Challenges in Brucella bacteraemia

Follow-up of antibody changes in brucellosis patients in Gansu, China

Brucellosis, caused by the intracellular bacterium Brucella, often leads to chronic infection with recurrent symptoms, posing significant therapeutic challenges. Effective monitoring of antibody dynamics is crucial for understanding disease progression and enhancing clinical outcomes. To investigate the longitudinal dynamics of antibody titers and antigen-specific responses in animal husbandry practitioners exposed to brucellosis in Gansu, China. We conducted a serological study involving 400 animal husbandry workers, identifying 21 seropositive individuals (5.25%). Antibody titers and antigen-specific responses to lipopolysaccharide (LPS) and BP26 protein were assessed using the Rose-Bengal test (RBT), serum agglutination test (SAT), and western blotting. Acute brucellosis patients displayed a distinct three-phase antibody titer pattern: a rapid rise (12-38 days), a rapid decline (19-41 days), and a slow decline (42-148 days). BP26-specific antibodies persisted significantly longer than LPS antibodies, remaining detectable up to 395 days post-infection. Early treatment reduced acute-phase antibody titers, correlating with disease control. This study combined dynamic antibody titer monitoring with specific antigen monitoring, enhancing the accuracy and specificity of brucellosis diagnosis and offering a basis for chronic infection detection. The findings are highly significant for clinical practice and public health strategies, particularly in high-incidence areas, prevention and control, as well as high-risk population surveillance.

IMPORTANCE

Brucella, a zoonotic intracellular bacterium, poses significant threats to both human health and economic security. Clinically, brucellosis can be challenging to differentiate from other long-term febrile illnesses, necessitating prompt and standardized treatment to prevent chronic persistent infections and multi-organ damage, which are notoriously difficult to treat. Thus, gaining a comprehensive understanding of the disease's progression is essential for early diagnosis and effective treatment strategies. This paper delves into the dynamics of serum antibody titers in patients with acute brucellosis, shedding light on the temporal patterns of antibody titers. Such insights are pivotal for monitoring disease progression and assessing the efficacy of treatment interventions. Furthermore, through western blotting analysis, the study reveals that antibodies against the BP26 protein in brucellosis patients persist over an extended period, which is helpful to identify the durable immune response of brucellosis and provides a theoretical basis for vaccine development and treatment strategy formulation.

Risk perception, seroprevalence, and real-time PCR detection of Brucella among pyretic patients and domestic animals in Kwara State, Nigeria

Brucellosis is a neglected, reportable, and under-reported zoonosis that poses a significant public health challenge in endemic countries like Nigeria. In this study, the risk perception was assessed and 103 pyretic patients from three local government areas of Kwara State, Nigeria were screened by using Rose Bengal plate test (RBPT) and confirmed the analytical sensitivity through real-time PCR (qPCR). We further screened 150 cattle and 52 goats from within a 1-km radius of pyretic patients to determine disease burden in domestic animal reservoirs. Our findings revealed that most of the farmers have heard of brucellosis (89.3%, n = 92/103) while 38.8% (n = 40/103) reported they could identify the symptoms of brucellosis in their herds. The most important risk factors were the consumption of raw milk (92.2%, n = 95/103) and animal abortion within the last year (19.4%, n = 20/103). Also, most study participants (94.2%, n = 97/103) did not believe that they could be infected with the disease. The seroprevalence of brucellosis in humans was 5.8% (n = 6/103) and there was 100% concordance between the results of the RBPT and qPCR in humans. The seroprevalence was 18% and 25% in cattle and goats respectively. The qPCR revealed a lower prevalence rate of 11.3% and 15.4% in cattle and goats respectively. There was high discordance in sensitivity between the RBPT and qPCR in animal samples screened, although both tests had an analytical specificity of 100%. There was no association between awareness and positivity for brucellosis among the study participants and none of the sociodemographic variables significantly influenced the brucellosis positivity rate of humans. Public health physicians and community health workers should consider brucellosis as a differential diagnosis when clerking pyretic patients. In addition, we advocate for mass animal vaccinations and public education with an emphasis on identified risks.

