Neurobrucellosis: A report of two cases

Neurobrucellosis is a rare complication of brucellosis, a common zoonosis with multisystem involvement. Its clinical presentation is quite heterogeneous and diagnosis requires a high index of suspicion in patients from endemic areas. We present two cases of neurobrucellosis with widely varying clinical involvement from a tertiary center in Pakistan. Our case report emphasizes that neurobrucellosis should be considered in evaluation of patients with unexplained neurological symptoms..

Effect of hydroxychloroquine on treatment and recurrence of acute brucellosis: a single-blind, randomized clinical trial

Brucellosis is associated with a high recurrence rate and requires more than one course of standard treatment; therefore, more research is required to find more effective treatments that lead to prompt recovery, and reduce the relapse of disease. This single-blind, randomized study was designed to evaluate the effect of the standard treatment for brucellosis in combination with hydroxychloroquine. A total of 177 patients with acute brucellosis were randomly assigned to one of two treatment groups: doxycycline-streptomycin (DS) and doxycycline-streptomycin-hydroxychloroquine (DSH). Clinical symptoms and signs, serological tests, and side effects of therapy were compared between the two groups during the treatment course and at three and six months after the end of drug therapy. Of the 177 patients, with a mean age of 40.5 ± 16.9 years, 66.1% were males. The mean duration of clinical signs prior to admission was 43.4 ± 41.1 days. Appropriate clinical responses, relapse, treatment failure, and adverse drug reactions were seen in 98.9%, 1.2%, 0.0%, and 12.6% of patients, respectively, in the DSH group vs. 86.7%, 11.6%, 2.3%, and 19.8% of patients, respectively, in the DS group. There were significant differences in clinical response and relapse rates between the two groups. The addition of hydroxychloroquine to a doxycycline-streptomycin regimen appears to increase the efficacy of treatment, accelerate improvement of clinical symptoms, and significantly reduce the rate of relapse of brucellosis.

The host immune enhancing agent Korean red ginseng oil successfully attenuates Brucella abortus infection in a murine model

ETHNOPHARMACOLOGICAL RELEVANCE

Panax ginseng Meyer (Araliaceae), is one of the most valuable traditional Chinese medicines and is used for the treatment of various human diseases. In this study, we elucidated the protective mechanism of the essential oil from Korean red ginseng (RGO) against Brucella infection.

MATERIALS AND METHODS

The effects of RGO on Brucella abortus viability, NO production, uptake and intracellular growth in macrophages were investigated. Mice were intraperitoneally infected with B. abortus and orally treated with RGO for 14 days. The weights and bacterial numbers from each spleen were monitored, and the sera were evaluated for cytokine production.

RESULTS

B. abortus viability was not affected, whereas NO production, internalization and intracellular replication were inhibited in RGO-treated macrophages. Bacterial adherence, F-actin polymerization and MAPK signaling protein phosphorylation (ERK1/2, JNK and p38α) were reduced and the co-localization of B. abortus-containing phagosomes with LAMP-1 was augmented in RGO-treated cells compared to untreated cells. RGO displayed protective effects against cell damage by inhibiting nitrite production during B. abortus infection in macrophages. Moreover, the spleen weight and bacterial burden were lower in the RGO-treated group than in the control group. The uninfected RGO-treated mice displayed increased TNF-α and IFN-γ production, whereas the B. abortus-infected RGO-treated mice showed reduced IL-10 production compared to the control.

CONCLUSION

RGO exhibits protective effects against B. abortus infection in vitro and in vivo, which emphasize the beneficial effects of RGO in the prevention and treatment of brucellosis.

Intestinal brucellosis associated with celiac artery and superior mesenteric artery stenosis and with ileum mucosa and submucosa thickening: A case report

RATIONALE

Brucellosis is a multisystem infection found worldwide that has a broad range of characteristics, which range from acute fever and hepatomegaly to chronic infections that most commonly affect the central nervous system, cardiovascular system, or skeletal system. Gastrointestinal and splanchnic artery involvements in brucellosis are relatively uncommon.

