BRUCELLOSIS

MICROBIOLOGY

• 6 SPECIES, 4 CAN BE TRANSMITTED TO MAN.

• GRAM NEGATIVE, NON-MOTILE, NON-SPORE FORMING.

• THE ORGANISM IS FACULATIVE.• CULTURE CAN TAKE LONG TIME.• SURVIVAL CAN BE VERY LONG.• OPTIMUM TEMPERATRE IS 37 °C (20-

40 °C)

ANTIGEN STRUCTURE OF BRUCELLA

Outer Membrane

(OM)

(Cytoplasmic Membrane) NH = native hapten

Poly B = B poly-saccharide

OM = Phospholipides Lipopolysaccharides

Proteins = (outer membrane; proteins; OMP )

PMN T Suppresser

Ant. Pr. Cell

T. helper

B cell

Macrophage

Elimination

OR

AFTER ENTERING THE BODY Leukocyte

ORRegional Lymph node

OR Blood Stream

Liver Spleen Bone Marrow Lymph Node

OR

Microgranuloma Micro abscess formationOR OR

Blood Stream

BLOOD STREAM

BLOOD STREAM

BLOOD STREAM

FREQUENCY OF COMMON SYMPTOMS IN STUDIES FROM SAUDI ARABIA

STUDYRMHAL-KUHER TEACHING HOSPITAL

KFNGH

SYPMTOMFREQUINCE OF SYMPTOM

FEVER100&90%56%

BODY ACHES100%N/D32%

LETHARGY100%N/D24%

BACK PAIN64%34%35%

JOINT PAIN64%34%21%

SWEATING56%33%27%

ANOREXIA33%17%28%

IRRITABILITY10%N/D7%

HEADACHE25%30%20%

WEIGHT LOSS26%N/D15%

CLINICAL FINDINGS

SPLENOMEGALLY29 %

JOINT TENDERNESS28 %

HEPATOMEGALLY20 %

SPINAL TENDERNESS13 %

SACRO ILEITIS13 %

LYMPHADENOPATHY10 %

IMPAIRED STRAIGHT LEG RAISING

6 %

REGIONAL DISTRIBUTION OF SEROPOSITIVITY ACCORDING TO THE MICROPLATE AGGLUTINATION TEST

REGIONTOTAL SAMPLE

POSITIVEPERCENTAGE

EASTRERN2939119340.6

WESTERN7131383953.8

NORTHERN3152132041.9

SOUTHERN4794242150.5

CENTRAL5597271848.5

TOTAL236131149148.9

SEROLOGCAL TESTS

• STANDARD TUBE AGGLUTINATION TEST• MICROPLATE AGGLUTINATION TEST• 2-MERCAPTOETHANOL AGGLUTINATION

TEST• COOMBS TEST• COMPLEMENT FIXATION TEST• ROSE BENGAL TEST• ENZYME-LINKED IMMUNOSORBENT

ASSAY• GEL PRECIPITAITON TEST

POSITIVE BLOOD CULTURES FOR BRUCELLA

TIME IN WEEKSNUMBER OF POSITIVE CULTURES

12

25

34

41

91

101

TOTAL14

ACTIVE DISEASE

• Clinical evidence (symptoms & signs) of brucellosis plus:

Positivity at > 1:160 by STAT Positivity at > 1:140 by 2-ME test Positivity by ELISA (high IgG & low IgM)

TREATMENT FOR HUMAN BRUCELLOSIS

CategoryTreatmentDoseDuration

Bone & JointSTM +

Rif.

Doxy

1.0 g bid

900 mg/d

100 mg bid

3

12

12

Meningio-

Enceph.

Rif. +

TMP-SMZ

?Doxy

900 mg/d

300 mg(T)/kg-d

12

2

12

EndocarditisSTM +

Rif. +

TMP-SMZ+

Doxy

1.0 g bid

900 mg/d

30 mg(T) kg-d

100 mg bid

13

13

3

12

TREATMENT FOR HUMAN BRUCELLOSIS

CategoryTreatmentDoseDuration

Adult & children (>8 years)

Doxy + STM100 mg bid

1.0 g bid

6

2 – 3

Children

< 8 years

Rif + TMP – SMZ

15 g (kg-d)

30-60 mg (T*)/kg-d

2 or 8

3 or 8

Preg. Women

1st Trim.