The many faces of brucellosis: diagnostic and management approach

PURPOSE OF REVIEW

This review aims to highlight the multifaceted nature of brucellosis, emphasizing the latest advancements in its diagnosis and management. Given the global prevalence and potential complications of brucellosis, understanding recent advancements in diagnostic techniques and treatment strategies is crucial for clinicians.

RECENT FINDINGS

Recent literature reveals significant progress in diagnostic methods, including the application of fluorescence polarization immunoassay and time-resolved fluorescence resonance energy transfer technologies as well as the invention of artificial Brucella antigens, which offer enhanced sensitivity and specificity. Advances in molecular diagnostics and serological tests have improved early detection rates, however their interpretation remains challenging. Evolving treatment regimens such as the use of hydroxychloroquine as part of triple therapy and the use of nano-delivery systems in therapies have shown promise, in hopes of reducing relapse rates and managing chronic cases.

SUMMARY

The findings underscore the necessity for clinicians to adopt a comprehensive approach to diagnosing and managing brucellosis. Integrating advanced diagnostic tools with tailored therapeutic strategies can significantly improve patient outcomes. Future research should focus on optimizing these diagnostic techniques and exploring novel therapeutic agents.

Comparative Analysis of Pediatric Brucellosis Cases With and Without Bacteremia

Introduction: Brucellosis, which is among the endemic regions of Turkey, is a common zoonotic disease. The gold standard in diagnosing brucellosis is culture. We aimed to compare demographic characteristics, risk factors, and clinical and laboratory variables between cases with culture positivity and undetected in culture. Materials and Methods: This single-center study was conducted between January 2007 and April 2022. Clinical and laboratory data of patients with brucella growth in blood culture and patients without growth were compared. Results: A total of 150 patients were included in the study. The median age was 10 (1-18 years). Of the patients, 66 (44%) were female and 84 (56%) were male. Forty (26.7%) of the patients were bacteremic and 110 (73.3%) were nonbacteremic. In the bacteremic group, white blood cell count, platelet, and hemoglobin counts were lower, and aspartate aminotransferase (AST) and alanine aminotransferase (ALT) values were higher. In clinical evaluation, fever, hepatomegaly, splenomegaly, and abdominal pain were more common in the bacteremic group. Conclusion: The distinction between bacteremic and nonbacteremic brucellosis can be predicted using laboratory values such as white blood cells, hemoglobin counts, platelet, ALT, and AST, and clinical findings such as fever, abdominal pain, hepatomegaly, and splenomegaly.

Brucella Spondylitis: Current Knowledge and Recent Advances

The most prevalent zoonotic disease is brucellosis, which poses a significant threat for worldwide public health. Particularly in endemic areas, spinal involvement is a major source of morbidity and mortality and can complicate the course of the disease. The diagnosis of Brucella spondylitis is challenging and should be suspected in the appropriate epidemiological and clinical context, in correlation with microbiological and radiological findings. Treatment depends largely on the affected parts of the body. Available treatment options include antibiotic administration for an adequate period of time and, when appropriate, surgical intervention. In this article, we examined the most recent data on the pathophysiology, clinical manifestation, diagnosis, and management of spinal brucellosis in adults.

Brucellosis: epidemiology, pathogenesis, diagnosis and treatment-a comprehensive review

