BRUCELLA SPPS

DR NKOLIKA S C UWAEZUOKE
 OUTLINE
• HISTORICAL BACKGROUND
• INTRODUCTION
• MICROBIOLOGY
• EPIDEMIOLOGY
• PATHOGENESIS
• CLINICAL FEATURES
• DIAGNOSIS
• TREATMENT
• PREVENTION
 HISTORICAL BACKGROUND
• Sir David BRUCE (1855-1931)
-A British Army physician and microbiologist who
discovered Micrococcus melitensis.
He isolated B. melitensis from British soldiers who
died from Malta fever in Malta.
• Bernhard Bang (1848-1932)
-Danish physician and veterinarian
-Discovered Bacterium abortus (1897) could infect
cattle, horses, sheep and goats.
• The Genus Brucella was named after Sir David Bruce!
 INTRODUCTION
• Brucella spps are the causative agents of Brucellosis, a
highly contagious zoonotic disease primarily affecting
animals but can be transmitted to humans via
contaminated dairy products or direct contact with
infected animals.
• Also the cause of infectious (contagious) spontaneous
abortion in cattle.
• Can also cause abortions in man.
• During pregnancy, brucellosis can lead to premature
delivery, congenital or neonatal infection
 INTRODUCTION
• Survive well in aerosols and resist drying
• Candidate agents of bioterrorism and belong
to category 3 pathogens
 INTRODUCTION-TAXONOMY
• Domain- Bacteria
• Phylum-Protebacteria
• Class- Proteobacteria alpha
• Order- Rhizobiales
• Family-Brucellaceae
• Genus- Brucella
 INTRODUCTION
• Brucellosis is a zoonotic disease caused by Gram negative
bacteria of the Genus Brucella characterized by an acute
febrile stage and a chronic stage with relapses of fever,
weakness, sweating and vague aches and pain.
• Human brucellosis is a grave a and debilitating disease that
may leave disabling sequelae.
• It is one of the Neglected tropical diseases (NTDs)
• It has various names such as Undulant fever,
Mediterreanean fever, Maltese fever, Gilbraltar fever,
Cyprus fever, Remitting fever, Crimean fever, Goat fever
and Bang’s disease
 INTRODUCTION-Various names of Brucella
spp
HUMAN DISEASE ANIMAL DISEASE
Malta Fever Bang’s Disease
Undulant Fever Enzootic Abortion
Mediterranean Fever Epizootic Abortion
Rock Fever of Gibraltar Ram Epididymitis
Gastric Fever Slinking of calves
Contagious Abortion
 INTRODUCTION
• The main Brucella species causing disease in man are:
-B.abortus (cattle)
-B.melitensis (sheep and goats)
-B.suis (hogs,swine,hares, )
-B.canis (dog)
• Of these , B.melitensis is the spp infecting humans
frequently, the most virulent and prevalent species causing
the most severe cases of brucellosis.

• Both man and domestic animals could be infected with any

of these species
 INTRODUCTION
• Brucella spps infecting animals include:
• B. abortus
• B. suis
• B. melitensis
• B. canis
• B. ovis (sheep)
• B. neotomate (Desert wood rat)
• B. maris (marine animals)
 MICROBIOLOGY (MORPHOLOGY)
• In young cultures, Brucella species are small,
Gram-negative, aerobic coccobacilli.
• Non-motile, non-capsulated, and non-spore
forming
• Measure 0.5-0.7µm x 0.6-1.5 µm in size,
arranged singly or in short chains.
• Sometimes, they may appear as cocci or short
rods
 MORPHOLOGY (CULTURAL
CHARACTERISTICS)
• Can be grown on blood agar (BA),chocolate
agar(CA), Trypticase soy agar with selective
agents.
• On BA, non-haemolytic, non-pigmented small
colonies are seen
• May require 48-72hrs for colonies to be
discrete and evident.
• Colonies are visible after 3-5 days incubation.
 MORPHOLOGY (CULTURAL
CHARACTERISTICS
• Colonies are1-2mm in diameter, round, entire
edged, smooth, glistening, translucent and a pale
honey color when plates are viewed in the daylight.
• B. abortus, B.suis and B.melitensis form smooth
colonies while B.ovis and B.canis form rough
colonies.
• All strains grow best in a medium enriched with
animal serum and glucose.
• Requires 5-10% CO2 (except B. melitensis) which
enhances growth
B. abortus after 24 hrs incubation
Brucella abortus on sheep blood agar after
48 hrs
 MICROBIOLOGY- GRAM
STAIN/BIOCHEMICALS
• Tiny, often faintly stained Gram-negative coccobacilli
• Could be mistaken as cocci
• May even retain crystal violet stain in blood culture
smears
• Urea positive rapidly
• Oxidase and Catalase positive
• Negative for IMViC reactions
• Nitrate are reduced
• H2S Production by B. abortus and B.suis
 MICROBIOLOGY-LAB DIAGNOSIS
Acceptable Specimen Types include:
• Whole blood: 5-10ml blood in EDTA, and/or
Inoculated blood culture
• Liver or spleen biopsy, or abscess
• Lymph node or bone marrow aspirate (1ml)
• Synovial fluid
• CSF (1ml)
• Bone marrow cultures is more sensitive than
blood
 MICROBIOLOGY
• Brucella spps may be misidentified by
automated systems as:
• Moraxella spp,
• Micrococcus spp,
• Corynebacterium spp
• “Slow growing’’ Staphylococcal spp
• Haemophilus spp
• Pasturella spp
 EPIDEMIOLOGY
• Occurs worldwide but is endemic in Africa, the middle
East, Central and South East Asia, South America and
some Mediterrnean countries.
