus infection.

Epidemiology

Incidence

The reported frequency in USA is 0.04 per 100,000 people [2]. It has been known to cause more than 500,000 infections annually worldwide.

Age

Brucellosis can occur at any age but it is more common in young adults. Infection among children is generally more benign than in adults with respect to likelihood and severity of complications and response to treatment [3].

Sex

Brucellosis is much more common in males than in females. This predisposition to the male gender is attributed to males being more involved in activities, such a cattle farming, that increase chances of exposure.

Sex distribution
Age distribution

Pathophysiology

The organisms enter the body either by ingestion of contaminated milk products or through skin due to contact in occupational setting such as an abattoir [4]. Once inside, these organisms localise in the reticuloendothelial system, where some of them are phagocytosed by macrophages. Some, however, survive within the cells and remain protected from antibodies.

The host response is granulomatous, with lymphocytes and epitheloid giant cells, which can progress to form focal abscesses [4].  The incubation period is usually one to four weeks; occasionally, it may be as long as several months [5].

Prevention

Prevention can be possible with pasteurisation of milk, immunisation of animals, and slaughtering of infected animals. There is no human vaccine [4].

Summary

Brucellosis is a systemic infection with a broad clinical spectrum, ranging from asymptomatic disease to severe and/or fatal illness [1]. It has many other names such as Crimean Fever, Malta Fever, Undulant Fever, Mediterranean Fever, etc. It comes under the category of zoonotic diseases which refers to the group of diseases caused by organisms associated with animal reservoirs. Brucellosis is the most common zoonotic disease.

Patient Information

Definition

Brucellosis is a systemic infection which has a broad clinical spectrum. It may be asymptomatic to, in some extremely rare cases, fatal. It is also known as undulant fever, Malta fever, Mediterranean fever, etc.

Cause

It is caused by a bacteria called Brucella, which lives in animals like sheep, goats, dogs and pigs. Drinking unpasteurised milk or eating the meat of infected animals may result in this infection.

Symptoms

Symptoms include fever with chills and rigors, fatigue, headache, abdominal pain, muscular pain, sweating and sometimes it may be accompanied with skin rashes, eye infections and CNS disorders.

Treatment

Antibiotics are the treatment of choice and this disease can be completely cured in a few weeks of therapy.

Prevention

Brucellosis is easily preventable. By avoiding the use of unpasteurised milk and other dairy products, and eating the meat only from high quality stores, brucellosis can be prevented.

References

Article

  1. Colmenero JD, Reguera JM, Martos F, et al. Complications associated with Brucella melitensis infection: a study of 530 cases. Medicine (Baltimore) 1996; 75:195.
  2. Maloney GE. Brucellosis. eMedicine. Apr 2009. Retrieved Sept 26 2014.
  3. Mantur BG, Amarnath SK, Shinde RS. Review of clinical and laboratory features of human brucellosis. Indian J Med Microbiol 2007; 25:188.
  4. Warren Levinson. Review of Medical Microbiology and Immunology. 11th ed. Pa: McGraw Hill. Lange. Chap 20 p146-7. ISBN 978-0-07-170028-3.
  5. Fiori PL, Mastrandea S, Rappelli P, Cappuccinelli P. Brucella abortus infections quoted in microbiology laboratories. J Clin Microbiol 2000; 38:2005.
  6. Karcaaltincaba D, Sencan I, Kandemir O, et al. Does brucellosis in human pregnancy increase abortion risk? Presentation of two J Obstet Gynecol Res. 2010 Apr;36(2):418-23.
  7. Young EJ. Brucella species. In: Mandell GL, Bennett JE, Dolin R, eds. principles and Practice of Infectious Disease. 7th ed. Philadelphia. PA: Elsevier Churchill Livingstone. 2009:chap 226.
  8. Davidson's Principles and Practice of Medicne: A textbook for students and doctors. Christopher RWE, Ian ADB, eds. 16th ed. PA: Elsevier Churchill Livingstone. Chap 5, p130-1.
  9. el-Desouki M. Skeletal Brucellosis: assessment with bone scintigraphy. Radiology. Nov 1991;181(2):415-8 [Medline].
  10. Hasanjani Roushan MR, Mohraz M, Hajiahmadi M, et al. Efficacy of gentamycin plus doxycycline versus streptomycin plus doxycycline in the treatemt of brucellosis in humans. Clin Infect Dis. 2006 Apr 15;42(8):1075-80. epub 2006 Mar 13. 

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Last updated: 2017-08-09 17:43