Background: Brucellosis is a pervasive zoonotic disease caused by various Brucella species. It mainly affects livestock and wildlife and poses significant public health threats, especially in regions with suboptimal hygiene, food safety, and veterinary care standards. Human contractions occur by consuming contaminated animal products or interacting with infected animals. Objective: This study aims to provide an updated understanding of brucellosis, from its epidemiology and pathogenesis to diagnosis and treatment strategies. It emphasizes the importance of ongoing research, knowledge exchange, and interdisciplinary collaboration for effective disease control and prevention, highlighting its global health implications. Methods: Pathogenesis involves intricate interactions between bacteria and the host immune system, resulting in chronic infections characterized by diverse clinical manifestations. The diagnostic process is arduous owing to non-specific symptomatology and sampling challenges, necessitating a fusion of clinical and laboratory evaluations, including blood cultures, serological assays, and molecular methods. Management typically entails multiple antibiotics, although the rise in antibiotic-resistant Brucella strains poses a problem. Animal vaccination is a potential strategy to curb the spread of infection, particularly within livestock populations. Results: The study provides insights into the complex pathogenesis of brucellosis, the challenges in its diagnosis, and the management strategies involving antibiotic therapy and animal vaccination. It also highlights the emerging issue of antibiotic-resistant Brucella strains. Conclusions: In conclusion, brucellosis is a significant zoonotic disease with implications for public health. Efforts should be directed towards improved diagnostic methods, antibiotic stewardship to combat antibiotic resistance, and developing and implementing effective animal vaccination programs. Interdisciplinary collaboration and ongoing research are crucial for addressing the global health implications of brucellosis.

The Development of Diagnostic and Vaccine Strategies for Early Detection and Control of Human Brucellosis, Particularly in Endemic Areas

Brucellosis is considered one of the most serious zoonotic diseases worldwide. This disease affects both human and animal health, in addition to being one of the most widespread zoonotic illnesses in the Middle East and Northern Africa. Human brucellosis generally presents in a diverse and non-specific manner, making laboratory confirmation of the diagnosis critical to the patient's recovery. A coordinated strategy for diagnosing and controlling brucellosis throughout the Middle East is required, as this disease cannot be known to occur without reliable microbiological, molecular, and epidemiological evidence. Consequently, the current review focuses on the current and emerging microbiological diagnostic tools for the early detection and control of human brucellosis. Laboratory assays such as culturing, serology, and molecular analysis can frequently be used to diagnose brucellosis. Although serological markers and nucleic acid amplification techniques are extremely sensitive, and extensive experience has been gained with these techniques in the laboratory diagnosis of brucellosis, a culture is still considered to be the "gold standard" due to the importance of this aspect of public health and clinical care. In endemic regions, however, serological tests remain the primary method of diagnosis due to their low cost, user-friendliness, and strong ability to provide a negative prediction, so they are commonly used. A nucleic acid amplification assay, which is highly sensitive, specific, and safe, is capable of enabling rapid disease diagnosis. Patients who have reportedly fully healed may continue to have positive molecular test results for a long time. Therefore, cultures and serological methods will continue to be the main tools for diagnosing and following up on human brucellosis for as long as no commercial tests or studies demonstrate adequate interlaboratory reproducibility. As there is no approved vaccine that prevents human brucellosis, vaccination-based control of animal brucellosis has become an important part of the management of human brucellosis. Over the past few decades, several studies have been conducted to develop Brucella vaccines, but the problem of controlling brucellosis in both humans and animals remains challenging. Therefore, this review also aims to present an updated overview of the different types of brucellosis vaccines that are currently available.

Prevalence, diagnosis, and manifestations of brucellosis: A systematic review and meta-analysis

Objectives

Brucellosis is one of the most prevalent zoonotic diseases common between humans and animals. Despite eradication efforts, the burden of the disease is well-known in endemic countries and in countries where brucellosis has not been an important health issue until recently. The aim of this study was to evaluate the prevalence, diagnosis, and manifestations of brucellosis.

Methods

In this study, PubMed, Web of Science, Scopus, Embase, and Google scholar databases were systematically searched to find studies published from 2011 to 2021. The search was conducted using text words and Medical Subject Headings (MeSH) Terms on the prevalence of brucellosis. Stata software 14.0 was used for all analyses.

