Bacteria as agents of biowarfare. How to proceed when the worst is suspected

Recognition of an increasing incidence of uncommon pneumonias with a high mortality rate, clusters of cases, or a high incidence of pet illnesses or death should alert medical personnel to the possibility of terrorism with bacteriologic agents. Prompt reporting of such unusual occurrences to the local health department is of paramount importance for early identification of cases, treatment initiation, and institution of preventive measures.

[Functional and metabolic activity of leukocytes in patients with chronic brucellosis]

AIM

Investigation of functional-metabolic activity of leukocytes by assessment of basic components of the microbicidal system in the course of chronic brucellosis with reference to the stage, severity, complications and concomitant diseases.

MATERIAL AND METHODS

Time course of changes in myeloperoxidase, acid and alkaline phosphatase activity, levels of cation protein, glycogen and lipids in leukocytes were studied in seventy-one 16-70-year-old patients with exacerbation of chronic brucellosis. The diagnosis of primary-chronic, secondary-chronic brucellosis, subcompensation was made in 13, 58 and 69 patients, respectively. 14 patients had chronic infectious inflammatory diseases, 13 patients had chronic non-inflammatory diseases.

RESULTS

Patients with chronic brucellosis at the height of the exacerbation had suppressed activity of myeloperoxidase and lowered level of cationic protein with high activity of acid and alkaline phosphatases, elevated glycogen and lipids in leukocytes. General condition of the patients improved in parallel with multidirectional shifts in the levels of microbicidal system components with normalization at the stage of persistent remission.

CONCLUSION

Changes in the level of intracellular components of leukocytes depended on brucellosis stage, severity, complications, concomitant diseases, completeness of recovery. This is of clinico-diagnostic significance.

Clinical features, complications and treatment outcome of childhood brucellosis in central Greece

OBJECTIVES

To examine the epidemiology, clinical and hematological characteristics, complications and treatment outcome of childhood brucellosis in central Greece.

METHODS

Retrospective record review of all patients 0-14 years of age with brucellosis admitted during a 16-year period between 1984 and 1999.

RESULTS

A total of 39 cases (23 males, median age 132 months) were recorded in which the diagnosis was confirmed by a positive culture (n=30) or detection of IgM antibodies with ELISA (n=9). About 38% of these patients came from families of farmers or shepherds who owned a few domestic animals or small herds of goats or sheep and another 43% had consumed dairy products bought from shepherds. In 41% of the cases another family member developed symptomatic infection. Most of the patients presented with fever (61%) and musculoskeletal symptoms (69%). Splenomegaly was recorded in 38% and hepatomegaly in 28% of the cases. Anemia (39%) and monocytosis (31%) were the most common hematological manifestations, followed by lymphopenia (18%). Unusual complications were detected in two patients who developed thrombocytopenic purpura and acute facial nerve palsy, respectively, but recovered without long-term sequelae. None of the 22 patients who received a combination of two or three antibiotics for > or =6 weeks and had adequate follow-up had a relapse.

CONCLUSION

Childhood brucellosis remains an important public health problem in central Greece. It usually occurs in families that raise small ruminants and the development of symptomatic infection in more than one family member is common. It may cause serious complications in children and treatment with at least two antibiotics for not less than six weeks appears to be effective.

Chronic hepatosplenic abscesses in Brucellosis. Clinico-therapeutic features and molecular diagnostic approach

In order to analyze the clinical and therapeutic features of chronic hepatosplenic abscesses, and to define the diagnostic yield of new molecular techniques, we describe seven cases, four hepatic and three splenic, of this uncommon complication of Brucellosis. Onset of symptoms in all cases was insidious and the diagnostic delay considerable. Abdominal CT scan showed large, poorly defined lesions, with heterogeneous attenuation and thick central calcifications surrounded by hypointense areas. Histologically, all cases presented granulomas with central necrosis, a polymorphic infiltrate, few giant cells and peripheral fibrosis. The diagnostic yield with conventional microbiologic techniques was poor, whereas a Brucella PCR-assay of a tissue or pus sample was positive in all six cases in which it was performed. Conservative therapy with antibiotics, either alone or combined with percutaneous drainage, failed in all cases, so that in this type of lesion, the treatment of choice should be medical-surgical, in order to guarantee excision of the central calcium nucleus responsible for the persistence of the infection.

