Bacterial and

Mycotic Infections in
Immunocompromised
Hosts: Clinical and
Microbiological
Aspects
Edited by
Maria Teresa Mascellino
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www.esciencecentral.org/ebooks
001
Brucellosis: A Global Re-
emerging Zoonosis History,
Epidemiology, Microbiology,
Immunology and Genetics
Al-Anazi KA* and Al-Jasser AM
Consultant Hemato-Oncologist, Department of Adult Hematology and
Hematopoietic Stem Cell Transplant, Oncology Centre, King Fahad
Specialist Hospital, P.O. Box: 15215, Dammam 31444, Saudi Arabia
*Corresponding author: Khalid Ahmed Al-Anazi, Consultant Hemato-
Oncologist, Department of Adult Hematology and Hematopoietic Stem
Cell Transplant, Oncology Centre, King Fahad Specialist Hospital, P.O.
Box: 15215, Dammam 31444, Saudi Arabia, Tel: 966–03–8431111;
Fax: 966–03–8427420; E-mail: kaa_alanazi@yahoo.com

Abbreviations: SB.: Brucella; WHO: world health organization; FAO: food and agriculture organization; WOAH:
world organization for animal health; MME: mediterranean and middle east; CDC: centers for disease control and
prevention; LPS: lipopolysaccharide; TGF: transforming growth factor; MHC: major histocompatibility complex; IFN:
interferon; IL: interleukin; TNF: tumor necrosis factor; NK cells: natural killer cells; GM-CSF: granulocyte monocyte-colony
stimulating factor; MLVA: multiple-locus variable- number tandem-repeat analysis; MALDI-FOS-MS: mixed-assisted
laser desorption/ionization time-of-flight mass spectrometry; HOOF-Prints: hypervariable octameric oligonucleotide
finger-prints; BBP: Brucella bioinformatics portal; STM: signature-tagged transposon mutagenesis.

Introduction
Brucellosis is an infectious disease of animals (zoonosis) that is transmittable to humans. Wild and domestic animals are
the only source of brucellosis and humans are always accidental hosts [1]. At least 6 Brucella species have been identified,
4 of which are human pathogens (Table 1) [1,2]. Brucella does not bear classic virulence factors and they tend to invade
and persist in human hosts [2].
The infection is global in distribution and it is endemic in many geographic locations including the Mediterranean and
Middle East (MME) regions, Indian subcontinent, Mexico and parts of Central and South America [3-5]. Approximately
60% of emerging human pathogens are zoonotic and brucellosis is considered the commonest zoonotic infection worldwide
[4,6-10]. The global map of human brucellosis has significantly changed over the past decade as the infection keeps re-
emerging in many foci worldwide [3,4,7,9]. In developing countries, brucellosis is an important public health problem that
is associated with minimal mortality and substantial residual morbidity [7,10]. However in the era of globalization and
international tourism, brucellosis has become a common imported disease in the developed world [7,9].