Results

Based on the results, the pooled prevalence of brucellosis was 15.27% (95% CI: 9.68-21.86; heterogeneity I 2 index: 97.43; p < 0.001) for man and 15.33% (95% CI: 7.19-25.75; heterogeneity I 2 index: 98.19; p < 0.001) for woman. Age (coefficient: 0.240; p = 0.480), gender (coefficient: -0.017; p = 0.800), and publication year (coefficient: 0.114; p = 0.861) showed no significant effect on heterogeneity among studies. Egger's test indicated a significant publication bias for the prevalence of brucellosis (coefficient 3.894; p < 0.001). Moreover, the trim-and-fill method exhibited that the adjusted prevalence of brucellosis (18.30%, 95% CI: 14.10-22.52) was not significantly different from the original prevalence of brucellosis.

Conclusion

The pooled estimate for brucellosis prevalence was estimated as 15.53%. To better understand the epidemiology of brucellosis globally, more extensive studies are needed to be conducted throughout the world, especially in developing and low-income countries.

Microbiological Laboratory Diagnosis of Human Brucellosis: An Overview

Brucella spp. are Gram-negative, non-motile, non-spore-forming, slow-growing, facultative intracellular bacteria causing brucellosis. Brucellosis is an endemic of specific geographic areas and, although underreported, represents the most common zoonotic infection, with an annual global incidence of 500,000 cases among humans. Humans represent an occasional host where the infection is mainly caused by B. melitensis, which is the most virulent; B. abortus; B. suis; and B. canis. A microbiological analysis is crucial to identifying human cases because clinical symptoms of human brucellosis are variable and aspecific. The laboratory diagnosis is based on three different microbiological approaches: (i) direct diagnosis by culture, (ii) indirect diagnosis by serological tests, and (iii) direct rapid diagnosis by molecular PCR-based methods. Despite the established experience with serological tests and highly sensitive nucleic acid amplification tests (NAATs), a culture is still considered the “gold standard” in the laboratory diagnosis of brucellosis due to its clinical and epidemiological relevance. Moreover, the automated BC systems now available have increased the sensitivity of BCs and shortened the time to detection of Brucella species. The main limitations of serological tests are the lack of common interpretative criteria, the suboptimal specificity due to interspecies cross-reactivity, and the low sensitivity during the early stage of disease. Despite that, serological tests remain the main diagnostic tool, especially in endemic areas because they are inexpensive, user friendly, and have high negative predictive value. Promising serological tests based on new synthetic antigens have been recently developed together with novel point-of-care tests without the need for dedicated equipment and expertise. NAATs are rapid tests that can help diagnose brucellosis in a few hours with high sensitivity and specificity. Nevertheless, the interpretation of NAAT-positive results requires attention because it may not necessarily indicate an active infection but rather a low bacterial inoculum, DNA from dead bacteria, or a patient that has recovered. Refined NAATs should be developed, and their performances should be compared with those of commercial and home-made molecular tests before being commercialized for the diagnosis of brucellosis. Here, we review and report the most common and updated microbiological diagnostic methods currently available for the laboratory diagnosis of brucellosis.

Epidemiological, Clinical and Laboratory Characteristics of Patients with Brucella Infection in Anhui Province, China

Background

Brucellosis is currently one of the most widespread zoonotic diseases caused by Brucella genus, and the Brucella melitensis is the major pathogen. The number of people infected with Brucella has gradually increased in Anhui Province.

Purpose

To retrospectively evaluate the epidemiological, clinical, and laboratory data of brucellosis patients in Anhui Province.

Patients and Methods

A total of 109 brucellosis patients were admitted to the First Affiliated Hospital of Anhui Medical University from January 2012 to March 2021. Data from all patients were retrieved from the hospital’s electronic medical system. The final results were grouped and compared according to the presence or absence of bacteremic brucellosis and three phases of brucellosis.