Combined brucella melitensis and streptococcal viridans endocarditis

Infectious endocarditis is a potentially lethal inflammation of the hearts' inner lining invaded by microorganisms. The mortality from this illness increases as the number of infective organisms rises to 2, due to involvement of the left side of the heart. These microorganisms usually arise from the patient's own flora but can be acquired from the environment. Fever and heart murmurs are the principal clinical manifestations followed by a plethora of peripheral signs due to dissemination of microorganisms via the bloodstream. Echocardiographic imaging and sensitive culture techniques form the cornerstone of diagnosis. We report a patient with rheumatic heart disease who had combined brucella melitensis and streptococcus viridans endocarditis complicated by heart failure and an aortic root abscess. He was diagnosed on the basis of a history of prolonged fever and occupational risk as a shepherd, the presence of heart murmurs, positive blood cultures and echocardiographic evidence of aortic vegetations. He had an excellent response to intravenous antibiotic therapy combined with aortic valve replacement, which nowadays is regarded as the safest therapeutic approach for aortic valve endocarditis.

Biological and chemical agents: a brief synopsis

The objective of this article is to provide a concise overview of the most likely biological and chemical agents that could be used as biochemical weapons. The diagnosis, pathology, prevention, decontamination, treatment, and disposition of these biological and chemical agents are presented in a tabular format for quick reference purposes. The information provided outlines the bare essentials needed to deal with any emergency or catastrophic event involving these agents.

Brucellar spondylodiscitis: MRI diagnosis

Early diagnosis of brucellar spondylodiscitis is often difficult because of the long latent period. Radiographs of the spine, bone scan, and computed tomography (CT) scan provide insufficient data. Among 25 patients with brucellar spondylodiscitis studied by magnetic resonance imaging (MRI), 9 were in the acute stage and 16 were in the chronic stage. MRI is the investigation method of choice in diagnosing brucellar spondylodiscitis.

Unusual complication of breast implants: Brucella infection

Brucellosis is hyperendemic in Saudi Arabia. We report infection in a breast implant as an unusual complication of laboratory-acquired brucellosis. A 48-year-old female developed fever, rigors, headache, arthralgia and weight loss. A blood culture for Brucella was positive. A 6-week course of antibiotics effected a clinical and bacteriological cure but the resolution was short-lived. Six weeks later a relapse of her febrile symptoms occurred together with the appearance of a breast abscess. Cultures of the abscess and blood yielded brucella. A second course of antibiotics together with surgical drainage and subsequent reconstruction resulted in a cure.

Brucellar spondylitis and meningoencephalitis: a case report

Brucellosis, a zoonosis with a worldwide distribution, is a systemic infection that can present with involvement of both nervous and musculoskeletal systems. We report a case of spondylitis and meningoencephalitis and describe the clinical features, and difficulties in treatment. Osteoarticular complications of brucellosis are common but involvement of the nervous system is rare and it should be included in the differential diagnosis of any obscure neurologic disorder.

Brucellar spinal epidural abscess of cervical location: report of four cases

Spinal epidural abscesses account for 1 or 2 of every 10,000 hospital admissions, Staphylococcus aureus being the bacterium most frequently involved. Brucellosis is a disorder of worldwide distribution, relatively frequent in South America and in Mediterranean countries in Europe and Africa. Whilst in the USA only 200 cases are reported every year, in Spain it is the most frequent zoonosis. This systemic disease seldom produces spondylodiscitis which in a minority of cases may be complicated by spinal epidural abscesses, in general of lumbar location. The purpose of this article is to analyse 4 cases of brucellar spinal epidural abscess of cervical location and diagnosed in the Province of Teruel, Spain, an endemic area for the disease, through 10 consecutive years (1990-1999). We consider noteworthy the following facts: the first case was a technical employee who acquired the infection in our laboratory of microbiology, the second presented with an extensive purulent collection invading prevertebral and retropharyngeal regions, the third case was cured only with antibiotics without residual deficits. In the fourth case we were not able to demonstrate spondylodiscitis accompanying the epidural abscess at the C2-C6 levels. We discuss especially the epidemiological aspects of brucellosis, the existence of epidural abscess without spondylodiscitis, the clinical manifestations, the diagnosis by means of magnetic resonance imaging, specific serological tests for Brucella, antibiotic treatment and the prognosis of our cases.

Brucella endocarditis: case report and review of the literature

Cardiac involvement in childhood brucellosis is rare and, when present, findings are usually seen in acute rheumatic fever with endocarditis. We report a successfully treated case of Brucella endocarditis in which the aortic valve was affected. Medical therapy did not cure this patient who, due to hemodynamic deterioration, required valve replacement. This case report suggests that successful management of Brucella endocarditis requires a combination of medical and early surgical therapy.

Successful management of Brucella mellitensis endocarditis with combined medical and surgical approach

OBJECTIVES

Brucella endocarditis is an underdiagnosed complication of human brucellosis, associated with high morbidity and mortality. We report the successful management of a number of cases of Brucella mellitensis endocarditis.