PATIENT CONCERNS

We report a case of brucellosis in an adolescent presenting as intermittent abdominal pain, diarrhea, and fever, with intestinal tract involvement. And stenosis of the celiac artery and the superior mesenteric artery was found after exposed to risk factors of Brucella infection. Splanchnic vessels stenosis and an endothelial lesion may exacerbate the prevalent symptom of abdominal pain, as a form of colic pain, occurring after eating.

DIAGNOSES

The patient was diagnosed as brucellosis. The narrowing of the SMA and CA was suspected to be vasculitis secondary to the brucellosis.

INTERVENTIONS

The patient was treated with minocycline and rifampicin for 12 weeks totally.

OUTCOMES

The gastrointestinal manifestations of brucellosis recovered rapidly under intensive treatment. However, follow-up imaging revealed that the superior mesenteric artery and celiac artery stenosis was unimproved.

LESSONS

In brucellosis, gastrointestinal manifestations may be the only observable features of the disease. Splanchnic arterial stenosis is a rare complication of brucellosis. Sonography and computed tomography may be useful for both diagnosis and follow-up.

Brucella melitensis Methionyl-tRNA-Synthetase (MetRS), a Potential Drug Target for Brucellosis

We investigated Brucella melitensis methionyl-tRNA-synthetase (BmMetRS) with molecular, structural and phenotypic methods to learn if BmMetRS is a promising target for brucellosis drug development. Recombinant BmMetRS was expressed, purified from wild type Brucella melitensis biovar Abortus 2308 strain ATCC/CRP #DD-156 and screened by a thermal melt assay against a focused library of one hundred previously classified methionyl-tRNA-synthetase inhibitors of the blood stage form of Trypanosoma brucei. Three compounds showed appreciable shift of denaturation temperature and were selected for further studies on inhibition of the recombinant enzyme activity and cell viability against wild type B. melitensis strain 16M. BmMetRS protein complexed with these three inhibitors resolved into three-dimensional crystal structures and was analyzed. All three selected methionyl-tRNA-synthetase compounds inhibit recombinant BmMetRS enzymatic functions in an aminoacylation assay at varying concentrations. Furthermore, growth inhibition of B. melitensis strain 16M by the compounds was shown. Inhibitor-BmMetRS crystal structure models were used to illustrate the molecular basis of the enzyme inhibition. Our current data suggests that BmMetRS is a promising target for brucellosis drug development. However, further studies are needed to optimize lead compound potency, efficacy and safety as well as determine the pharmacokinetics, optimal dosage, and duration for effective treatment.

[A case of brucellosis presenting with suppurative parotitis involvement]

Brucellosis is a common zoonotic infection caused by Brucella bacteria. Brucella infections are usually presented with various clinical manifestations, and often accompanied by multiple organ involvements. In this article, we present a case of brucellosis with suppurative parotitis involvement accompanied by parotid abscess and fistula in a 60-year-old male patient. According to the literature review we conducted regarding complications of brucellosis, our case is the first case reported in the literature. Significant improvement in patient's suppurative parotitis and clinical findings was observed at the fifth week of combination antibiotic therapy. Patient's complaints resolved completely after eight weeks of treatment.

Evaluation of CD4+ CD25+ FoxP3+ regulatory T cells during treatment of patients with brucellosis

Cell-mediated immunity (CMI) plays a critical role in the control of brucellosis. Regulatory T cells (Tregs) have a functional character in modulating the balance between host immune response and tolerance, which can eventually lead to chronic infection or relapse. The aim of this study was to assess the alteration of Tregs in cases of brucellosis before and after treatment. Thirty cases of acute brucellosis with the mean age of 41.03±15.15 years (case group) and 30 healthy persons with the mean age of 40.63±13.95 years (control group) were selected and assessed. Peripheral blood mononuclear cells (PBMCs) were isolated from peripheral blood of all individuals. We analyzed the alteration of Treg cell count using flow cytometry for CD4, CD25, and FoxP3 markers. The level of CD4+ CD25+ FoxP3+ Treg cells was increased in active patients compared with controls (2.5±0.99% vs 1.6±0.84%, p= 0.0004), but it had declined in the treated cases (1.83±0.73%, p=0.02). The level of Tregs was elevated in three relapsed cases. The frequency of Tregs and Treg/Teff (effector T cell) ratio was correlated with inverse serum agglutination test (SAT) and, 2-mercaptoethanol (2-ME) titers as markers of treatment in brucellosis. Based on our findings, we suggest that regulatory cells, such as CD4+ CD25+ FoxP3+ Treg cells, may contribute to the development of infection processes involving immune responses in brucellosis, and evaluation of regulatory T-cell levels may be a potential diagnostic strategy for the treatment outcome in chronic and relapsed cases of brucellosis.