Results

The most common symptoms among all 109 brucellosis patients were fever (89.0%), followed by chills (52.3%), arthralgia (48.6%), and weight loss (30.3%), and laboratory results presented with anemia (65.1%), elevate of C-reactive protein (CRP) (91.7%), erythrocyte sedimentation rate (ESR) (86.2%), aspartate aminotransferase (AST) (40.4%), and lactate dehydrogenase (LDH) (43.1%). The percentage of fever (96.1%), arthralgia (58.8%), anorexia (35.3%), leukopenia (31.4%), and the AST (51.0%) were higher in bacteremic than nonbacteremic group. Additionally, the median level of LDH (332.0 mg/L, IQR, 209.0–553.0) was higher in bacteremic than nonbacteremic group. Nevertheless, the albumin (36.0 mg/L, IQR, 33.9–38.2) was lower in the bacteremic group. The percentage of fever (94.9%) and the median LDH level (316.0 U/L (IQR,218.0–517.5)) in the acute phase of brucellosis were higher than the percentage of fever (72.0%) and the median LDH level (209.0 U/L (IQR,162.0–276.0)) in the subacute phase of brucellosis.

Conclusion

Brucellosis has become an important public health issue in Anhui Province. Brucellosis is a disease with diverse clinical manifestations. Our data showed that unexplained fever, arthralgia, and elevated AST and LDH should be considered as a diagnosis of bacteremia brucellosis for early treatment intervention.

Isolation of Brucella melitensis biovar 1 from human milk confirms breastfeeding as a possible route for infant infection

Brucellosis during pregnancy is associated with major concerns for mothers but, it is still not clear whether the infection could be transmitted through breastfeeding to newborns. This study aimed at evaluating the shedding of Brucella melitensis through human milk. We describe phenotypic and genotypic characterization of Brucella isolate from human milk. The characterized isolate by Bruce-ladder PCR, AMOS PCR and biotyping confirmed the presence of Brucella melitensis biovar 1 from human milk. However, the breastfeeding of newborn baby induced no serious abnormality, although occasional weakness, loss of appetite and vomiting were reported by the parents. All Brucella serological tests including RBT, SAT and 2 ME test were also positive for the baby and her mother, although the blood culture was negative for the baby. Evaluation of the blood DNA from mother and her baby also confirm the presence of Brucella melitensis in the blood samples. Therefore, the isolation of B. melitensis biovar 1 from human milk as well as presence of Brucella melitensis in the blood samples confirms breastfeeding as a possible route for infant infection.

Epidemiological and clinical characteristics of bacteremic brucellosis

Objective

To retrospectively investigate the epidemiological features, clinical manifestations and laboratory characteristics of bacteremic brucellosis.

Methods

Brucellosis patients admitted to our clinic from January 2015 to December 2017 were included in the study. Patient electronic medical records were reviewed for epidemiological features, clinical manifestations, and laboratory findings.

Results

A total of 132 brucellosis patients were analyzed (64 cases with bacteremic brucellosis and 68 cases with nonbacteremic brucellosis). The median duration from exposure to onset of symptoms was 6.9 weeks (range: 1 day to 32 weeks) and 21.9 weeks (range: 1–76 weeks) in patients with bacteremic and nonbacteremic brucellosis, respectively. More bacteremic than nonbacteremic patients presented with fever and chills. Arthritis was observed in 34 (25.8%) patients, and was more commonly observed in nonbacteremic patients. Using C-reactive protein (CRP) and procalcitonin (PCT) as serological markers, the areas under the receiving operating characteristic curves were 0.64 [95% confidence interval (CI): 0.54–0.73] and 0.61 (95% CI: 0.51–0.70), respectively, for distinguishing bacteremic from non-bacteremic brucellosis.

Conclusion

Fever and chills were frequently observed in bacteremic brucellosis patients, whereas arthritis was more common in nonbacteremic brucellosis patients. Serum CRP and PCT can be used as potential serological markers for diagnosing bacteremic brucellosis.

