Brucellosis (overview) A23.9

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 29.10.2020

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Synonym(s)

Bang disease; Bang's disease; Brucellosis; Brucellosis caused by Brucella canis; Bruce's septicaemia; Febris mediterranea; Malta fever; Mediterranean fever; Porcine brucellosis; Undulating fever

History
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Marston 1861; Bruce 1887

Definition
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Notifiable anthropozoonoses caused by infection with brucella (B.) melitensis, B. abortus, B. suis, B. ovis). After the stage of bacteremia with undulating fever, formation of granulomatous inflammation, especially in the lymph nodes, spleen and liver, and arthritis of the ileosacral, intervertebral and hip joints.

Pathogen
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Brucells are small, gram-negative, unflagellated rod bacteria. There are 3 species which cause clinically very similar diseases:
  • Brucella abortus (pathogen of M. Bang = Febris undulans bovina): The main host is the cattle (causes a feverish general infection there).
  • Brucella melitensis (causative agent of Malta fever = Mediterranean fever, Febris mediterranea, Febris undulans melitensis, Bruce septicaemia, wave fever): Main hosts are sheep and goats.
  • Brucella suis (porcine brucellosis suis): the main host is the pig.

Occurrence/Epidemiology
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B. abortus: Occurs worldwide, especially in temperate and tropical areas where cattle breeding is practised.

Brucella melitensis: Mediterranean, Africa, South America.

B. suis: North America.

Etiopathogenesis
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Infection with Bruzella spp., in particular transmission by raw milk, direct contact with infected animals (sheep, goats, cattle, pigs) or their tissues and inhalation of infected aerosols. The pathogens frequently occur on previously damaged skin or conjunctiva (smear infection). Human-to-human transmission only in exceptional cases.

Clinical features
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Incubation period 2-6 weeks. A prodromal stage with uncharacteristic general symptoms is followed by the stage of bacteremia with typical, but not obligatory, wave-like temperature spikes (undulating fever): fever slowly rising to 38-40 °C over 5-7 days, followed by an equally slow decline. These episodes can be repeated for weeks or months. In addition, hepatosplenomegaly, headaches, aching limbs and possibly gastrointestinal symptoms. The skin may show extremely varied, more or less generalized exanthema, macular, papular, psoriasiform, hemorrhagic, erythema exudativum multiforme.

In the subsequent stage of organ manifestation, formation of granulomas in lymph nodes, liver, bones and other organs. Rarely in the skin as uncharacteristic, ulcerating nodules, plate-like infiltrates, ecthymata-like efflorescences.

Diagnosis
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Medical history (farmers, butchers, veterinarians, drinking raw milk; travel to Mediterranean countries). Microscopic and cultural pathogen detection from blood and body fluids, organ punctates, lymph node biopsy. Antibody detection (IgG, IgM, titer increase) with ELISA, CFT or agglutination reaction according to Widal.

Differential diagnosis
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Therapy
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Therapy of choice: Doxycycline 200mg/day p.o. + Rifampicin 600-900mg/day p.o. over 6 weeks

Alternative: Combination of tetracycline (e.g. tetracycline Wolff) 2 g/day for 3-6 weeks and streptomycin (e.g. strepto-fatol) 1 g/day i.v. or i.m. for 2 weeks. For mild infections monotherapy with tetracyclines is sufficient.

Alternatively: Doxycycline 2 times/day 100 mg p.o. instead of tetracycline.

In children under 12 years of age: Trimethoprim/Sulfamethoxazol (e.g. Cotrimox-Wolff Saft 1/2-2 measuringsl. depending on age) for 4 weeks. Combination of this therapy with rifampicin (e.g. Eremfat) 10-15 mg/kg bw/day p.o. is recommended. Treatment with rifampicin alone is not recommended due to rapid development of resistance.

Progression/forecast
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With therapy in the acute phase (start of therapy during the first 3 months) the chances of recovery are 90-100%, later 60-80%.

If therapy is started late, it is often not possible to eliminate the pathogens completely; chronic, long lasting courses with recurrent flare-ups of the disease are possible. In approx. 5% of the treated cases, relapses due to persistent sensitive pathogens occur, so that a new therapy attempt with the existing regime may be possible (antibiogram!).

Literature
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  1. Ariza J et al (1992) Treatment of human brucellosis with doxycycline plus rifampicin or doxycycline plus streptomycin. A randomized, double-blind study. Ann Internal Med 117: 25-30
  2. Bang B (1897) The etiology of infectious discarding. Z Veterinary Medicine 1: 241-278
  3. Bruce D (1887) Note on the discovery of a microorganism in Malta fever. Practitioner (London) 39: 161-170
  4. Marston JA (1861) Report on fever (Malta). Royal Army Med Dept Rep 3: 486-521
  5. Mazokopakis E et al (2003) Acute brucellosis presenting with erythema nodosum. Eur J Epidemiol 18: 913-915
  6. McLean DR et al (1992) Neurobrucellosis: clinical and therapeutic features. Clin Infect Dis 15: 582-590
  7. Metin A et al (2001) Cutaneous findings encountered in brucellosis and review of the literature. Int J Dermatol 40: 434-438
  8. Milionis H et al (2000) Cutaneous manifestations in brucellosis: case report and review of the literature. Infection 28: 124-126
  9. Weil Y et al (2003) Brucella prosthetic joint infection: a report of 3 cases and a review of the literature. Clin Infect Dis 36: e81-86

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Please ask your physician for a reliable diagnosis. This website is only meant as a reference.

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Last updated on: 29.10.2020