د/عبد الله حــامد أبو جبــل استشــــارى الحميـــات بســم الله الرحمــن الرحيــــم د/عبد الله حــامد أبو جبــل استشــــارى الحميـــات مستشفى حميـــات امبابه imbabafevers.com

Brucellosis Common classical zoonotic disease of worldwide distribution

Br. Melitensis → Goats , Sheeps & camels. Reservoir: Br. Melitensis → Goats , Sheeps & camels. Br. Suis → Pigs. Br. Abortus → Cattles. Br. Canis → Dogs

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Causative organism: Brucella sp. A small , non motile non capsulated,non spore forming ,gram –ve coccobacilli. Aerobic , facultative i.c bacteria. Killed by boiling, pasteurization,lactic a.& strong salts. Not killed by freezing. imbabafevers.com

Uncommon routes blood transfusion&bone m.transpl. Mode of transmission: Orally Inhalation Skin Conganctiva Uncommon routes blood transfusion&bone m.transpl. Unproved routes, trnsplacental,sexual&breast milk feeding

Portals of entry for Brucella species. imbabafevers.com

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I.P: Onset Devided into Clinical picture: 1-3 weeks may be sudden [1-2days] or gradual [1 week or more] Onset acute, chronic & complications Devided into

Acute Brucellosis: Symptoms: Fever Rigors Sweating low backache.

Less common chest pain abdominal pain Palpitation constipation

Signs: Lymphadenopathy, May be lacking. Temp. is always high Hepatosplenomegaly Lymphadenopathy, Spondylitis,bursitis, osteomyelitis,epidydemo-orchitis, meningo-encephalitis & endocarditis may occur specilly in Br. Miletensis

Lassitude may be present and may continue after successful ttt. Full recovery is likely, in spite of the severity, by proper therapy Relapse may occurs after ttt. precipitated by new infection, trauma, surgery or stress

Table 2. Symptoms and Signs of Brucellosis Symptoms Fever Constitutional symptoms* Sweats Chills Arthralgias Gastrointestinal symptoms** Headache Lumbar pain Myalgias Cough/dyspnea Weight loss Neurological symptoms*** Testicular pain % 98 94 85 79 53 51 (400) 42 (400) 39 35 19 (400) 18 (400) 14 (400) 5 Signs Hepatosplenomegaly Hepatomegaly Splenomegaly Osteoarticular Relative bradycardia Adenopathy Neuro/CNS**** Orchitis/epididymitis Cutaneous % 41 (400) 38 22 23 21 (530) 9 8 6 (400) 3 (530) N= 930, unless specified in ( ). * Anorexia, asthenia, fatigue, weakness, malaise ** Abdominal pain, constipation, diarrhea, vomiting *** Anxiety, confusional psychosis, depression, insomnia **** Paralysis, nuchal rigidity, papilledema imbabafevers.com

Chronic brucellosis: Signs: Symptoms: Onset is insidious recurrent flu with lassitude headache , pain & sweat depression. Signs: Temp. may be normal Moderate Splenomegaly may be in the minority of cases

Skeletal system [bones&joint] Occurs in about 10% of cases. Complications: May occur with acute or chronic &may be the presentation. Skeletal system [bones&joint] Occurs in about 10% of cases. a-Arthritis Reactive Septic b-Spondylitis C-Ostceomyelitis

Spondylitis of lumber spine 4 due to Brucellosis imbabafevers.com

Spondylitis with para vertebral soft tissue mass due to Brucellosis imbabafevers.com

Tuberculous Spondylitis with Psoas Abscesses imbabafevers.com

Crdiovascular Endocarditis Myocarditis Pericarditis aortic root abscess Mycotic aneurysm Neurobrucellosis Meningitis Meningo- encephalitis multiple cerebral or cerebellar absc. rupture mycotic aneurysm cranial n. lesions Transient E.A Hemiplegia myelitis Genitourinary epididymo-orchitis in children prostatitis &seminal vesiculitis in adult Dysmeno.,ameno. Tubo-ovarian abscess, chr.salpingitis&cervasitis A.nephritis

Acute unilateral scrotal swelling in a 27-year-old man with brucellosis. imbabafevers.com

. Conjunctivitis [accidental], G.Intestinal hepatitis with mild jaundice liver &splenic abscesses Respiratory: Rarely, hilar& paratracheal lymphadenopathy pneumonia, lung absces solit.or mult. Shadows pleural eff., empyema mediastinitis Ocular: . Conjunctivitis [accidental], . keratitis, …..

Hepatic Granuloma due to Brucellosis imbabafevers.com

Skin(Uncommon) In pregnancy Other rare complications contact dermatitis maculopapular eruptions, erythema nodosum, purpura In pregnancy normal delivery. Abortion I.U. Fetal death Premature delivery. Retention of placenta Other rare complications Thyroiditis adrenal insuffeciency.

Diagnosis: Depends on the presence of 1-Coming from or presence in endemic area 2-clinical features 3-Lab. investigations

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Lab. Investigations Blood or tissue culture +ve in about 50 -70% of cases PCR +ve in about 70% of cases Roose Bengal TEST Standard aggl. Test: a titre of 1/160 in non endemic areas & 1/320 in endemic areas are significant Compl.fixation t.,Radio-I-Assay,Coombs t., ELISA t.: Blood picture: Non sp., but exclude pyogenic inf.&T.B.

Treatment: The optimum antibiotic therapy is still disputed Treatment: The optimum antibiotic therapy is still disputed . According to WHO 4 drugs only are mainly used for treatment: Doxycycline in adults Dose: Orally 100mg cap 12 hourly Aminoglycoside e.g: Streptomycin 15 mg/kgm body wt. i.m . Daily Gentamicin:2-5 mg/kgm body wt. daily. Rifampicin Dose:orally 10-20 mg/kgm body wt. on empty stomach. Co-Trimoxazole 8-10 mgm/kg oral or i.v. in 2 devided doses

C-Pregnency & Children At least 6 weeks of double therapy ( Doxycycline +Rifampicin) or Triple therapy(Doxycycline +Rifampicin +Aminoglycoside) for 2 weeks then complete wth double therapy A: Adult, acute without complications Triple therapy for 3 months B-Chronic without complications Rifampicin +Co-Trimoxazole for at least 6 weeks In the first trimester of pregnancy mono-therapy with rifampicin can be used C-Pregnency & Children

D- Bone affection & neuro-brucellosis Triple therapy for 9-12 months. N.B: In bone affection, Doxycycline should be always and in CNS affection Rifampicin should be always. D- Bone affection & neuro-brucellosis Compensated liver: Treated as usual. Terminal stage liver failure: Ciprofloxacin 750 mg tid for one month. E-In case of Hepatitis Doxycycline is completely metabolized by the liver and excreted in bile and can be used in usual dose in renal impairment F-Renal impairment