2nd & 3rd Trim.

[Doxy +

[Rif. TMP-SMZ

100 mg bid

900 mg bid

6 w

3 w

COMPARATIVE STUDY OF 3 DRUGS REGIMENS

RegimenDrug(s)DoseDuration

(Days)

Cure Rate

AOral Rif. +

Doxycycline

900 mg/d

200 mg/d

45

45

95%

“

BStreptomycin

Doxycycline

1.0 g/d

200 mg/d

14

45

96%

“

CStreptomycin1.0 g/d1459%

(WHO)Tetracycline2.0 g/d2159%

(Accole et al. 1989)

PREVENTION

• “ELIMINATION OF THE DISEASE IN ANIMALS”• PERSONAL HYGIENE (WASHING EXPOSED

CLOTHES)• ENVIRONMENTAL SANITATION (DISPOSAL

OF CONTAMINATED SUBSTANCES)• PASTURIZATION OF DIARY PRODUCTS• HEALTH EDUCATION• IMMUNIZATION

VACCINES

• B. abortus strain 19

• B. melitensis strain Rev I

• B. suis strain 2s

• B. abortus strain 45/20

• B. melitensis strain H38

CLASSIFICATION OF SALMONELLA

• According to their ecologic niches

• Serotyping [kanfmann white]– O antigen A-I– H antigen (subtypes)

* Over 2000 serotypes

• Spectrum of clinical manifestations of salmonella

• Gastroenteritis

• Enteric fever

• Bacteremia– With metastatic disease– Without metastatic disease

• Asymptomatic carrier state

TYPHOID FEVER(Enteric Fever)

Definition:A disease characterized by prolonged fever, abdominal pain, diarrhea, delirium, rash (rose spots) & splenomegaly.

Etiology:Salmonella Typhi & paratyphi A & B-A motile gram-negative bacilli, which possess:

• H-Antigen (associated with flagella)• O-Antigen (a LPS associated with cell wall)• VI-Antigen (a PS associated with cell capsule)

EPIDEMIOLOGY OF TYPHOID FEVER

It affects all age groups. No sex difference. Common in developing countries. Infecting dose 7x10(6) in Africa, Asia & Latin

America. Transmission is through Oral-fecal route. Affected individuals may become asymptomatic

carriers particularly females & older males (Underlying cholecystitis).

S-Typhi is resistant to drying & cooling.

SYMPTOMS & SIGNS

SymptomsSignsPathology

1st wk.Fever, Chills headache

Abdominal tenderness

Bacteremia

2nd wk.Rash, abdominal pain,

Rose spotsMononuclear vasculitis of skin, hyperplasia of peyer’s batches typhoid nodules

SIGNS & SYMPTOMS(cont,)

______________________________________

Symptoms Signs Pathology

_____________________________________________________________

3rd wk Intestinal Melena Ulcerations, perforation

bleeding, per- rigid abdomen with peritonitis.

foration & shock ileus, coma

____________________________________________________________

4th week Resolution Recurrence Cholecystitis, chronic

& later relapse of acute fecal carriage of bacteria

weight loss disease,

cachexia.

ANTIBIOTIC USED FOR SALMONELLA TYPHI

- Chloramphenicol

- Ampicillin, Amoxil

- Co-trimoxazole

- 3rd generation cephalosporins

- Quinolones

PROGNOSIS

Case fatality dropped 12% to 4% It is still +\- 10% in developing countries Perforation +\- 5% Chronic fecal carriers 1-3%

VACCINATION FOR S.TYPHI

- Inactivated S.typhi:- 2 SC injections:- 55-88% protection for 3-5yr.

