Brucella

Brucella is a zoonotic bacteria that causes a disease called Brucellosis (aka Malta fever, Bang's disease,Gibraltar fever, Malta fever, Maltese fever, Mediterranean fever, rock
fever, or undulant fever),

Classification
The major human pathogens include; Brucella abortus from Cattle, causes a mild disease in humans B.melitensis from goats and sheep, causes a serious disease B.suis from pigs causes destructive lesions and runs a prolonged course B.canis in dogs The classification is based on two surface antigens A and M. Organisms with a high concentration of antigen A are classified as B.abortus, those with a higher M are Classified as B.melitensis while those with an equal amount of A and M are classified as B.suis

Properties
Small (0.5-0.6, 1.5m), non motile, non capsulated, gram negative coccobacilli. Are aerobic but B.abortus culture requires supplemental CO2 Human isolates are catalase and oxidase positive Are intracellular parasites of the reticulo-endothelial syndrome (RES) and able to evade the hosts humoral response. The intracellular survival is mediated by inhibition of the polymorpho-nuclear leukocyte degradation

Epidemiology and pathogenesis

Transmission and pathogenesis Brucellosis is usually an occupational disease; most cases occur in abattoir workers, veterinarians, hunters, farmers, reindeer/caribou herders and livestock producers. Brucellosis is also one of the most easily acquired laboratory infections the infection is acquired through inhalation. People who do not work with animals, tissues or bacterial cultures usually become infected by ingesting unpasteurized dairy products or contaminated meat, bone marrow etc Dr.KTH, 13/11/2009 Page 1

Accidental injection of live brucellosis vaccines meant for animals. Human to human transmission is rare, but has been reported after blood transfusion, bone marrow transplantation or sexual intercourse. Rare congenital infections seem to result from transplacental transmission or the ingestion of breast milk. Congenital infections might also occur if the infant is exposed to organisms in the mothers blood, urine or feces during delivery. Other cultural practices, such as eating bone marrow from reindeer and caribou incidentally infected with B. suis, are risk factors in some populations. In humans the bacteria localise in cells of the RES especially the LN, liver, spleen, bone marrow where they are protected from antibodies. The host response is granulomatous with lymphocytes and epitheloid giant cells. These can result in focal abscesses and caseation.

Clinical manifestation
In the natural host, Brucella causes a mild or asymptomatic disease with a preference to organs rich in a carbohydrate called Erythritol (found only in animals). The organs rich in this substance include; breasts, uterus, placenta and the epididymis thus there is a high bacterial count in these tissues.

In cattle, B. abortus causes abortions, stillbirths and weak calves; abortions usually occur during the second half of gestation. The placenta may be retained and lactation may be decreased. After the first abortion, subsequent pregnancies are generally normal; however, cows may shed the organism in milk and uterine discharges. Epididymitis, seminal vesiculitis, orchitis and testicular abscesses are sometimes seen in bulls. Infertility occurs occasionally in both sexes, due to metritis or orchitis/epididymitis. Hygromas, particularly on the leg joints, are a common symptom in some tropical countries. Arthritis can develop after long-term infections. Systemic signs do not usually occur in uncomplicated infections, and deaths are rare except in the fetus or newborn. Infections in nonpregnant females are usually asymptomatic.

Infection in humans Many human infections are asymptomatic or self-limiting; however, some symptomatic infections can be prolonged, with slow recovery and a small possibility of complications. Increased numbers of symptomatic infections could be seen after a biological attack with aerosolized bacteria. The incidence and severity of disease varies with the species of Brucella. -B. melitensis is considered to be the most severe human pathogen in the genus. -B. abortus and B. suis biovars 1, 3 and 4 are also important human pathogens. -B. suis biovar 2 and B. canis infections are rarely reported in humans. Dr.KTH, 13/11/2009 Page 2