PATIENTS AND METHODS

Seven consecutive cases of Brucella mellitensis endocarditis were treated over the last 20 years, based on high suspicion of the disease at first place. The early suspicion of Brucella endocarditis relied on medical history and a standard tube agglutination titer > or =20. Blood and/or cardiac tissue cultures were positive in all patients, but available late following surgery. All patients were successfully treated with a combination of aggressive medical and early surgical therapy. All affected valves were replaced within 1 week from admission (five aortic and three mitrals). Medical treatment included co-trimoxazole, tetracyclines and streptomycin, before surgery, followed by co-trimoxazole and tetracyclines for a median of 12 months (range: 3-15 months) after surgery until the titers returned to a level < or =1:160.

RESULTS

There were neither operative deaths nor recurrence of infection. One patient died two years after the operation due to massive cerebrovascular accident. Ten-year survival was 85.7+/-13.2%.

CONCLUSION

Although Brucella mellitensis endocarditis is a rare entity, its optimum management should be a combination of aggressive medical treatment and early surgical intervention, based on high degree of suspicion in areas with high incidence of the disease.

A case of prosthetic mitral valve endocarditis caused by Brucella abortus

Endocarditis is a rare but serious complication of brucellosis. We report here a case of Brucella abortus endocarditis occurring on a prosthetic mitral valve. The diagnosis was established by positive serology, the presence of vegetation on the mitral prosthesis and isolation of B. abortus from the blood and valve cultures. The patient was successfully treated with combined medical and surgical therapy.

Current understanding and management of chronic hepatosplenic suppurative brucellosis

To outline the characteristics and define appropriate management of chronic hepatosplenic suppurative brucellosis (CHSB), 905 patients with brucellosis were analyzed. Sixteen episodes of CHSB (14 in the liver and 2 in the spleen) were found in 15 patients. Six patients had had previous remote brucellosis. Twelve patients presented with systemic symptoms, and 12 with local symptoms. Cultures of blood samples yielded negative results in all cases except 1, and the results of cultures of pus specimens were positive for Brucella melitensis in only 2 cases. All patients showed calcium deposits surrounded by a hypodense area on computed tomography. Patients often had low titers of agglutinating antibody. In patients who were receiving conservative management, early response was successful in 50% and late response was successful in 33.3%. In the patients who underwent surgery and concomitant antibiotic therapy, early and late response was successful in 100%. Thus, CHSB mainly represents a local reactivation of previous brucellosis. Its diagnosis may be difficult to establish and surgery may be required to cure many patients.

Management of spinal brucellosis and outcome of rehabilitation

STUDY DESIGN

Review of cases.

OBJECTIVE

To review cases of brucellosis in order to clarify diagnostic guidelines, treatment regimes and prognosis.

SETTING

University Hospital, Turkey.

METHODS

Study of 11 patients (9 male, 2 female) with either brucellar spondylitis or epidural brucellar abscess. Diagnosis made on clinical presentation, laboratory findings, radiographic evidence and a minimum brucellar anti body of 1 : 160, a positive bacteriological culture and/or histological finding of inflammation of granulomatous tissue. All patients were treated with a combination of oral antibiotics. Surgery was performed in 8 patients.

RESULTS

At least 6 months antibiotic therapy using Rifampicin and Doxycycline is recommended. Surgery is indicated in the presence of spinal instability, cord compression or radiculopathy. In our series eight patients required surgery.

CONCLUSION

The patients complaining of back pain, particularly in endemic areas should be investigated as possible cases of brucellosis.

Identification of protective outer membrane antigens of Brucella ovis by passive immunization of mice with monoclonal antibodies

Outer membrane proteins (OMPs) and rough lipopolysaccharide (R-LPS), the main surface antigens of Brucella ovis, display surface-exposed epitopes. Mixtures of monoclonal antibodies (mAbs) to both antigens were previously shown to protect mice against a B. ovis challenge. To further identify the antigens involved, seven mAbs against Brucella OMPs (Omp10, Omp16, Omp19, Omp25, Omp31, Omp2b and Omp1) and three to R-LPS were tested for protection either individually or in combinations. Significant reduction in spleen infection in challenged mice, relative to controls, was used as the protection criteri. Controls included nonimmunized mice and mice given an irrelevant, anti-O-polysaccharide (OPS), mAb. For comparison, a group received a mouse serum containing antibodies to both OMPs and R-LPS; this serum was prepared by immunization with a B. ovis hot-saline extract which, as described previously, induces protective immunity in mice and rams. Significant protection was observed with both mAbs to OMPs and R-LPS. mAbs to Omp16, Omp19 and Omp31 afforded the highest protection and prevented the development of splenomegaly. The protective effect of mAb to Omp31 was not interfered with by nonprotective mAbs in different mixtures. The data presented confirm the protective role of antibodies to OMPs and R-LPS against B. ovis, and identify several OMPs, especially Omp31, which are promising candidates for a subunit vaccine against ram epididymitis.

