Brucellosis

and

Pregnancy

Prof. Aboubakr

Elnashar

Benha University

Hospital, Egypt

Aboubakr Elnashar

Other names for Brucellosis

Undulant fever

Malta fever

Mediterranean fever.

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CONTENTS

1. Causative organism

2. Epidemiology

3. Transmission to human

4. Clinical Manifestation

5. Investigations

6. Treatment

7. Prevention

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1. Causative organism

Brucella

Coccobacillus, gram negative, non-sporing

Non-motile aerobic bacterium

Hosts: mostly animals.

Four species:

Melitensis: most frequent human infection

Abortus

Suis

Canis

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2. Epidemiology

Major zoonotic disease.

Worldwide

Major endemic areas:

Mediterranean basin

Arabian Gulf

Indian subcontinent,

Parts of Mexico

Central and South America

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Risk factors:

1. Family history of brucellosis

2. Stockbreeding

3. Ingestion of non-pasteurized dairy products:

most common source of transmission.

Occupational status and

family history of brucellosis should be

obtained during prenatal care in at-risk areas.

تربيه الماشيه

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Brucellosis in Saudi Arabia

Endemic

National prevalence: 15%

1. Persistence of domestic animal reservoirs for

Brucella species

2. Human consumption of unpasteurized products

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Brucellosis in Egypt:

Incidence:

common.

Among pregnant women

3.5%{Sherif et al.2003]

12 .2 %(Alshamy and Ahmed, 2008)

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3. Methods of transmission

1. Direct

1. inoculation through cuts and skin abrasions from handling animal carcasses, placentas, or contact with animal vaginal secretions

2. Direct conjunctival inoculation

2. Inhalation

of infectious aerosols

3. Ingestion

of contaminated food such as raw milk, cheese made from unpasteurized (raw) milk, or raw meat

Venereal

has been suggested, but the data are not conclusive

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Types of transmission

1. Consumption of:

1. unpasteurized milk

2. soft cheeses made from the milk of infected

animals, primarily goats, infected with B melitensis

2. Occupational

1. laboratory workers

2. Veterinarians

3. Slaughterhouse workers.

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Incubation period

Few days to a few months.

In most patients 2 and 6 w

Duration depend on: virulence of the infecting strain size of the inoculum route of infection resistance of the host

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Portals of entry

Oral entry

Most common route

Ingestion of contaminated animal products

(often raw milk or its derivatives)

Contact with contaminated fingers

Aerosols

Inhalation of bacteria

Contamination of the conjunctivae

Per cutaneous

through skin abrasions or by accidental

inoculationAboubakr Elnashar

4. Clinical ManifestationUsually Acute febrile illness

accompanied by a wide array of other symptoms

Night sweats

Malaise

Anorexia

Arthralgia

Fatigue

Weight loss

Depression.

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Fever

1. Acute stages: high

2. undulant stages: low grade and intermittent

3. Chronic stages: low grade or absent

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Complications may affect any organ system

1. Osteoarticular disease

most common complication (i.e., sacroiliitis and

peripheral arthritis)

2. Genitourinary disease

second most common complication.

3. Liver disease

second most common medical complication in

brucellosis are more susceptible to develop

liver disease.

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4. Hematological disease

Anaemia:

found in 72.3%

{role of iron in the biology of Brucella}

Leukopenia and lymphopenia(the latter considered a prognostic factor)

Leukocytosis

23.1%

Thrombocytopenia:

occurs rarely

: fatal CNS bleeding.

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The disease may persist as

Relapse

Chronic localized infection

Delayed convalescence

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Brucellosis and pregnancy outcome:

1. Abortion.

The incidence : 27%

There was a statistically significant difference in

abortion rates between patients with a titre

more than 1/160 and those with a titre less than

1/160

Causes of spontaneous abortion and IUFD

Maternal bacteremia

Toxemia

Acute febrile reaction

DIC

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2. IUFD

More frequently than do other bacterial infections

12%

3. Chorioamnionitis,

4. Preterm labour

10%.

The frequency of fetal loss among patients with

brucellosis is very high.

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5. Investigations

CBC:

Total counts:

Normal/reduced

Thrombocytopenia

ESR/CRP:

Normal/Increased

CSF/Body fluid analysis:

Lymphocytosis, low glucose levels, elevated ADA

Biopsied samples of lymph node, liver:

non caveating granuloma without acid fast bacilli.

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Serological Tests

Main laboratory method of diagnosis

based on antibody detection

include:

Serum agglutination (standard tube agglutination)

ELISA Rose Bengal agglutination

Complement fixation

Indirect Coombs

Immunecapture-agglutination (Brucellacapt)

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Serum agglutination test

most widely used

measures agglutination for IgG, IgM, IgA

Diagnostic level:

1 : 160: non endemic area

1 : 320: endemic area

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6. Treatment

Drugs against Brucella

Tetracycline's

Aminoglycosides

Streptomycin since 1947

Gentamicin

Netilmicin

Rifampicin

Quinolones - ciprofloxacin

?3rd generation cephalosporins

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WHO recommends

Non pregnant:

Regimen A:

Doxycycline 100 mg orally twice daily for 6 w +

Streptomycin 1 g IM once daily for 2-3 w

more effective, mainly in preventing relapse.

Regimen B:

Doxycycline 100 mg orally twice daily plus

Rifampin 600 to 900 mg (15 mg/kg) orally once

daily for 6 w.

more convenient but probably increases the

risk of relapse

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Pregnant

Rifampicin:

900 mg once daily for 6 w

mainstay of treatment of brucellosis during

pregnancy OR

Rifampicin:

900 mg once daily plus

Trimethoprim-Sulphmethoxazole

5 mg/kg of the trimethoprim component twice daily

for 4 w

incidence of abortion was not different among

patients who received TMP-SMX alone or received

TMPSMX and rifampicin

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Prevention

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Conclusion

1. Causative organism: Melitensis: most frequent

human infection

2. Epidemiology: Among pregnant women

3.5%-12 .2 %

3. Transmission to human: direct, inhalation, ingestion

4. Clinical Manifestation: Abortion, IUFD,

Chorioamnionitis, PTL5. Investigations: Serum agglutination test Diagnostic level:1 : 160: non endemic area and 1 : 320: endemic area6. Treatment: Rifampicin7. Prevention: occupational and food hygiene

Aboubakr Elnashar

Aboubakr Elnashar

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