Laboratory Diagnosis of Human Brucellosis

The clinical presentation of brucellosis in humans is variable and unspecific, and thus, laboratory corroboration of the diagnosis is essential for the patient's proper treatment. The diagnosis of brucellar infections can be made by culture, serological tests, and nucleic acid amplification assays. Modern automated blood culture systems enable detection of acute cases of brucellosis within the routine 5- to 7-day incubation protocol employed in clinical microbiology laboratories, although a longer incubation and performance of blind subcultures may be needed for protracted cases. Serological tests, though they lack specificity and provide results that may be difficult to interpret in individuals repeatedly exposed to Brucella organisms, nevertheless remain a diagnostic cornerstone in resource-poor countries. Nucleic acid amplification assays combine exquisite sensitivity, specificity, and safety and enable rapid diagnosis of the disease. However, long-term persistence of positive molecular test results in patients that have apparently fully recovered is common and has unclear clinical significance and therapeutic implications. Therefore, as long as there are no sufficiently validated commercial tests or studies that demonstrate an adequate interlaboratory reproducibility of the different homemade PCR assays, cultures and serological methods will remain the primary tools for the diagnosis and posttherapeutic follow-up of human brucellosis.

Proteomic Analyses on an Ancient Egyptian Cheese and Biomolecular Evidence of Brucellosis

The material analyzed in this study is probably the most ancient archeological solid residue of cheese ever found to date. The sample was collected during the Saqqara Cairo University excavations in the tomb of Ptahmes dated to XIX dynasty ( El-Aguizy, O. Bulletin de l'Institut Française d'Archéologie Orientale (BIFAO) 2010 , 110 , 13 - 34 (ref (1) ); Staring, N. Bulletin de Institut Français d'Archéologie Orientale (BIFAO) 2015 , 114 , 455 - 518 (ref (2) )). Our biomolecular proteomic characterization of this archeological sample shows that the constituting material was a dairy product obtained by mixing sheep/goat and cow milk. The interactions for thousands of years with the strong alkaline environment of the incorporating soil rich in sodium carbonate and the desertic conditions did not prevent the identification of specific peptide markers which showed high stability under these stressing conditions. Moreover, the presence of Brucella melitensis has been attested by specific peptide providing a reasonable direct biomolecular evidence of the presence of this infection in the Ramesside period for which only indirect paleopathological evidence has been so far provided ( Pappas, G.; Papadimitriou P. Int. J. Antimicrob. Agents 2007 , 30 , 29 - 31 (ref (3) ); Bourke, J. B. Medical History 1971 , 15 ( 4 ), 363 - 375 (ref (4) )). Finally, it is worth noting that, although proteomic approaches are successfully and regularly used to characterize modern biological samples ( D'Ambrosio, C.; Arena, S.; Salzano, A. M.; Renzone, G.; Ledda, L.; and Scaloni, A. Proteomics 2008 8 , 3657 - 3666 (ref (5) ), their application in ancient materials is still at an early stage of progress, only few results being reported about ancient food samples ( Yang, Y.; Shevchenko, A.; Knaust, A.; Abuduresule, I.; Li, W.; Hu, X.; Wang, C.; Shevchenko, A. J. Archaeol. Sci. 2014 , 45 , 178 - 186 (ref (6) ). In the absence of previous relevant evidence of cheese production and/or use, this study, undoubtedly has a clear added value in different fields of knowledge ranging from archaeometry, anthropology, archeology, medicine history to the forensic sciences.

Biochemical Characterization of WbkC, an N-Formyltransferase from Brucella melitensis

It has become increasingly apparent within the last several years that unusual N-formylated sugars are often found on the O-antigens of such Gram negative pathogenic organisms as Francisella tularensis, Campylobacter jejuni, and Providencia alcalifaciens, among others. Indeed, in some species of Brucella, for example, the O-antigen contains 1,2-linked 4-formamido-4,6-dideoxy-α-d-mannosyl groups. These sugars, often referred to as N-formylperosamine, are synthesized in pathways initiating with GDP-mannose. One of the enzymes required for the production of N-formylperosamine, namely, WbkC, was first identified in 2000 and was suggested to function as an N-formyltransferase. Its biochemical activity was never experimentally verified, however. Here we describe a combined structural and functional investigation of WbkC from Brucella melitensis. Four high resolution X-ray structures of WbkC were determined in various complexes to address its active site architecture. Unexpectedly, the quaternary structure of WbkC was shown to be different from that previously observed for other sugar N-formyltransferases. Additionally, the structures revealed a second binding site for a GDP molecule distinct from that required for GDP-perosamine positioning. In keeping with this additional binding site, kinetic data with the wild type enzyme revealed complex patterns. Removal of GDP binding by mutating Phe 142 to an alanine residue resulted in an enzyme variant displaying normal Michaelis-Menten kinetics. These data suggest that this nucleotide binding pocket plays a role in enzyme regulation. Finally, by using an alternative substrate, we demonstrate that WbkC can be utilized to produce a trideoxysugar not found in nature.

