Brucellosis in patients infected with the human immunodeficiency virus

Point-of-care ultrasound for tuberculosis and HIV-revisiting the focused assessment with sonography for HIV-associated tuberculosis (FASH) protocol and its differential diagnoses

BACKGROUND

The 'Focused assessment with sonography for HIV-associated tuberculosis' (FASH) protocol has been applied and researched for over a decade in HIV-infected patients with suspected extra-pulmonary tuberculosis. Interpretation of target FASH features may be challenging as they can also indicate alternative opportunistic diseases.

OBJECTIVES

The primary aim of the review was summarizing the accumulated evidence on the diagnostic accuracy of the FASH protocol including description of diagnoses of target FASH features.

SOURCES

Literature was searched using PubMed, Google Scholar, and publications referencing the original FASH publications; data from identified studies were compiled with data from studies identified by a preceding Cochrane review. A meta-analysis was performed based on a generalized linearized mixed model. Data on differential diagnoses were compiled by literature review and retrospective evaluation of clinical data.

CONTENT

We identified ten studies; abdominal target FASH features were most studied. Sensitivity and specificity estimates were 39% (95% CI 25-54) and 89% (95% CI 83-96) for enlarged lymph nodes (ten studies), and 30% (95% CI 16-45%) and 93% (95% CI 89-98%) for hypoechoic spleen lesions (eight studies). In people living with HIV differential diagnoses of target FASH features are multiple and primarily include other opportunistic infections and malignancies such as non-tuberculous mycobacterial infection, bacillary angiomatosis, hepato-splenic brucellosis, meliodiosis, visceral leishmaniasis, invasive fungal infections, and lymphoma as well as Kaposi sarcoma. Ultrasound-guided diagnostic sampling may assist obtention of a definitive diagnosis.

IMPLICATIONS

On the basis of current evidence, although limited by methodology, and personal experience, we recommend basic ultrasound training, including the FASH protocol and ultrasound-guided diagnostic interventions, for all healthcare providers working with people living with HIV in resource-limited settings.

HIV and Mediterranean Zoonoses: A Review of the Literature

A zoonosis is an infectious disease that has jumped from a non-human animal to humans. Some zoonoses are very common in the Mediterranean area and endemic in specific regions, so they represent an important problem for public health. Human Immunodeficiency Virus (HIV) is a virus that has originated as a zoonosis and is now diffused globally, with the most significant numbers of infected people among the infectious diseases. Since the introduction of antiretroviral therapy (ART), the history for people living with HIV (PLWH) has changed drastically, and many diseases are now no different in epidemiology and prognosis as they are in not-HIV-infected people. Still, the underlying inflammatory state that is correlated with HIV and other alterations related to the infection itself can be a risk factor when infected with other bacteria, parasites or viruses. We reviewed the literature for infection by the most common Mediterranean zoonoses, such as Campylobacter, Salmonella, Brucella, Rickettsia, Borrelia, Listeria and Echinococcus, and a possible correlation with HIV. We included Monkeypox, since the outbreak of cases is becoming a concern lately. We found that HIV may be related with alterations of the microbiome, as for campylobacteriosis, and that there are some zoonoses with a significant prevalence in PLWH, as for salmonellosis.

Risk factors for leptospirosis and brucellosis in people living with human immunodeficiency virus who attended a referral hospital in southeastern Brazil

INTRODUCTION:

Leptospirosis and brucellosis cause immunosuppression that worsens the clinical condition of people living with HIV/AIDS (PLWHA). We investigated the serological profile and risk factors of PLWHA.

METHODS:

Serum samples (n=238) were researched for Brucella spp. antibodies using Rose Bengal and tube agglutination tests and Leptospira spp. antibodies using the microscopic agglutination test.

RESULTS:

All samples were negative for Brucella spp. For leptospirosis, four samples (1.69%) were positive, and Andamana was the prevalent serovar.

CONCLUSIONS:

Low or no detection of these zoonoses does not reduce their importance in PLWHA. Vigilant, educational, and preventive measures should be adopted.

The current therapeutical strategies in human brucellosis

Prompt and adequate treatment of human brucellosis continues to be the most important strategy in its management, as eradication of animal brucellosis is not possible so far, and there is no adequate vaccine for humans. The goal of antibrucellar treatment is to alleviate and shorten the symptomatic period and reduce complications, relapses, and chronicity. Contemporary trends in the treatment of human brucellosis are postulated on the ability of Brucellae to persist in host macrophages through the inhibition of phagolysosome fusion and to survive for prolonged periods intracellularly without restricting basic cellular functions. As a result of this and despite satisfactory antibiotic treatment, relapses and therapeutical failures are inevitable to a certain degree. The current principles for the treatment of brucellosis advocate for a long enough treatment duration combined with antimicrobial regimens that possess activity in the intracellular acidic environment. In the future, other antimicrobial agents, immunomodulation, decrease in the intracellular acidic environment, or development of agents that would act on well-defined molecular bacterial targets, might be incorporated to improve the therapeutical effects.