Comparison of three different combination therapies in the treatment of human brucellosis

The efficacy and tolerability of three different combination treatment regimens in human brucellosis were compared in 118 uncomplicated patients enrolled in a prospective study between May 1997 and December 2002. Brucellosis was diagnosed using standard clinical and microbiological findings. Patients with central nervous system involvement, spondylitis, endocarditis or children under 16 years of age were excluded from the study. Patients were randomly assigned to receive 400 mg of ofloxacin plus 600 mg of rifampicin (OR, n = 41), 200 mg of doxycycline plus 600 mg of rifampicin (DR, n = 45) or 1g intramuscularly streptomycin (administered for three weeks) plus 200 mg doxycycline (DS, n = 32) daily for 6 weeks. All patients were followed up at least 6 months after cessation of therapy.

There was no statistical difference between the groups on relapse rates and clinical response to the treatment ( P>0.05). Five patients in OR (12.8%), six patients in DR (14.3%) and three patients in DS groups (9.7%) suffered relapse. The side-effects were seen in eight (19.5%), 21 (46.7%) and eight (25.0%) patients of OR, DR and DS groups, respectively.

The use of combination therapy of ofloxacin plus rifampicin for 6 weeks was found to be as effective as DR and DS. The side-effects of therapy in OR and DS groups was less severe than in the DR group.

[THE PERSPECTIVES OF STUDYING OF POLYMORPHISM OF GENES OF GAMMA-INTERFERON UNDER CHRONIC BRUCELLOSIS]

The brucellosis is an actual zoonotic disease in many countries, Russia included. The complexity of individual prognosis of disease and choice of tactics of maintenance of patients is explained by heterogeneity of clinical manifestations of brucellosis and different rate of progression of organs pathology. Despite of low mortality, this pathology quite often results in disability of patient. The frequent transition of acute process into chronic one (40-60%), probability of development of primary chronic brucellosis determines interest of researchers to issues of immunopathogenesis of this disease. The article presents review of achievements in studies of polymorphism of genes of gamma-interferon in the given area.

[BRUCELLA MELITENSIS (BM) BACTEREMIA IN HOSPITALIZED ADULT PATIENTS IN SOUTHERN ISRAEL]

BACKGROUND

Southern Israel is endemic for Brucella melitensis (BM) infection.

AIMS

This study aims to describe clinical manifestations and laboratory abnormalities in hospitalized adults with BM-bacteremia and to assess the relationship between various laboratory parameters, outcomes and complications of brucellosis.

METHODS

This is a retrospective study. All BM bacteremic patients hospitalized in the Soroka University Medical Center (SUMC) during 2006-2011 were included. Demographic, clinical data and laboratory results were collected from the medical records.

RESULTS

A total of 114 patients were included in the study, mostly of Bedouin-Arab origin (92%). The average age was 44 years (±18.4) and included 62 females (54%) of whom 11 were pregnant. Most of the subjects were exposed to sheep or their milk or meat products. The main symptoms included fever, arthralgia, myalgia, headache, and low back pain. Complications were present in 22 patients (19%): arthritis and osteomyelitis (59%), spontaneous abortion (36% of pregnant woman), endocarditis and epididymitis. The incidence of complications was correlated to anemia and leukopenia (p=0.03) and to a low neutrophil count (p=0.009). A decrease of albumin by one unit correlated with an increased hospitalization length by 1.9 days; older age also correlated with a prolonged stay. Complications were present in 45% of pregnant women vs. 10% in non-pregnant women (p=0.011. Relapse occurred in nine patients (8%); only one of these received adequate antibiotic treatment.

CONCLUSIONS

MB-bacteremia in southern Israel occurs mainly in Bedouin-Arabs after exposure to sheep or their products. Older age and low albumin levels increase hospitalization. Leukopenia, mainly low neutrophil count, and low thrombocyte count can predict complications. Pregnant women have a higher incidence of complications. Relapse is rare under adequate antibiotic treatment.

