4/5/2015

Overview

Most common zoonotic infection.

8 species: named after the source animal
4 species: Human pathogens
B. melitensis
Sheep
B. abortus
Cattle
B. suis
Swine
B. canis
Dogs
Localize in reproductive organs of host animals: abortions
and sterility.
Shed via: urine, milk, placental fluid
Humans are accidental hosts
Transmission: Ingestion of infected milk/ meat products.
Direct contact with an infected animal
Inhalation of aerosols

Brucellosis
Dr Debasis Biswas

Occupational risk

Overview

Slaughterhouse workers
Farmers and shepherds
Veterinarians
Laboratory workers

Small, aerobic intracellular Gram-ve coccobacilli.

Invade both phagocytic & non-phagocytic cells.
Survive intra-cellularly by evading the immune system.
Systemic illness; can involve almost every organ system
Febrile manifestations: Mediterranean fever
Malta fever
Gastric remittent fever
Undulant fever.
Diagnosis based on: Culture/ Serology/ Both.

Higher in more agrarian societies and in places where

handling of animal products and dairy products is less
stringent.

Virulence attributes
Invade circulating PMNs and macrophages
LPS coat: facilitates intracellular survival
Production of AMP & GMP, which inhibit phagosomal
fusion and oxidative burst activity.
Poor inducers of inflammatory cytokines like TNF & IFNs
Do not activate the alternative complement system
Inhibit programmed cell death

Pathogenesis
Entry thru wound/ conj mucosa/ inhalation/ ingestion
Intracellular survival in phagocytes
Transported via lymphatics to local LNs . Replication
Hematogenous dissemination Distant organs
Predilection for placenta . Erythritol
May also replicate in: Kidney; Liver; Spleen; Breast;
Joints
After replication in the ER, brucellae are released with
the help of hemolysins and induce cell necrosis.
Localized and Systemic infection.

Can involve:
CNS, Heart, Joints,
Genitourinary system,
Lungs & Skin

Fever
Sweat
Fatigue

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Immune Response

Acute vs Chronic Brucellosis

Protective immunity: CMI (mainly)

Th1 response .. Activated Mes Eliminate Brucella

Acute

Antibodies: partial protection from re-infection

IgM IgG
IgM: primary response
IgG: Chronic or relapsed infection
IgA: Elaborated late & persist for long

Prolonged Bacteremia
Irregular Fever
Systemic manifestations:
fatigue, anorexia,
drenching sweats,
musculo-skeletal pain
Complications: Articular,
Osseous, Visceral,
Neurological

Host response:
B abortus:
Granulomas
B melitensis & B suis: Visceral microabscesses
(commonly)

[1]

Recurrent Acute & Chronic

Brucellosis

Non- bacteremic (lowgrade infection with

periodic exacerbations)
Minimal or no fever
Symptoms related to a
state of hypersensitivity in
the patient.

Species-wise pathogenicity
Highest
pathogenicity
High
pathogenicity

Most severe & acute cases

B. abortus

Moderate
pathogenicity

B. canis

Moderate
pathogenicity

Mild-to-moderate
sporadic disease;
complications rare
Insidious onset, frequent
relapses, does not
commonly cause chronic
brucellosis.

B. melitensis

Recurrent symptoms of Ac. Brucellosis

Systemic, OR
Localized
May occur even in properly treated patients
May evolve into chronic brucellosis
Systemic
Localized (Neurobrucellosis)
Additional treatment indicated:
Rifampicin added to Tetracycline
Progressive disease, if untreated

[1]

Infection can be latent, subclinical

Chronic

B. suis

Prolonged illness, often

assoc. with suppurative &
destructive lesions.

[1]

Prognosis

Diagnostic Approach

T/t within the first few months of onset:

Easily curable
Low risk of relapse or chronic disease.
Presentn. with CCF d/t Endocarditis: ~ 85% Mortality

Isolation
Blood
Tissues (e.g. bone marrow biopsy or liver aspiration)
Body fluids (Synovial/ Pleural/ CSF): Low yield

Recovery quicker with B. abortus than with B. melitensis

or B. suis.

Serology
Slide Agglutination
Tube Agglutination
ELISA

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[1]

[1]

CBC in Brucellosis

CSF in Brucellosis

Anaemia
Leukopenia
Neutropenia with relative Lymphocytosis
Thrombocytopenia is reported in 40% (secondary to
hepatosplenomegaly or from immune thrombocytopenia)

Mild to modest lymphocytic pleocytosis of 88 - 98%.

Protein levels : Elevated
Glucose levels: Normal

Culture

Biochemical reactions

[1]

Aerosol transmission: Sample handling in Bio-safety

Cabinet
Bone Marrow Culture:
RE system holds a high concentration of Brucella
Sensitivity: 80- 90%.
Media: Serum dextrose agar, serum potato infusion agar,
trypticase soy agar or tryptose agar
Selective: Bacitracin, Polymyxin & Cycloheximide
Castaneda Method (Biphasic Trypticase Soy Broth/
Brucella broth)
Sensitivity further ed by Lysis Centrifugation technique

No carbohydrates are ordinarily fermented.

Catalase positive, oxidase positive.
Urease positive.
Nitrates are reduced to nitrites.
IMViC: Negative

Strict aerobes
6-8 weeks: To declare -ve

Speciation
CO2 Requirement (B. abortus is capnophilic)
H2S production (Most strains of B. abortus are H2S +ve)
Sensitivity to dyes (Basic fuchsin and Thionin)
Lysis by Tblisi phage (B. melitensis is resistant)
(B. abortus is sensitive)
Antigenic structure (B. melitensis: M= 20 x A)
(B. abortus: A= 20 x M)

Each species is further divided into biotypes

Serology
Tube Agglutination test: SAT
Detects Anti- LPS antibodies
2- Mercapto ethanol test
Detects IgG class of Anti- LPS antibodies
Titers higher than 1:80 define active infection
Endemic Areas: Titers > 1:320 are more specific
Persistent infection/ Relapse:
A high IgG antibody titer
Titer that is higher after treatment
Potential cross-reactivity with other organisms, e.g.
Francisella tularensis
Yersinia enterocolitica serotype O9
Vibrio cholerae
Escherichia coli 0:116; 0:157

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Prozone Phenomenon

ELISA

May occur 2ry to high Ab levels

False negative results
Routine dilution of sera (typically beyond 1:320) is
necessary to avoid this problem.

PCR

Histopathology

Two major genetic targets:

BCSP31
16S & 23S rRNA operon
16S & 23S rRNA operon: more sensitive
Not widely used in clinical practice and needs more
standardization.
Possible applications would include evaluating cases of
relapse and monitoring response to therapy.

Cytoplasmic proteins as antigens

Measures IgM, IgG, and IgA class of antibodies
Follow-up: Levels decrease with effective treatment
ELISA of CSF: Helps diagnose neurobrucellosis

Mixed inflammatory
infiltrates with
lymphocytic
predominance
and granulomas
with necrosis

Hepatic granuloma in Brucellosis.

Brucella species are poorly staining, small Gramnegative coccobacilli and are seen mostly as single
cells with an appearance resembling "fine sand."