Landmarks in The History of Brucellosis

In the year 1853, Jeffery Allen Marston made the first accurate description of the disease in British army troops serving
in Malta during the Crimean war [1]. In 1887, David Bruce isolated Gram negative coccobacilli, named later Brucella
melitensis (B. melitensis), from spleens of fatal cases. In 1895, Bernard Bang isolated B. abortus from placental tissues of
cattle. In 1897, M.L. Hughes published a review on the clinical and pathological features of the disease and suggested the
name undulant fever (Table 1) [1-3]. In 1897, Wright and Semple succeeded in applying serum agglutination method for
differentiating brucellosis from other febrile illnesses. In 1904, the Commission of Mediterranean Fever was established
[1]. Between 1904 and 1907, several reports on epidemiology, bacteriology and pathology of brucellosis were published.
Species Biotype Animal Hosts First Description Human Virulence
B. melitensis 1-3 Goats, sheep and camels Bruce, 1887 High
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B. abortus 1-6, 9 Cows, camels, yaks and buffalos Bang, 1897 Intermediate
B. suis 1-5 Pigs, wild hares, caribou, reindeer, wild rodents Traum, 1914 Low
B. canis - Dogs Carmichael and Bruner, 1968 Low
B. ovis - Sheep Van Drimmelen, 1953 None
B. neotomae - Rodents Stoenner and Lackman, 1957 None
B. pinnipediae and
- Minke whales, dolphins, porpoises and seals Ewart and Ross 1994 None
B. cetaceae (provisional)
002
Table 1: Basic Microbiological Details of Brucella Species.
In 1905, Themistocles Zammit identified a Maltese goat as the animal host of brucellosis. In 1918, Alice Evans published
data on the antigenic relatedness between B. melitensis and B. abortus. Subsequently, the genus was named Brucella to
honor David Bruce. In 1924, human infection with B. abortus was documented by Orpen in the U.K. Similar studies on
B. abortus were performed by Morales-Otero in Puerto Rico [1]. In 1914, Jacob Traum isolated B. suis from an aborted
swine fetus (Table 1) [1-3]. In 1909, Hutyra and Marek might have recovered the organism in Hungary [1]. In 1953, van
Drimmelen made identification of B. ovis in sheep. In 1957, Stoenner and Lackman identified B. neotomae in rodents
(Table 1) [2]. In 1964, Carmichael and Bruner identified B. canis in the canines [1,2]. In 1994, Ewalt, Ross and colleagues
identified B. pinnediae and B. cetacear (provisionally) in Minke whales, dolphins, porpoises as well as seals (Table 1) [1,2].
In 1979, the WHO (world health organization) established a specialized program with a unit coordinating and managing
activities (The Mediterranean Zoonoses Control Centre) operating from Athens in Greece [4]. In 1986, the WHO and FAO
(food and agriculture organization) recommended treatment for acute brucellosis in adults with a combination regimen
composed of rifampicin and doxycycline orally for 6 weeks [5-7]. In 2004, WHO/FAO/WOAH (world organization for
animal health) joint consultation on emerging zoonotic diseases held in Geneva defined an emerging zoonosis as a pathogen
that is newly recognized or newly evolved or that has occurred previously but shows an increase in incidence or expansion
in geographical, host or vector range [8]. In November 2006, a panel of international experts met in Ioannina in Greece
and they made a number of therapeutic recommendations that included treatment of uncomplicated brucellosis using a
combination of oral doxycycline for 6 weeks and parenteral streptomycin for 2 to 3 weeks or oral rifampicin for 6 weeks [7].

Epidemiology of Brucellosis
It is estimated that 60% of emerging human pathogens are zoonotic [8]. Brucellosis is the commonest zoonotic infection
worldwide as it has been reported in 56 countries [4]. Also, more than 500,000 new cases of brucellosis are reported annually
[9]. However, the reported annual incidence rate of human brucellosis in endemic areas worldwide varies from <0.01 to
>200 cases per 100,000 population. In the year 2005, the annual incidence rate per 100,000 population was: 160.30 in Syria,
60.60 in Mongolia, 26.20 in Turkey and 21.40 in Saudi Arabia [10].
The epidemiology of human brucellosis has dramatically changed over the last 25 years, because of various sanitary,
socioeconomic and political reasons in addition to the evolution of international travel in the era of globalization. Several
areas that had been traditionally considered to be endemic such as France and Latin America, have achieved control of
the disease [9]. In certain countries such as Portugal, Spain, Tunisia and Jordan, the incidence of brucellosis has decreased
significantly. On the contrary, the incidence is on the rise in countries like Turkey, Algeria in addition to several areas in
South Europe and Africa, while the situation in other countries such as Syria has been rapidly worsening. Despite the
adopted control measures, the disease is still present, in varying trends, both in Europe and in the USA [9]. MME regions are
considered the most important areas for the historic development and the concentration of zoonoses. Twenty five countries
in the Middle East keep record of the disease and 6 of them report 90,000 cases per year [4].
Brucellosis is a notifiable disease in most countries [11]. However, brucellosis cases remain often unrecognized and
underestimation of cases is clearly seen reflecting inadequacy of diagnostic laboratory services in most of the MME
countries [4,12]. Social, technological and environmental factors continue to have a dramatic effect on infectious diseases
worldwide, facilitating the emergence of new diseases and the re-emergence of old ones sometimes in drug resistant forms.
For brucellosis, the geographical pattern is constantly changing with new foci emerging and re-emerging. The causes and
explanations for the resurgence and the recent increase in the incidence of brucellosis include: (1) socioeconomic changes,
(2) wars and political turbulence in some MME countries, (3) inadequate control programs in some countries, (4) ease of
human international travel recently, (5) uncontrolled animal transportation across open borders and (6) brucellosis being a
complex disease that has different cycles of expansion and regression [12-15].
The risk factors for Brucella infection include: consumption of raw milk and unpasteurized dairy products, direct contact
with animals and their products, male sex and age between 40 and 49 years [10,11,16-20]. Brucellosis is an occupational
disease that poses risk to: shepherds, abattoir workers, veterinarians, diary-industry professionals and personnel in
microbiology laboratories [18-20].
Brucella strains have been isolated from terrestrial and marine mammals. Experimentally, a marine mammal Brucella
species isolated from a pacific harbor seal has induced seroconversion and abortion in cattle. Recently, marine mammals
Brucellae have been identified in 2 patients from Peru with neurobrucellosis and intracerebral granulomas [20].