[Ocular syndromes in patients with neurobrucellosis]

OBJECTIVE

To investigate the clinical features of ocular syndromes in patients with neurobrucellosis.

METHOD

This is a retrospective series case study. The clinical data of 5 patients with neurobrucellosis, who were treated in Department of Neurology, Beijing Tongren Hospital, Captical Medical Uinversity, from May 2009 to January 2015, were collected. Their epidemiological information, clinical manifestation, laboratory and radiologic examination, therapy and prognosis were analyzed.

RESULTS

Among the five patients, there were 3 males and 2 females, and their ages ranged from 20 to 67 years. The median age was 25 years. All patients had ever exposed to sheep. 1 patient lived close to a slaughterhouse and 2 patients lived in epidemic areas of brucellosis. 5 patients presented with binocular vision loss, 8 eyes with fundus edema, 3 patients with ophthalmoplegia;4 patients with fever,4 patients with headache,3 patients with neck stiffness,1 patient with movement and sensation disorders. Cerebrospinal fluid (CSF) pressure elevated, white cell number and protein increased with glucose reduction were detected respectively in 3 cases. While, CSF chloride decreased in 2 cases. Serum agglutination test for brucella was positive in 5 patients. Serum brucella culture was positive in 1 patient and CSF brucella culture was positive in 1 patient. Brain magnetic resonance imaging (MRI) showed that the optic nerve was involved in 3 patients,the meninges were involved in 1 patient and the brain white matter was involved in 1 patient. The combination of rifamycin, tetracycline, ceftriaxone sodium or quinolone were given to all patients and showed appreciated effects.

CONCLUSIONS

The clinical features of ocular syndromes are atypical in patients with neurobrucellosis. Vision loss and ophthalmoplegia are more common to be seen. Neurobrucellosis should be considered when patients with ocular signs and other system symptoms without a definite diagnosis.

Integrated health messaging for multiple neglected zoonoses: Approaches, challenges and opportunities in Morocco

Integrating the control of multiple neglected zoonoses at the community-level holds great potential, but critical data is missing to inform the design and implementation of different interventions. In this paper we present an evaluation of an integrated health messaging intervention, using powerpoint presentations, for five bacterial (brucellosis and bovine tuberculosis) and dog-associated (rabies, cystic echinococcosis and leishmaniasis) zoonotic diseases in Sidi Kacem Province, northwest Morocco. Conducted by veterinary and epidemiology students between 2013 and 2014, this followed a process-based approach that encouraged sequential adaptation of images, key messages, and delivery strategies using auto-evaluation and end-user feedback. We describe the challenges and opportunities of this approach, reflecting on who was targeted, how education was conducted, and what tools and approaches were used. Our results showed that: (1) replacing words with local pictures and using "hands-on" activities improved receptivity; (2) information "overload" easily occurred when disease transmission pathways did not overlap; (3) access and receptivity at schools was greater than at the community-level; and (4) piggy-backing on high-priority diseases like rabies offered an important avenue to increase knowledge of other zoonoses. We conclude by discussing the merits of incorporating our validated education approach into the school curriculum in order to influence long-term behaviour change.

Reduced Susceptibility to Rifampicin and Resistance to Multiple Antimicrobial Agents among Brucella abortus Isolates from Cattle in Brazil

This study aimed to determine the susceptibility profile of Brazilian Brucella abortus isolates from cattle to eight antimicrobial agents that are recommended for the treatment of human brucellosis and to correlate the susceptibility patterns with origin, biotype and MLVA16-genotype of the strains. Screening of 147 B. abortus strains showed 100% sensitivity to doxycycline and ofloxacin, one (0.68%) strain resistant to ciprofloxacin, two strains (1.36%) resistant to streptomycin, two strains (1.36%) resistant to trimethoprim-sulfamethoxazole and five strains (3.40%) resistant to gentamicin. For rifampicin, three strains (2.04%) were resistant and 54 strains (36.73%) showed reduced sensitivity. Two strains were considered multidrug resistant. In conclusion, the majority of B. abortus strains isolated from cattle in Brazil were sensitive to the antimicrobials commonly used for the treatment of human brucellosis; however, a considerable proportion of strains showed reduced susceptibility to rifampicin and two strains were considered multidrug resistant. Moreover, there was no correlation among the drug susceptibility pattern, origin, biotype and MLVA16-genotypes of these strains.