• Highest incidence is in the Mediterranean countries,
Middle East and tropics.
• Human to human transmission though rare can occur via
breast milk, sexual transmission and congenital disease.
• May also occur through the occupational exposure of lab
workers, vets, and those that slaughter animals.
• IP ranges from a few days to a few months.
 EPIDEMIOLOGY-Who is at risk ?
• Brucellosis is mainly an occupational Disease of those working with
infected animals or their tissues. Examples
-Cattle ranchers/dairy farmers
-Vetinerians/Livestock producers
-Abbatoir workers
-Meat inspectors/meat packers
-Lab workers
-Hunters
• Travelers- consuming local delicacies
• Consumers of unpasteurized dairy products, eg milk
• Children
Brucellosis manifests similarly in neonates, children and adults.
 EPIDEMIOLOGY
• About 500,000 new human cases of
brucellosis are diagnosed each year,
representing the world’s most prevalent
bacterial zoonosis.
• The global disease burden in livestock is even
greater, and conservative estimates are that
>300 million of the 1.4 billion worldwide cattle
population are infected with the pathogen.
• Most prevalent in rural areas
 PATHOGENESIS
• Following ingestion or entry through skin abrasions or
the inhalation of infected dust, the bacteria travel via the
lymphatics and reside in the regional lymph nodes.
• They then enter the circulation via haematogenous
spread and consequently enter different parts of the
reticulo-endothelial system forming granulomatous
lesions.
• Brucella spps can survive within the granulomas, leading
to relapses of acute disease or chronic brucellosis.
• Brucellae are intracellular pathogens
 CLINICAL FEATURES
• Various clinical presentations abound in
brucellosis. They include:
• Undulant Fever or wave-light Fever-which leads
to fever which rises and falls over weeks. Seen
in approximately 90% of untreated patients.
• Malodorous perspiration is pathognomonic.
Other presenting features include presence of
localized infections such as osteoarticular in
30%, and epidyidymo-orchitis in 6%.
 CLINICAL FEATURES
Other symptoms seen especially in acute form (<8 weeks
from illness onset) include:
• Weakness
• Anorexia
• Night sweats
• Headache
• Depression
• Myalgia/Arthralgia/back pain
• Body pains
• Hepato-splenomegaly maybe present in
• Weight loss
 CLINICAL FEATURES
• Brucellosis can involve any organ or system and has
a very insidious onset with varying clinical signs.
• Incubation Period (IP) is about 2-4 weeks.
• The one common symptom in most, if not all
patients is an intermittent /irregular fever with
variable duration (waxing and waning of fever in a
cycle lasting 2-4 weeks), hence the name undulant
fever.
• Lymph node enlargement may be the only clinical
evidence.
 ClINICAL FEATURES
• In the undulant form(<1yr from onset)
sympyoms include fever, undulant in nature,
arthritis, and orchiepididymitis in young males.
• In the chronic form (>1 yr from onset,
symptoms may include chronic fatigue-like
syndrome and depresssive episodes.
• Illness in people can be protracted and painful
resulting in an inability to work and the loss of
income.
 COMPLICATIONS
Highly variable and include:
• Granulomatous hepatitis/hepatic suppuration
• Arthritis/spondylitis
• Anaemia
• Leucopenia
• Thrombocytopenia
• Meningitis/Encephalitis
• Uveitis
• Optic neuritis
• Subacute bacterial Endocarditis
• Bone lesions
• Cholecystitis
 COMPLICATIONS
• The most frequent complication appears to be
the involvement of the bones and joints.
• The sacro-iliac joint is often affected in countries
where B. melitensis predominates.
• Arthritis of the hips, knees and ankles also occurs
with spondylitis being the primary complaint.
• Complications involving the bones and joints are
reported in 20%-60% of patients with clinical
Brucellosis.
 COMPLICATIONS
• The liver is generally involved in most cases of
brucellosis as it is an organ involved in the
reticulo-endothelial sysyetm (RES).
• Hepatomegaly may occur as a result of the
liver trying to remove the infection .
• It is possible to isolate the organisms from the
liver without signs of hepatic sysfuction or
liver disease.
 COMPLICATIONS
• Genito-urinary complications can occur with the
testicles being most frequently affected.
• Evidence of orchitis or epididymo-orchitis can occur in
association with systemic infection.
• Renal involvement is rare.
• Cardiovascular complications are rare but endocarditis
accounts for the majority of death from this disease.
• Suppurative localized infections usually refractory to
antibiotic treatment may require surgical intervention
before a cure can be achieved.