Pathogenicity and Immunology

The pathogenicity of human brucellosis is attributed to factors such as lipopolysaccharide (LPS), adenine and guanine
monophosphate, vitamin B, 24 KDa protein and urease enzyme [3]. Brucellae may enter the host via ingestion, inhalation or
through conjunctiva or skin abrasion. They colonize in different body organs with predilection for lymphoreticular system
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[3]. Brucella species that are pathogenic to humans can be arranged in a decreasing order of virulence as follows: (1) B.
melitensis (2) B. suis (3) B. abortus (4) B. canis (Table 1). The first three species are classified as smooth organisms based on
the length of their LPS O-side chains, while B. canis is a naturally occurring rough strain [21]. The severity of brucellosis is
variable, ranging from lethal to subclinical in humans as in most cases Brucellae establish long-term parasitic relationships
with their human hosts. Survival and replication of Brucellae in macrophages is critical for maintenance of such chronic
infections [21]. Survival of Brucellae within monocytes is the single most important aspect of pathogenesis contributing to 003
persistence of bacteria in host tissues [22].
 Virulence of Brucella species depends on survival and replication properties in the host cells. Brucella has developed
specific strategies to influence antigen presentation mediated by cells and an evolutionary stealthy strategy to escape
recognition by the innate immunity. It has also modulated not only the adaptive immunity of the host but also the signaling
events during host adaptive immune response [23]. Brucella modulates both (the innate and the adaptive) functional
arms of the human immune system leading to T-cell anergy and chronic infection [24]. Brucella periplasmic cyclic β-1,2-
glucan plays an important role during bacterium-host interaction [25]. Cyclic β-1,2-glucan must be transported into the
periplasmic space to exert its action as a virulence factor [26]. However, cyclic β-1,2-glucan succinylation is not required for
virulence and no low-osmotic stress conditions must be overcome during infection [25].
In the past decade, the mechanisms of Brucella pathogenesis and host protective immunity against Brucella infections
have been extensively investigated using the cutting edge systems biology and bioinformatics approaches [27]. Integrative
experimental Omics and computational bioinformatics analyses have dramatically advanced our understanding of how
Brucella species infect different host species, how Brucella gene expressions are regulated in cell cultures or inside host
cells and how host cells respond to Brucella infections [27]. Acquired immunity to brucellosis has been studied through
observations of naturally infected hosts e.g. cattle and goats, mouse models and human infection. New systems biology
analyses of antigens recognized by human innate responses in brucellosis have identified large numbers of protein antigens
with the potential of understanding mechanisms of pathogenesis and immune evasion and may point the way toward novel
vaccines and diagnostic approaches [28].
CD80/CD28 costimulation enhances the interaction of antigen / major histocompatibility complex (MHC) and is
critical for adequate induction and maintenance of the Th1 response [24,29]. In humans, brucellosis is characterized by an
intense Th1cytokine production with strikingly high serum levels of interferon (IFN)-γ and evidence of defective monocyte
function [30]. Although CD4 and CD8 cells are closely involved in the production of IFN-γ and despite that CD8 T cells
may be cytotoxic, the role of natural killer (NK) cells and cytotoxicity in protective immunity to brucellosis have not been
substantiated experimentally. Also, antibodies have been shown to have a limited role in passive transfer studies [31].
Although infected macrophages may persist in the presence of Brucella-specific T cells, CD8 T cells have been shown to