Clinical manifestations, complications, and treatment of brucellosis: evaluation of 72 cases

AIM

Brucellosis is an important disease in developing countries. We aimed to determine the epidemiologic, clinical, and laboratory characteristics of brucellosis, which still has a high morbidity in Turkey.

MATERIALS AND METHODS

Seventy-two patients with brucellosis, monitored at our clinic from January 2004 to July 2010, were reviewed retrospectively.

RESULTS

The average age was determined to be 44.8 ± 18 years, and 40 of the patients were female (55.6%). The most frequent transmission route was the use of raw milk and dairy products, in 45 of the patients (62.5%). The most frequent complaints were joint pain, high fever, weakness, low back pain, and gastrointestinal symptoms, whereas the most frequent physical examination findings were fever, osteoarticular involvement, splenomegaly, hepatomegaly, and lymphadenopathy. All of the patients were positive for Rose Bengal testing. The standard tube agglutination titer was 1/160 or higher in 64 (88.9%) patients. Brucella melitensis was isolated from blood cultures of 13 (18.1%) patients and bone marrow cultures of 7 (9.7%) patients. Complications of sacroiliitis in 6 (8.3%), spondylodiscitis in 4 (5.6%), endocarditis in 2 (2.8%), neurobrucellosis in 1 (1.4%), and epididymo-orchitis in 1 (1.4%) of the patients were observed.

CONCLUSION

Brucellosis has various clinical presentations. It should be included in the differential diagnosis of high fever and joint pains in endemic countries.

La neurobrucellose: une cause curable de surdité neurosensorielleà ne pas méconnaitre

La brucellose est une zoonose ubiquitaire touchant en particulier les pays méditerranéens et le Moyen-Orient. Les manifestations neurologiques sont assez diverses. Nous rapportons l'observation d'un patient âgé de 45 ans, agriculteur, ayant consulté pour une surdité profonde bilatérale depuis 2 mois associée à des céphalées, des épisodes d'hémiparésie à bascule, de trouble de langage, spontanément résolutifs en quelques minutes et des sensations vertigineuses intermittentes depuis 09 mois. Les résultats de la ponction lombaire, de l'imagerie par résonnance magnétique et surtout la sérologie ont permis de conclure à une neurobrucellose. L’évolution sous bi-antibiothérapie a été favorable, avec régression des signes neurologiques, normalisation du LCR et amélioration de la surdité. La neurobrucellose est une affection grave dont le pronostic dépend de la précocité du diagnostic et du traitement. Nous pensons qu'un tableau clinique associant une surdité neurosensorielle et une symptomatologie neurologique progressive doit évoquer en premier une neurobrucellose, d'autant plus que le patient est à risque et dans les pays où cette maladie est endémique.

Administration of a triple versus a standard double antimicrobial regimen for human brucellosis more efficiently eliminates bacterial DNA load

The effects of doxycycline-streptomycin-rifampin versus a standard doxycycline-streptomycin regimen on residual Brucella DNA were compared in 36 acute brucellosis patients. At admission, all patients given triple (n = 22) and double (n = 14) regimens had detectable Brucella DNA with similar mean loads (P = 0.982). At follow-up, 14 to 20 months postpresentation, significantly more patients receiving triple than double regimens had undetectable Brucella DNA (P = 0.026). The doxycycline-streptomycin-rifampin regimen eliminates Brucella DNA more efficiently than doxycycline-streptomycin, which may result in superior long-term clearance of Brucella.

[Clinical, serological and polymerase chain reaction follow-up of a family with brucellosis]

INTRODUCTION

Human brucellosis diagnosis is based on isolation of Brucella spp. from blood or tissue cultures with a positivity rate of 40-70% and serology techniques are used as complementary tools; recently molecular biology diagnostic techniques have been developed intending to optimize the etiological confirmation.

AIM

The main objective of this work was to compare the polymerase chain reaction (PCR), against serological diagnostic tests during the clinical follow-up of a family presenting brucellosis.