Investigation of the molecular epizootiological characteristics and tracking of the geographical origins of Brucella canis strains in China

Brucellosis is a global pandemic infectious zoonosis. Brucella canis is a rare source of human brucellosis in China, and its public health significance remains under debate. Moreover, data pertaining to the epizootiological characteristics and geographical origin of B. canis on a nationwide scale are limited, and the risk to public safety posed by B. canis infections is unknown. The MLVA (multilocus variable-number tandem repeat analysis) assay can be helpful to analyse epidemiological correlations among Brucella isolates and to track their geographic origins. To accomplish this task, MLVA-16 was used to analyse the epidemiological links of 63 isolates obtained from dogs and humans. Sixty-three B. canis strains were sorted into three large clusters (A, B and C) and 50 different genotypes (GT1-50), and 43 unique genotypes were represented by single isolates, suggesting that these strains had no obvious epidemiological links and that canine brucellosis is predominantly sporadic in China. The other seven shared genotypes (among a total of 20 isolates) were each represented by two to eight isolates, indicating that strains from each shared genotype were epidemiologically correlated. Five of the shared genotypes were from 16 strains obtained from Beijing, indicating that canine brucellosis in Beijing originates from multipoint outbreaks with multiple sources of infection. Based on comprehensive case analysis of clinical B. canis infection, we preliminarily suggest that human B. canis infections are associated with Mycoplasma pneumoniae infection that results in decreased patient immunity. B. canis may have limited epidemiological significance for the healthy population, but it remains a significant threat to the canine breeding industry and to humans who come into close contact with dogs. Based on MLVA-11 data, B. canis strains were clustered into 16 genotypes and divided into five evolutionary branches; these data confirm that this population covers an extensive geographic area and exhibits characteristics of the origin and evolution of co-existing introduced and locally native lineages. We believe this study will contribute to strengthening efforts to prevent and control canine brucellosis and to improve public understanding of the health risks posed by B. canis.

Brucellosis in Dogs and Public Health Risk

Brucella canis infects dogs and humans. In dogs, it can cause reproductive failure; in humans, it can cause fever, chills, malaise, peripheral lymphadenomegaly, and splenomegaly. B. canis infection in dogs is underrecognized. After evaluating serologic data, transmission patterns, and regulations in the context of brucellosis in dogs as an underrecognized zoonosis, we concluded that brucellosis in dogs remains endemic to many parts of the world and will probably remain a threat to human health and animal welfare unless stronger intervention measures are implemented. A first step for limiting disease spread would be implementation of mandatory testing of dogs before interstate or international movement.

Prevalence and risk factors of brucellosis among febrile patients attending a community hospital in south western Uganda

Human brucellosis, a chronic disease contracted through contact with animals and consuption of unpasteurized dairy products is underreported in limited-resource countries. This cross-sectional study aimed to determine the prevalence and risk factors of brucellosis among febrile patients attending a community hospital in South western Uganda. A questionnaire that captured socio-demographic, occupational and clinical data was administered. Blood samples were tested for Brucella antibodies using Rose Bengal Plate Test (RBPT) and blood culture with standard aerobic BACTEC bottle was done. Of 235 patients enrolled, prevalence of brucellosis (RBPT or culture confirmed) was 14.9% (95% CI 10.6-20.1) with a culture confrmation in 4.3% of the participants. The factors independently associated with brucellosis were consumption of raw milk (aOR 406.15, 95% CI 47.67-3461.69); history of brucellosis in the family (aOR 9.19, 95% CI 1.98-42.54); and selling hides and skins (aOR 162.56, 95% CI 2.86-9256.31). Hepatomegaly (p < 0.001), splenomegaly (p = 0.018) and low body mass index (p = 0.032) were more common in patients with brucellosis compared to others. Our findings reveal a high prevalence of brucellosis among febrile patients and highlight a need for implementing appropiate tests, public awareness activities and vaccination of animals to control and eliminate the disease.

Human Brucellosis in Rural Uganda: Clinical Manifestations, Diagnosis, and Comorbidities at Kabale Regional Referral Hospital, Kabale, Uganda

Background

Brucellosis is a zoonotic infection transmitted to humans through direct contact with infected animals, their products, or excreta such as urine or dung. Brucellosis is associated with significant morbidity in Southwestern Uganda, where cattle and goat rearing are a major economic industry. As in many settings in sub-Saharan Africa, diagnosis and management of brucellosis remain a challenge due to the presence of comorbidities and limitations in resources for diagnostic testing and therapy.