 LAB DIAGNOSIS
• Human Brucellosis lacks pathognomonic symptoms and so
lab tests are essential for diagnosis.
• The correct diagnosis of brucellosis in humans is crucial
not only for early and adequate patient management but
has also serious public health significance, as it may reveal
-exposure to sick animals,
-consumption of contaminated food (especially dairy
products),
-breach of laboratory safety practices, or
-the intentional release of brucellae as a biological warfare
 LAB DIAGNOSIS
• The microbiological diagnosis of human
brucellosis relies on three different modalities:
-culture,
-serology, and
-nucleic acid amplification tests (NAATs).
 LAB DIAGNOSIS
• Isolation of the bacterium is indisputable evidence of the disease.
• Culture recovery of the bacterium permits its precise identification to
species level and genotyping, making it possible to track the source,
differentiate between wild and vaccine Brucella strains, and perform
antibiotic susceptibility testing when indicated.
• Detection of brucellae in blood cultures also makes it possible to
confirm the presence of the disease in its early stages, when the
serological tests results are still negative or show low or borderline
antibody titers .
• An additional benefit of the isolation of brucellae is the fact that it
establishes a solid diagnosis in patients in whom the infection is not
clinically suspected but the organism is recovered from a blood culture
obtained as part of the routine workup of a nonspecific febrile
syndrome
 LAB DIAGNOSIS
SEROLOGY TESTING- testing bld for antibody presence
• Antibodies appear within 7-14 days after infection and identification of B.
abortus, melitensis and suis can be achievd via the Serum agglutination test-SAT
(standard tube agglutination)
-A Four-fold or greater rise in titre in brucella antibody titre over a period of 4
weeks is highly suggestive and considered diagnostic.
-Samples taken 2 weeks apart
• Rose Bengal (dichlorotetraiodofluorescein) Test, RBT- a rapid slide agglutination
test that is used to diagnose human brucellosis. Often used as a screening test.
• Immunofluorescence Method
-Organisms in clinical specimens
• Molecular Testing- PCR for rapid diagnosis in human blood specimens, gaining
popularity
• Lateral flow immunochromatography assay (LRiC) for IgM ,IgG and IgA detection
and assessment.
 LAB DIAGNOSIS
• ELISA
• Brucellacapt
• Castaneda strip test- strip with a colored brucella antigen on
a filter paper is used
• Brucella skin test: A delayed type of hypersensitivity reaction
to brucella antigen using brucellin,a protein extract from the
organism as antigen.
• The presence of erythema and induration of 6mm or more
within 24hrs is suggestive of a positive reaction
• The test is only positive in chronic brucellosis.
• Repeated negative skin test excludes brucellosis.
 LAB DIAGNOSIS
• Milk Ring test
• Complement fixation test- detects IgG and IgM
antibodies.
• Lysis centrifugation
• Imaging Techniques/Radiology: For patients with
spine symptoms. Plain radiographs, joint ultrasound,
CT Scan, MRI
• Change or alterations in affected vertebrae (Pedro
Pons sign ) and marked osteophytes are suspicious
of brucellic spondylitis.
 LAB DIAGNOSIS
Other lab investigations;
• FBC
-Total counts-Normal or reduced
-Thrombocytopenia
• ESR/CRP-Normal /Increased
• CSF/Body fluid analysis-Lymphocytosis, low glucose
levels
• Biopsied samples of lymph node and liver: non-
caseating granuloma without acid fast bacilli.
 LAB DIAGNOSIS
• Blood and bone marrow culture are positive in
50% of patients with acute illness.
 TREATMENT
• Treatment with clinically effective antibiotics
should be prolonged to ensure adequate
penetration of these intracellular pathogens.
• Treatment with single agents has been
associated with a high incidence of relapses, so
combination therapy is used .
• Combination therapy has shown the best
efficacy for treatment in adults.
.
 TREATMENT
• Examples of such regimens include:
• Doxycycline orally for 6 weeks in combination
with streptomycin for 1 gram IM daily for 2-3
weeks.
• Doxycycline 100mg bid in combination with
rifampicin 600-900mg for 6 weeks has also
been used with success
 TREATMENT
• CNS cases will require extensive long term
tretament
• Same also for patients with endocarditis along
with replacement of damaged valves.
 TREATMENT
• Indications for surgery:
• Endocarditis- valve replacemrtor debridement
• Abscess formation –require drainage or
excision, eg spinal abscess
• Removal of infected foreign bodies, eg,
pacemaker wires, prosthetic joints
 PROGNOSIS
• May last days, months or years
• Recvery is common
• Disability could be pronounced
• About 5% of treated cases relapse as a result
of: Failure to complete treatment
• Infection requiring drainage
• Case-fatality rate :<2% (untreated)
 CONTROL MEASURES
• Pasteurization of milk
• Use of PPE (goggles and gloves)by persons handling
animals or carcasses
• Programs to detect and eliminate infected animals,
including
-routine screening of livestock,
-culling of infected herds, and
-vaccination of healthy animals,
• This has resulted in the successful control of the
disease in most industralized nations.
THANK YOU