have an important role in clearance of Brucellae following the peak of infection and may act by lysing chronically infected
macrophages [32]. NK cells may be capable of modulating the development of Brucella infection in human beings by lysing
infected host cells. Chronicity or elimination of Brucella infection depends upon the balance between the contradictory
effects induced by the bacteria that favor either the host or the pathogen [31,33]. CD4 (+) invariant NK T cells have
antibacterial activity and participate directly in the elimination of bacteria and/or in the control of bacterial growth by
killing infected cells. These cells inhibit intramacrophagic growth of Brucellae by different mechanisms [34].
Human Vγ9Vδ2 T cells play a crucial role in the early immune response to intracellular pathogens. In brucellosis, these
cells are drastically increased in the peripheral blood during the acute phase of infection. They are able to use a combination
of mechanisms that reduce the total numbers of B. suis thus they may benefit the host by limiting the spread of Brucella
species [35]. Interleukin (IL)-37 is a soluble factor responsible for part of the bactericidal activity of Vγ9Vδ2 T cells [36].
Murine and bovine γ/δ T cells are important for early protection against B. abortus infections [37]. These cells increase
considerably in acute brucellosis and decrease significantly following efficient treatment. Hence, γ/δ T cell receptor bearing
cell counts may be used as a supplementary marker for monitoring brucellosis [38].
An important feature of brucellosis is the persistence of bacterial colonization in cells of the reticuloendothelial system
[39]. Chronicity of brucellosis results from the ability of some Brucellae to survive the reactive oxygen intermediate and the
nitric oxide killing in the host phagocytes, following which they activate bacterial genes in response to the acidic phagosome
environment, prevent fusion of phagolysosomes by remodeling the intracellular compartment and subsequently replicate
intracellularly. The crucial component of immunity that results in survival of the host and thus maintenance of the chronic
infective state is IFN-γ [31]. The interrelationship between different cells must be taken into consideration in the analysis of
bacterial virulence and in the development of in vitro models of human macrophage infection [40].
The proper use of animal models, particularly mice, has recently allowed accumulation of valuable data regarding
pathogenicity, immunology and antibiotic susceptibility of Brucella species in vivo. New technologies in mouse genetics
are likely to bring about even greater insights into the interactions between Brucella species and the immune system that
lead to evolution of the disease in humans [41,42]. The shut-down of response to IFN-γ may be necessary for survival of
B. abortus in the short term and the lack of endogenous IFN-γ is more important to control brucellosis than CD8+ T cells
and IL-12-dependent IFN-γ deficiencies [43,44]. Production of IL-12 and tumor necrosis factor (TNF)-α usually occurs
early in intracellular bacterial infection. These cytokines contribute to resistance of the intracellular bacterium B. abortus by
different mechanisms, while IL-10 may downregulate the immune response to B. abortus by affecting both the macrophage
effector function and the production of protective Th1cytokine IFN-γ [45,46]. Once the infection has been established, B.
abortus 2308 selectively limits IL-18 secretion without affecting endogenous IFN-γ production [47]. However, the virulent
smooth strain B. abortus S2308 causes more apoptosis and necrotic dendritic cell death than the live-attenuated vaccine
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strain RB51 [48]. In murine models having chronic brucellosis, cytokine production is characterized by: prominent IL-6
production, increased IFN-γ production and substantial production of granulocyte monocyte-colony stimulating factor
(GM-CSF) [49].