Methods

A chart review was conducted to characterize the clinical manifestations, diagnosis, comorbidities, and management of 101 patients treated for brucellosis at the Kabale Regional Referral Hospital from September 2002 to May 2010.

Results

Patients presented with substantial comorbidities. The most common manifestation of illness was osteoarticular, but disease manifestations were quite varied. A high rate of focal illness in this cohort (77%) was observed.

Conclusions

Clinicians in this setting should be cognizant of the varied presentations, comorbidities, and treatment options for this disease.

Seroprevalence of Brucellosis in Human Immunodeficiency Virus Infected Patients in Hamadan, Iran

Objectives

Brucellosis is a systemic disease with a wide spectrum of clinical manifestations. This study aimed to determine the seroprevalence of brucellosis in human immunodeficiency virus (HIV) infected patients in Hamadan Province in the west of Iran.

Methods

A total of 157 HIV-infected patients were screened through standard serological tests, including Wright’s test, Coombs’ Wright test, and 2-mercaptoethanol Brucella agglutination test (2ME test), blood cultures in Castaneda media, and CD4 counting. Data were analyzed using Stata version 11.

Results

Wright and Coombs’ Wright tests were carried out, and only 5 (3.2%) patients had positive serological results. However, all patients had negative 2ME results, and blood cultures were negative for Brucella spp. Moreover, patients with positive serology and a mean CD4 count of 355.8 ± 203.11 cells/μL had no clinical manifestations of brucellosis, and, and the other patients had a mean CD4 count of 335.55 ± 261.71 cells/μL.

Conclusion

Results of this study showed that HIV infection is not a predisposing factor of acquiring brucellosis.

Brucellosis among hospitalized febrile patients in northern Tanzania

Acute and convalescent serum samples were collected from febrile inpatients identified at two hospitals in Moshi, Tanzania. Confirmed brucellosis was defined as a positive blood culture or a ≥ 4-fold increase in microagglutination test titer, and probable brucellosis was defined as a single reciprocal titer ≥ 160. Among 870 participants enrolled in the study, 455 (52.3%) had paired sera available. Of these, 16 (3.5%) met criteria for confirmed brucellosis. Of 830 participants with ≥ 1 serum sample, 4 (0.5%) met criteria for probable brucellosis. Brucellosis was associated with increased median age (P = 0.024), leukopenia (odds ratio [OR] 7.8, P = 0.005), thrombocytopenia (OR 3.9, P = 0.018), and evidence of other zoonoses (OR 3.2, P = 0.026). Brucellosis was never diagnosed clinically, and although all participants with brucellosis received antibacterials or antimalarials in the hospital, no participant received standard brucellosis treatment. Brucellosis is an underdiagnosed and untreated cause of febrile disease among hospitalized adult and pediatric patients in northern Tanzania.

Brucella canis causing infection in an HIV-infected patient

From the blood culture of an HIV-positive patient with a febrile syndrome (CD4 count 385 cells/microL and viral load nondetectable), Brucella canis was isolated. The patient was presumptively infected from his dogs, which tested positive, and showed good outcome after the therapy with doxycycline-ciprofloxacin, and the HIV infection would seem not to have been influenced by brucellosis. To our knowledge, no other case of B. canis in the setting of HIV infection has been reported in the literature, and the emerging zoonotic potential of the disease in urban areas should be considered.

Brucellosis serology in HIV-infected patients

BACKGROUND

An accelerated evolution of HIV to AIDS has been reported with brucellosis co-infection. The seroprevalence of brucellosis co-infection with HIV has not been investigated in a brucellosis endemic country like Iran.

METHODS

We performed a cross-sectional survey of brucellosis serology in HIV-infected patients attending a university hospital, as well as in healthy controls. A total of 90 HIV-positive patients and 100 healthy age-matched controls were recruited. The clinical characteristics, hemoglobin, and red blood cell, platelet, white blood cell, and CD4+ T cell counts were evaluated.

RESULTS

Positive brucellosis serology was significantly higher in HIV-infected patients than in controls (73.3% vs. 30%, respectively, odds ratio 6.42, p<0.001). It was also higher in males than females, p=0.001. Brucellosis-infected patients had significantly lower hemoglobin and white blood cell counts compared with brucellosis-uninfected patients (p<0.001). In HIV-positive patients, white blood cell count was significantly lower in brucellosis-infected than brucellosis-uninfected patients (p<0.05).

CONCLUSIONS

Our findings show that brucellosis infection is an important infection in HIV-infected patients. The treatment of brucellosis may be of great clinical importance in the management of HIV infection in a brucellosis endemic country like Iran.