- Attenuated S.typhi:- Liquid 3 doses- Enteric coated capsules- Protection 60-70%

PREVENTION

PREVALENCE OF SCHISTOSOMIASIS AS REPORTED BY THE STATIONS

StationNo. of Persons Examined

Prevalence(%)

S.HaematobiumS.ManSoni

Ovwrall Prevalence

AL-Baha20.412---13.013.0

Jizan30.8837.01.28.2

Taif39.5990.27.77.9

Abha23.0131.74.96.6

Madinah17.5911.93.65.5

Bisha16.7660.48.58.9

Najran8.8201.69.911.5

Mahael5.7837.6---7.6

Hayil4.335---14.212.2

Riyadh15.129---5.65.6

Makah25.8942.53.05.5

Al-Jouf12.5771.31.62.9

KATAYAMA FEVER(KATAYAMA River, Japan)

1. SEVERAL DAYS – 2-3 WEEKS

2. FEVER, CHILLS, HEADACHE, MALAISE, EDEMA, CONFUSION

3. HEPATOSPLENOMEGALLY

4. LYMPHADENOPATHY

5. EOSINOPHILIA

6. CEREBRAL EDEMA (CT)

S. MANSONI (SYMPTOMS)

SYMPTOMCASES

Abdominal Pain258

Fatigue221

Blood in Stool205

Mucous in Stool191

Tenesmus121

Depression108

Diarrhea54

Constipation1

BOTH (MANSONI & Haema.)

SYMPTOMS

Haematuria11

Abdominal Pain7

Tiredness7

Frequency6

Depression4

Tenesmus4

Blood in Stool3

Mucous in Stool3

SIDE EFFECTS OF ANTISCHISTOSOMAL DRUGS (%)

SYMPTOMSPRAZIQUANTELOXAMNIQUINEMETRIFONATE

NONE563040

DIZZINESS203610

ABDOMINAL PAIN

122512

JOINT PAIN101210

NAUSIA8106

RASH642

VOMITING6108

ITCHING610-

FATIGUE2128

HAIRFALL2--

CHANGE IN TASTE

122

DIARRHEA124

CONVULSION-1-

S. HAEMATOBIUM

SYMPTOMS

Haematuria89

Dysuria77

Abdominal Pain43

Frequency40

Tiredness33

Blood in Stool23

Mucous in Stool22

Depression8

PREVALENCE OF SCHISTOSOMIASIS AS REPORTED BY THE STATION*

/PREVALENCE (%)

STATIONNo. of Persons Examined

S. Haematobium

S. MansoniOverall Prevallence +

AL-BAHA20.412---13.013.0

JIZAN30.8837.01.28.2

TAIF39.5990.27.77.9

ABHA23.0131.74.96.6

MADINAH17.5911.93.65.5

BISHA16.7660.48.58.9

NAJRAN8.8201.69.911.5

MAHAEL5.7837.6---7.6

HAYIL4.335---14.212.2

RIYADH15.129---5.65.6

MAKAH25.8942.53.05.5

AL-JOUF12.5771.31.62.9•MODIFIED FROM ARFAA.

+ Appropriate, Since a small percentage has double Infection.

An Immunoblotting Study of Serologic Response in Patients with Acute Brucellosis

- Specific & Sensitive only in patients with Chronic Brucellosis

Leiva-Leon et al,. 1991

Diagon. Microbiol. Inf. Dis

DITRIBUTUTION OF BRUCELLA BY LEVEL OF EDUCATION

Level of Education

TotalPositive(%)Odds Ratio

Higher11622(0.2)1.0

Secondary249822(0.9)5.1

Primary468434(0.7)4.2

Read & Write

437779(1.8)10.7

Illiterate9723271(2.9)16.6 There is an Inverse relationship between the rate of positivity & the level of education

MEAN BRUCELLA TITERS/INITIAL4 WEEKS8 WEEKS

ABORTUS2560

(N-98)

1280

(N-56)

640

(N-25)

MELITENSIS1280

(N-82)

640

(N-53)

640

(N-21)

DISTRIBUTION OF BRUCELLA ACCORDING TO THE TYPE OF HOUSING

Type of Housing

TotalPositive(%)Odds Ratio

Palace/ Villa

7209122(1.7)1.0

Flat/ Small House

12442144(1.2)0.7

Low grade Housing*

3510146(4.2)2.5

*The rate of Positivity is Significantly Higher

BRUCELLOSIS IN THE KINGDOM OF SAUDI ARABIA

/NegativePositiveTotalRelative Risk

-95%CI

MILKING ANIMALS

(Significant)

Yes226015724175.5(4.4,6.7)

No2024125720498

1.0

No Data

6962

Modulation of the Intracellular Survival of B. abortus by Tufsin & Muramyl dipeptide

• Tufsin (T), physiologically bioactive peptide (animal origin).