Genetics and Genomics in Brucellosis

Brucella species are highly monomorphic with minimal genetic variation among species thus hindering the development
004
of reliable tools for epidemiologic and phylogenetic analyses. Current microbiological and low-resolution molecular typing
assays are useful for identifying Brucella isolates and determining species and biovar designations, but have limited value
for epidemiological trace-back investigations [50]. Multiple-locus variable-number tandem-repeat analysis (MLVA) targets
multiple repeat regions with higher mutation rates than other genomic markers and demonstrates higher genetic resolutions
when applied to Brucella species than assays targeting other more monomorphic molecular markers such as the outer
membrane proteins, the rpoβ gene and the insertion sequence regions [50]. Thus, MLVA is a useful tool for identifying and
genotyping Brucella strains and the resultant data can be used for epidemiological trace-back investigations [51]. MLVA-16
has a good discriminatory power for species determination, typing of B. melitensis isolates and inferring their geographic
origin [52]. It can be considered a valid alternative to standard genotyping techniques and is particularly useful in dealing
with a large number of samples in the short term [53]. The correlation found among B. melitensis groups and rpoβ types
suggests that study of the single nucleotide polymorphisms (SNPs) of rpoβ as an initial marker of brucellosis may be of use in
epidemiological surveillance [54]. Brucella hypervariable octameric oligonucleotide finger-prints (HOOF-Prints) technique
is highly discriminatory among Brucella species, among previously characterized Brucella strains and among unrelated
field isolates that cannot be differentiated by classical methods [55]. For human Brucella isolates, both MLVA and HOOF-
Print assays are rapid, highly discriminatory and reproducible. They significantly contribute to Brucella epidemiology
and may advance surveillance and control of human brucellosis [55,56]. Also, mixed-assisted laser desorption/ionization
time-of-flight mass spectrometry (MALDI-FOS-MS) is a rapid method for the analysis of biological samples. The accurate
identification of Brucella species can be achieved with MALDI-FOS-MS by constructing a Brucella reference library based
on the genetic relationships according to MLVA data [57].
The Brucella bioinformatics portal (BBP) is a gateway for Brucella researchers to search, analyze and curate Brucella
genome data originating from public databases and medical literature. Brucella gene mutations and genetic interactions
are annotated using Limix leading to better understanding of Brucella pathogenesis [58]. The sequence database provides a
powerful dataset for addressing ongoing controversies in Brucella taxonomy and a tool for unambiguously placing atypical,
phenotypically discordant and newly emerging Brucella isolates [59]. The identification of novel genes within previously
described groups has added insight with regard to the regulatory elements, nutritional demands and mechanisms required
for efficient intracellular growth and survival of the organism [60]. Four genes of B. suis that are necessary to resist specifically
the action of γ9δ2 T cells have been identified. B. suis that induces chronic disease in humans might have developed specific
strategies to subvert the immune system at the level of the innate secondary response [61].
Transposon mutagenesis is the most frequently used approach in the identification of genes involved in the virulence
of bacterial pathogens [62]. A recent modification of the classical transposon mutagenesis technique, signature-tagged
transposon mutagenesis (STM), allows the detection of a given mutant within a complex pool of mutants by hybridization
with a probe obtained by polymerase chain reaction (PCR) with primers based on constant regions [62]. Very little is
known about the genetic basis of Brucella virulence. However, stress response proteins and smooth LPS may be required
for virulence in vitro and in animal models. A two-component system (Bvr AS) and a type IV secretion system (VirB) have
recently been identified as essential virulence factors. More recently, the application of STM has allowed identification of
B. suis genes affecting intracellular survival in an in vitro human macrophage infection model [62]. The Brucella genome
contains an IS 711 transposon element that is often used in finger printing Brucella species samples. While B. suis 1330
and B. suis ATCC 23445 contain 7 and 13 IS71 copies respectively, B. suis VBI 22 has 8 copies. All 7 IS 711 loci in B. suis