[Brucellosis]

Brucellosis is a zoonosis, reported for the first time in 1859 by Marston, in Malta. It has also been referred to as Mediterranean Fever, Malta Fever and Bang's disease. Its causative agent was isolated by David Bruce in 1886; this was Brucella melitensis: five different strains were later described: B. abortus, B. suis, B. ovis, B. neotomae and B. canis. Recently, in 1994, the isolation of Brucella was reported in marine mammals, eventually pathogenic to man and unofficially designated "B. maris". Human brucellosis is still a public health problem in countries where the infection has not been eradicated from the animal hosts. When manifested, human disease may assume different courses, widely known, but whose physiopathology is still not totally clear. Much is already known about the agent's molecular biology and in vitro behaviour, but, doubts persist about its in vivo activity, including in human infection. We review some aspects of brucellosis, focusing on the pathogenesis, and referring to new and potential diagnostic methods, therapy and prevention.

Brucella disc infection mimicking lumbar disc herniation: a case report

Brucellosis is a zoonotic disease and still a major health problem in many geographical areas. In this paper a forty year-old woman with spinal brucellosis associated with epidural abscess formation and mimicking lumbar disc herniation is presented. Compression of spinal nerve root(s) by epidural masses due to brucella disc infection is a rare condition and should be kept in mind in differential diagnosis of lumbar disc herniation. The crucial role of magnetic resonance imaging in differential diagnosis is also emphasised.

Pyogenic osteomyelitis of the spine in the elderly: three cases of a synchronous non-axial infection by a different pathogen

STUDY DESIGN

A retrospective chart review of patients over 65 years of age treated at the Spine Care Unit for pyogenic vertebral osteomyelitis.

OBJECTIVES

To assess the reliability of peripheral blood, urine and sputum cultures in the treatment of pyogenic vertebral osteomyelitis in the elderly.

SETTING

Study performed at the Spine Care Unit, Meir Hospital, Kfar-Saba, Israel.

METHODS

The Meir Hospital records were searched for patients over 65 years of age, treated at the Spine Care Unit for pyogenic vertebral osteomyelitis. Charts, culture results and imaging studies were reviewed. A medline literature search was performed to survey the literature regarding pyogenic vertebral osteomyelitis in the elderly with emphasis on diagnostic imaging modalities and surgical treatment.

RESULTS

Three patients were identified with concurrent peripheral infection by a different organism than the organism causing the vertebral osteomyelitis. Delay in correct diagnosis led to neurologic impairment in all patients and surgical treatment was performed in all three to drain the epidural abscess, decompress the spinal cord and obtain direct tissue culture. Following decompression and epidural abscess evacuation, one patient has functionally recovered and was ambulating with a cane, two patients did not recover and remained paraparetic and ambulate in a wheelchair.

CONCLUSIONS

Pyogenic vertebral osteomyelitis in the elderly can be caused by a different pathogen than that isolated from blood, sputum or urine cultures. In the elderly, a biopsy of the vertebral lesion should be obtained for susceptibility studies prior to conservative treatment with bracing and intravenous antibiotics.

Primary psoas abscess. A review of 16 cases

OBJECTIVE

Most psoas abscesses are secondary. The objective of this study was to report on the clinical features, diagnosis and treatment of primary psoas abscess.

METHODS

We retrospectively studied 16 cases seen over a ten-year period (1987-1997) and compared our findings to published data.

RESULTS

There were 14 men and two women, with a mean age of 6 years (range, 17-57 years). The right side was affected in nine cases, the left side in six, and both sides in one. Fever, pain and psoas spasm were the presenting symptoms. Laboratory tests for inflammation were positive; four patients had a high neutrophil count. Ultrasonography demonstrated a fluid collection in the psoas in 13 patients. A computed tomography scan was done in 14 patients and showed either a fluid collection (n = 11) or a presuppurative abscess (n = 3). Magnetic resonance imaging was not used. The organism was recovered in nine patients and was a Staphylococcus aureus in seven, an Escherichia coli in one and a Pseudomonas aeruginosa in one. The Brucella agglutination test was strongly positive in two patients. Findings were negative from investigations done to look for a cause (discitis, urinary tract infection, Crohn's disease, ulcerative colitis, malignancy or infection in the vicinity of the psoas muscle). All patients received antimicrobial therapy. Drainage was percutaneous in six patients and surgical in ten. The outcome was favorable in every case.