• Muramyl dipeptide (MD). Synthetic bioactive glyco-peptide (microbial Origin)

• T & MD both enhance Ø Functions & increase non specific resistance against various pathogens.

• Addition of MD significantly (P<0.03) enhanced macrophage (Ø) to control intracellular replication of B. abortus.

• Cause conversion of permissive macrophage to restrictive macrophage.

• No additive effect of T & MD Together.

Price et al,.1993

Vet. Immunol Imuno Pathol.

Specific Antibody Profile in Human Brucellosis

• Comparison of STAT,MAT,RB & Coomb’s tests with Elisa I 761 Sera of patients.

• ELISA found to be more specific & sensitive (OM; or NH antigens)

• Chronic Brucellosis IgG persists.

• Relapsing brucellosis IgG peaks up

Ariza J et al, 1992

Clin. Infect. Dis.

Prevelance of Brucellosis in Al-Qaseem Area

Tube Agg. B. abortusNo.%

40402.6

801231.5

160660.8

320253200.3

640160.2

128060.1

256060.1

>512020.01

Negative766494.4%

Total8120

Active Dis.1.51%

Al-Balla S.R. Unpublished data

Antibody Prevalence of B. Abortus in Al-Qaseem Area

Micro. B. AbortusNo.%

101561.9

206307.8

407379.1

805817.1

1604295.3

3202903.6

6401511.9

1280630.8

2560410.5

5210210.3

1024070.1

>10240180.2

Negative500261.6

Immunotherapy in Chronic Brucellosis-Effect of Levamisole & Interferon

A. Interferon Alpha 2B

B.Levamisole

C.Conventional therapy

- A & B gave Quick Response + Quick Eradication of the organism

- A + B no Additive Effects

Printzis S et al,. 1994

Immunopharmacol – Immunotoxicol.

THE IMMUNE RESPONSE MAGNITUDE & DURATION IS AFFECTED BY:

1. Virulence of infecting strain

2. Size of inoculum

3. Age

4. Immune status

VACCINES FOR USE IN MAN

Live Vaccines

[USSR (Exposed Worker)]

• B. abortus 19-BA

• Intradermal injection, scarification

• Dose10(9) cells

• Repeated after 9-10 months if skin test and serologic are negative

VACCINES FOR USE IN MAN

Contd…

Live Vaccine Man

• China

• 104 M B. abortus

• Dose 7-10 x 10 cells (Scarifying)

S. PATHOGENESIS

- ID 10ˆ6 – 10ˆ9

- Penetration of the distal ileum mucosa

- Multiplication in the payer patches

- Diarrhea is caused by: - Prostaglandin Induced ˆ (c-AMP)

a. Local Inflammatory response

b. S. enterotoxin

SYMPTOMS & SIGNS

PREVENTION

ANTI-R IMMUNOGLOBULIN ISOTYPES

• IgM - early & the only Ig in a few days• IgG – later predominant• IgM + IgG = SAT – IgG = CF, 2 ME• Nonagglut. IgA = Coombs/ELISSA,

radioimmunoassay• IgE appear after IgM ad before IgG

BRUCELLOSIS & OTHER RISK FACTORS

Risk factorOdds ratioP value

Caring for delivering animal20.40.00001

Placental membrane12.90.00001

Consumption of raw milk products

4.20.001

EARLY LESION

Process starts ios Superior end-plate Erosion & sclerosis (bone repairs) may

simultaneously occur Sclerosis may extend further (Parrot

beak)

BRUCELLOSIS IN THE KINGDOM OF SAUDI ARABIA

NegativePositiveTotalRelative Risk95%CI

Breed Internally

(Significant)

YES

NO

No data

2944

19532

721

186

228

2

3130

19760

5.4

1.0

4.4,6.6)

●Leukocyte