1330 genome are observed in the genomes of ATCC 23445 and VBI 22 strains. B. suis VBI 22 has an additional IS 711
locus right after the stop codon of the BSB 122_A1627 gene, which has not yet been previously observed in any sequenced
Brucella species [63]. Obtaining the complete Brucella genome and identification of the global expression genetic profile of
Brucella species will be a great step in understanding: biology and evolution of the pathogen, virulence of the organism and
the interaction between Brucella and its host at the molecular level in order to improve the development of vaccines and
new antimicrobial therapies [64,65]. The STM technique is a powerful method that allows a large number of mutants to be
screened for attenuation. The isolation of attenuated mutants in virB operon and manB, that are known Brucella virulence
factors, has validated the application of STM in Brucella virulence studies [62].
The rough strains RB51, RB115 and B18 which are characterized by different antigenic and immunological properties
show differences in genes involved in LPS synthesis. Specific genes affected by such mutations have been identified [66].
Brucella global expression profile studies can provide novel information on growth phase-specific gene expression. Further
characterization of some genes that have been found to be differentially expressed in most invasive cultures will likely
bring new insights into the initial molecular interactions between Brucella and its host [65]. However, limited genome
diversity exists among Brucella species. Comparison of Brucella species whole genome is likely to identify factors responsible
for differences in host preference and virulence restriction. Deletions of genetic content identified in Brucella species are
conserved in multiple strains of the same species and genomic islands missing in a given species are often restricted to that
particular species [67].
The genome of B. melitensis strain 16M has been sequenced and found to contain 2,294,935 bp distributed over 2
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circular chromosomes of 2,117,144 and 1,177,787 encoding 3,197 ORFs [68]. Housekeeping genes including those involved
in DNA replication, transcription, core metabolism and cell wall biosynthesis are distributed on both chromosomes [68].
To date, no genome-wide study has scanned genes related to host specificity of Brucella species [69]. Comparative whole-
genome microarray analysis has revealed genomic islands, limited genome diversity in Brucella species and alterations as
well as deletions of genes responsible for virulence [70]. Pathogenicity islands, specialized secretion systems, virulence
plasmids, fimbriae, pili, adhesions and toxins are all classical virulence factors [71]. Genomic islands contribute to Brucella 005
pathogenicity by helping to establish Brucella infection and survival strategies. Biophotonic imaging suggests that Brucella
dissemination in mice parallels acute and chronic infections of humans [72,73].
Brucella enters macrophages through lipid raft microdomains, avoids their bactericidal attacks and phagolysosome
fusion, expressing a set of virulence genes and inhibiting TNF-α secretion and apoptosis by persistence in microorganisms
[70]. The first Brucella species was isolated and characterized almost 120 years ago but only recently the complete nucleotide
sequences of the genomes of a number of well-characterized Brucella strains have been determined [74]. A feature that
distinguishes Brucella species is that they do not express classical virulence factors. Disruption of putative virulence genes
and studying their effect on attenuation in cell lines of mouse models is a widely used method [74]. The genus Brucella
consists of 6 species, 3 of them including several biovars display a high degree of DNA homology. DNA polymorphism is
able to differentiate the 6 Brucella species and some of their biovars [75]. DNA polymorphism within the genus Brucella
might be involved in the differences in pathogenicity and host preference displayed by Brucella species [76].
Rifampicin is one of the most potent and broad-spectrum antibiotics against bacterial pathogens [77]. Mutations of the
rpoβ gene have been characterized in rifampicin-resistant (Rifs) strains of Escherichia coli and Mycobacterium tuberculosis.
Recent molecular studies have shown an association between rpoβ gene mutations and the development of rifampicin
resistant Brucella species [77]. Efflux plays an important role in Brucella sensitivity to erythromycin. Polymorphisms among
ribosomal loci from the reference Brucella species correlate with their highly differential susceptibility to erythromycin [78].