Brucellosis is a multi systemic disease The incubation period is 1-3 weeks, Brucellosis begins as an acute febrile illness with nonspecific flu-like signs such as fever, headache, non productive cough, malaise, back pain, myalgia and generalized aches. Drenching sweats can occur, particularly at night. Splenomegaly, hepatomegaly, coughing and pleuritic chest pain are sometimes seen. Gastrointestinal signs including anorexia, nausea, vomiting, diarrhea and constipation occur frequently in adults but less often in children. Enlargement of the spleen and liver is common Complications include; granuloma formation and destructive lesions in the liver, spleen and spine cord. In many patients, the symptoms last for two to four weeks and are followed by spontaneous recovery. Others develop an intermittent fever and other persistent symptoms that typically wax and wane at 2 to 14 day intervals. Most people with this undulant form recover completely in three to 12 months. A few patients become chronically ill. Relapses can occur months after the initial symptoms, even in successfully treated cases. Some patients may get hypersensitivity reactions that may mimic the symptoms of brucellosis

Lab DX Specimen: Multiple blood samples, bone marrow aspirate, spleen biopsy 1. Microscopic examination of stained smears can be useful for a presumptive diagnosis, particularly if the direct examination is supported by other tests. Brucellae are coccobacilli or short rods, usually arranged singly but sometimes in pairs or small groups. They are not truly acid-fast; however, they are resistant to decolorization by weak acids, and stain red against a blue background with the Stamp's modification of the Ziehl-Neelsen method. Other organisms such as Coxiella burnetii can resemble Brucella. 2. In humans, the definitive diagnosis is by culture or serology. Brucella species can sometimes be isolated from the blood early in the infection; bone marrow is often positive at this stage. Occasionally, bacteria can be recovered from the cerebrospinal fluid, urine or tissues. Brucella spp. can be isolated on a variety of plain media, or selective media such as Farrell's medium or Thayer-Martins modified medium. To avoid infection a dual culture system like the Castaneda method should be used the sample is incubated for 3 or more days and may take 4-6wks. Culture requires CL3 lab as the organisms are highly infectious. Dr.KTH, 13/11/2009 Page 3

Colony morphology varies with the species. Colonies of smooth forms (B. abortus, B. suis, B. melitensis and marine mammal Brucella) are round with smooth margins. When the plates are viewed in daylight through a transparent medium, these colonies are translucent and a pale honey color.

3. Serology is the commonest method of diagnosis. Tests used include serum agglutination (BAT), modified Coombs (antiglobulin) technique, ELISAs and immunoblotting (Western blotting). Serologic diagnosis is complicated by previous exposures and other factors; A definitive diagnosis usually requires a fourfold rise in titer or a convalescent titre of 1:160 or more. 4. Immunostaining, methods like direct fluorescent antibody test can sometimes demonstrate the presence of Brucella spp. in a clinical specimen. 5. PCR . NB Chronic brucellosis can be extremely difficult to diagnose, if the serologic results are equivocal and the organism cannot be cultured

Treatment
Requires use combination therapy to avoid resistance. Can use fluoroquinolones, tetracyclines, rifampicin and aminoglycoside.

Prevention
Human brucellosis is usually prevented by controlling the infection in animals through vaccination. Pasteurization of dairy products is an important safety measure where this disease is endemic. Unpasteurized dairy products and raw or undercooked animal products (including bone marrow) should not be consumed. Good hygiene and protective clothing/equipment are very important in preventing occupational exposure. Precautions should be taken to avoid contamination of the skin, as well as inhalation or accidental ingestion of organisms when assisting at a birth, performing a necropsy, or butchering an animal for consumption. Particular care should be taken when handling an aborted fetus or its membranes and fluids. Risky agricultural practices such as crushing the umbilical cord of newborn livestock with the teeth or skinning aborted fetuses should be avoided. The Strain 19 B. abortus vaccine and B. melitensis Rev-1 vaccine must be handled with caution to avoid accidental injection or exposure. Adverse events have also been reported with the B. abortus RB51 vaccine, although it is safer than Strain 19 Obstetricians should also take precautions when assisting at human births, particularly in regions where brucellosis is common.. In the laboratory, Brucella spp. should be handled under biosafety level 3 conditions or higher. Human vaccines are not available Page 4

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