METHODS

Seven family members who lived in the urban area of Mexico City, were monitored using the Rose Bengal test, the agglutination test as well as agglutination with 2 mecapto ethanol, blood cultures and serum PCR for a period of 27 months. The suspected source of infection was fresh goat cheese from a known endemic zone.

RESULTS

Brucella melitensis was isolated from the blood cultures of two patients. All of the patients were positive in serological and PCR tests at the beginning of this follow-up. At the end of the study, three patients responded well to the treatment and showed negative results in the serological and PCR tests. While two patients with diabetes mellitus type 2, showed positive results in the serological and PCR tests as well as persistent symptoms.

CONCLUSION

Clinical follow-up of patients with brucellosis is of great importance, to properly evaluate the given treatment. In this sense the PCR is a great supporting tool in diagnostic testing.

Increasing threat of brucellosis to low-risk persons in urban settings, China

Cases of brucellosis were diagnosed in 3-month-old twins and their mother. An epidemiologic survey suggested that raw sheep or goat meat might be the source of Brucella melitensis infection. This finding implies that the increasing threat of brucellosis might affect low-risk persons in urban settings in China.

First case report of brucellosis in a child in Thailand

Brucellosis is uncommon in children. In Thailand, there have been only seven adult cases reported, all with Brucella melitensis. We describe here the first reported pediatric case of brucellosis in Thailand. A 12-year old boy presented with prolonged fever for one month, pancytopenia, pneumonia and peritonitis. The blood culture grew out Brucella melitensis. He responded well to combination therapy consisting of doxycycline and gentamicin. He recovered fully without relapse during the 6 month follow-up.

Brucella melitensis sternal osteomyelitis following median sternotomy

Human brucellosis, a zoonotic infection, may present with a range of symptoms but is rarely described as a cause of surgical site infections. We present the first reported case of Brucella melitensis causing sternal osteomyelitis of a midline sternotomy for a coronary artery bypass graft. The operation was performed in a non-endemic country but the patient had travelled to Syria immediately before surgery, where the infection was assumed to have been acquired. The infection resolved following treatment with doxycycline, rifampicin and gentamicin. We review the literature for surgical site infections related to Brucella species and discuss the infection control implications. Human brucellosis has the potential to cause surgical site infections and it should be in the differential diagnosis of any patient with a relevant exposure history presenting with a febrile illness and musculoskeletal findings.

[Brucellar spondylodiscitis: case series of the last 25 years]

INTRODUCTION

Brucellosis is an endemic zoonosis in Portugal. Brucellar spondylodiscitis is one of the most frequent focal manifestations which may cause severe sequelae despite appropriate therapy.

MATERIAL AND METHODS

Retrospective study of patients with diagnosis of brucellar spondylodiscitis admitted to the Infectious Diseases Department of Centro Hospitalar e Universitário de Coimbra, over a 25-year period (1988-2012).

RESULTS

We identified 54 patients, 55.6% male, mean age of 54.8 years. In 81.5% an epidemiological context was identified, mostly contact with sheep and goats. The duration of symptoms prior to diagnosis was 5.5 months. The most common signs and symptoms were pain (98.1%), fever (46.3%) and neurological deficits (25.9%). Spinal magnetic resonance imaging was the most used imaging method (77.8%) showing abscesses in 29.6% of patients. Lumbar location predominated (77.7%). Diagnosis was attained in 47 patients (87.0%): positive blood cultures (3 patients), positive serology (32 patients) or by both methods (12 patients). Combined regimens of doxycycline and rifampicin (64.8%), or streptomycin (24.1%) were most used, for an average duration of 4.4 months. A patient was referred for surgery for abscess drainage. Evolution was mostly favorable (92.6%), no deaths occurring.

DISCUSSION

Research of the epidemiologic context turned out to be a major key leading to the diagnosis. Treatment of osteoarticular brucellosis is still controversial.

CONCLUSIONS

Brucellar spondylodiscitis should be considered in the differential diagnosis of patients with low back pain, even in the absence of fever, particularly in regions where the disease is endemic. Antibiotic regimen, its' duration and the need for surgery should be individualized to achieve a better prognosis. Cases have declined over the years, a fact related to better control of animal endemic.