Microbiological Aspects of Brucellosis

Brucellae belong to α-2 subdivision of proteobacteria [3]. The organism is a Gram negative, non-spore-forming,
coccobacillus [18]. It is aerobic, partially acid fast and has short rods. It is oxidase, catalase, nitrate reductase and urease
positive [3]. It is localized predominantly in organs with numerous macrophages e.g. lungs, liver, spleen, bone marrow and
synovium. At least 6 species have been recognized, 4 of them are pathogenic to humans: B. melitensis, B. abortus, B. suis and
B. canis [18]. The organism is shed in: milk, fetal membrane, semen and uterine discharges. Reservoirs of Brucella infection
include: goats, sheep, camels, cattle, dogs, pigs and deers (Table 1) [19].
The genome contains 2 circular chromosomes of 2.1 Mb and 1.5 Mb except for B. suis biovar which has a single
chromosome of 3.1 Mb. There are 2 types of smooth LPS surface antigens, designated A and M. The A antigen predominates
in B. abortus and B. suis, while the M antigen is the major antigen in B. melitensis. Numerous outer and inner membrane,
cytoplasmic and periplasmic proteins have also been characterized [3].

Transmission of Brucellosis and Means of Infection

Brucellosis is commonly transmitted by: (1) consumption of unpasteurized, contaminated animal dairy products, (2)
direct contact with infected animal parts and (3) inhalation of infected aerosolized particles. Person to person transmission
is less common, but has been reported [16-19]. The disease can be transmitted by blood transfusion. Reports of blood
transfusion as a means of transmission of brucellosis in recipients of blood product transfusion existed as early as the year
1950. Screening of blood donors for brucellosis has revealed presence of Brucella antibodies in serum samples of 0.057 to
3.19% of blood donors [79-81]. In Saudi Arabia, the national seroprevalence of brucellosis is 15% [82]. Brucellosis can also
be transmitted by transfusion of harvested bone marrow in recipients of hematopoietic stem cell transplantation [83]. Sexual
transmission, although rare, has been reported in humans. In the reported cases, Brucella was either cultured from semen or
its presence in serum was demonstrated by PCR [84,85].

Laboratory Exposure to Brucellosis and Bioterrorism

The potential use of Brucella as a bioweapon derives from its great infectivity (virulence), ability to incapacitate infected
individuals (potential lethality), the stubborn persistent nature of human disease (ability to develop resistance to known
antimicrobials) and the absence of a safe and an effective vaccine for use in humans. Both the USA and the former Soviet
Union weaponized Brucella in 1945 [86-88]. Brucella is classified by the centers for disease control and prevention (CDC) as
a category B pathogen that has potential for development as a bioweapon. Moreover, Brucella species are considered as the
most common laboratory-acquired pathogen [13,20,89]. However, it is crucial to discriminate between true brucellosis and Y
09 infections that cause false positive serological reactions in testing for brucellosis [20]. In the management of bioterrorism,
with the potential use of Brucella as a bioweapon, doxycycline should be considered a first-line antibiotic [87]. Discovery of a
laboratory exposure to Brucellae should prompt an exhaustive investigation of the event and its circumstances, definition of
the population at risk, enforcement of safe laboratory practices and administration of antimicrobial prophylaxis for exposed
individuals [19,89,90].

Conclussions
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Brucellosis is a common global re-emerging zoonosis that constitutes a major health and economic problem in many
parts of the world. Brucellae are Gram negative, intracellular coccobacilli that predominantly affect organs with rich
macrophage content. At least 6 species have been recognized species, 4 of them are human pathogens. Infection can be
acquired by: consumption of unpasteurized dairy products, direct contact with animals, blood product transfusion and
sexual transmission. In the era of globalization, international tourism and travel across free borders, brucellosis has become
a common imported disease in developed countries. Laboratory exposure to the organism and possible utilization as a 006
biological weapon add more to the pathogenic potential of the organism. The recent immunologic, genetic and genomic
advances have translated into better understanding of the pathogenesis of brucellosis and are likely to be utilized well in the
vaccination, prevention and therapy of this global infection.
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