Quantifying risk factors for human brucellosis in rural northern Tanzania

BACKGROUND

Brucellosis is a zoonosis of veterinary, public health and economic significance in most developing countries. Human brucellosis is a severely debilitating disease that requires prolonged treatment with a combination of antibiotics. The disease can result in permanent and disabling sequel, and results in considerable medical expenses in addition to loss of income due to loss of working hours. A study was conducted in Northern Tanzania to determine the risk factors for transmission of brucellosis to humans in Tanzania.

METHODS

This was a matched case-control study. Any patient with a positive result by a competitive ELISA (c-ELISA) test for brucellosis, and presenting to selected hospitals with at least two clinical features suggestive of brucellosis such as headache, recurrent or continuous fever, sweating, joint pain, joint swelling, general body malaise or backache, was defined as a case. For every case in a district, a corresponding control was traced and matched by sex using multistage cluster sampling. Other criteria for inclusion as a control included a negative c-ELISA test result and that the matched individual would present to hospital if falls sick.

RESULTS

Multivariable analysis showed that brucellosis was associated with assisted parturition during abortion in cattle, sheep or goat. It was shown that individuals living in close proximity to other households had a higher risk of brucellosis. People who were of Christian religion were found to have a higher risk of brucellosis compared to other religions. The study concludes that assisting an aborting animal, proximity to neighborhoods, and Christianity were associated with brucellosis infection. There was no association between human brucellosis and Human Immunodeficiency Virus (HIV) serostatus. Protecting humans against contact with fluids and tissues during assisted parturition of livestock may be an important means of reducing the risk of transferring brucellosis from livestock to humans. These can be achieved through health education to the communities where brucellosis is common.

[Bacterial, mycobacterial and fungal opportunistic infections in HIV-infected immigrants: diagnosis and treatment]

The number of HIV infected immigrants has increased sharply in Spain. These patients are prone to contracting several different types of opportunistic infections, including bacterial, mycobacterial, fungal and parasitic infections. The present article provides an in-depth review of bacterial and fungal infections, with particular emphasis on those not endemic in our country.

Protean clinical manifestations and diagnostic challenges of human brucellosis in adults: 16 years' experience in an endemic area

A prospective study was carried out to elucidate the clinical, epidemiological and laboratory features of human brucellosis. A total of 26 948 blood samples (from adults aged 15 years and above) were screened for serological evidence of brucellosis over a period of 16 years. The slide agglutination/Rose Bengal plate agglutination test gave positive results in 517 patients, of which 509 had detectable titres by the standard tube agglutination test (SAT). The diagnosis of brucellosis was documented in 495 (1.8 %) patients based on diagnostic titres (> or = 1 : 160, 490 cases) and rising titres from insignificant titres (four cases) by serology and for one case by blood-culture isolation alone. Blood cultures were carried out in 345 cases, of which 191 cases (55.3 %) yielded Brucella melitensis. In 77/79 cases undertaken for follow up, there was a steady fall in 2-mercaptoethanol (2ME) agglutination titres along with clinical improvement (P < 0.01). SAT titres remained detectable in most cases for a longer period in spite of an effective antimicrobial therapy and clinical recovery. A substantial number of patients (84.2 %) presented with fever, this being the only complaint in 51.1 % of the cases. Complications were present in 8.8 % of the patients (arthritis excluded): this included the unusual complications of hydrocele (two cases), Stevens-Johnson syndrome (one case) and urinary tract infection (one case). Brucella agglutinins were demonstrated in synovial, testicular, hydrocele and cerebrospinal fluids. There was no clinical suspicion of brucellosis in 439 cases (88.7 %) and the diagnosis was made only by routine serology. A two-drug regimen for 42-84 days with a follow-up 2ME test resulted in lower levels of relapse. These results suggest that, in endemic areas of the world, it should be mandatory to screen routinely for brucellosis due to protean clinical manifestations.

La brucellose à l’aube du 21e siècle

Human brucellosis is now a rare disease in countries where eradication programs (especially vaccination) against brucellosis in cattle, sheep, and goats have been successfully implemented. In France, fewer than 50 brucellosis cases are annually notified to the National Institute for Infection Surveillance. Human brucellosis, however, remains endemic in the Mediterranean basin, Middle East, Western Asia, Africa, and South America. Shortcomings of standard diagnostic methods for brucellosis (variable sensitivity of culture, frequent serological cross reactions) have been only partially resolved by modern molecular biology techniques. There are now 3 new challenges to be faced by the medical and veterinarian community: the expanding wildlife reservoir of brucellosis, with a possible impact on domestic animals; the emergence of Brucella. melitensis infections in cattle, for which prophylactic efficacy of available vaccines has not been established; and recent recognition of a huge animal reservoir of Brucella species in marine mammals, for which the potential virulence in humans remains unknown.