Human Brucellosis and Adverse Pregnancy Outcomes

Purpose of Review

Brucellosis is a neglected, zoonotic disease of nearly worldwide distribution. Despite brucellosis being recognized as a reproductive disease in animals, it has been historically known as a flu-like illness in humans with little or no significant role in maternal or newborn health. This review focuses on what is currently known relative to the epidemiology of brucellosis in human pregnancy as well as new insights of placental immunology.

Recent Findings

New evidence suggests that maternal infection poses a significant risk factor for adverse pregnancy outcomes including increased risk for miscarriage during the first and second trimester of gestation, preterm delivery, and vertical transmission to the fetus. Adverse pregnancy outcomes were not associated with any specific clinical sign. However, prompt diagnosis and treatment significantly decreased the risk of miscarriage or any other adverse effect.

Summary

Brucellosis during pregnancy should be considered a significant risk factor for adverse pregnancy outcomes in humans. The identification of the mechanism behind bacterial tropism should prove powerful for the development of new countermeasures to prevent these detrimental effects. Increased awareness concerning brucellosis in pregnant women, its transmission, and prevention measures should be considered as a pressing need.

Epidemiological, diagnostic, clinical, and therapeutic aspects of Brucella bacteremia in children in southern Israel: a 7-year retrospective study (2005-2011)

BACKGROUND

Data on the various aspects of brucellosis in children living in southern Israel are missing.

OBJECTIVES

Our aim was to study the epidemiological, microbiological, diagnostic, clinical, therapeutic and outcome features of brucellosis in children <19 years of age in southern Israel during 2005-2011.

PATIENTS AND METHODS

The study population included all patients hospitalized with a diagnosis of brucellosis, established according to a clinical presentation compatible with brucellosis+presence of Brucella bacteremia (BB).

RESULTS

A total of 128 (50.8%) of 252 patients admitted with a diagnosis of brucellosis had BB (all with Brucella melitensis). All patients were of Muslim Bedouin ethnicity. The mean incidence of BB in southern Israel was 16 cases/100,000 Bedouin, with no significant changes during the study period. Overall duration of symptoms before diagnosis was 10.1±10.9 days. Fever at diagnosis was recorded in <20% of the patients. The most frequent symptoms were arthralgia (61.7%), weakness (32.8%), gastrointestinal disturbances (27.3%), myalgia (25%), and headache (18.8%). The main clinical findings included monoarthritis (36.7%), hepatosplenomegaly (25%), lymphadenopathy (17.2%), heart murmur (11.7%), and skin rash (9.4%), respectively. Anemia, leukopenia, thrombocytopenia, and pancytopenia were reported in 17.6%, 29.6%, 12.8%, and 2.3% of the patients, respectively. Twenty-nine (30.5%) patients with BB had serum agglutinin titers ≤1/160 (13, 13.7%%, had titers <1/160). Twenty-seven (93%) of the 29 patients aged 0-4 years were treated with gentamicin and trimethoprim-sulfamethoxazole; a total of 77 (60.2%) patients received gentamicin and doxycycline.

CONCLUSIONS

Childhood brucellosis remains an important public health problem in southern Israel. BB was diagnosed in >50% of the children with brucellosis, and B. melitensis was identified in all cases. Arthralgia, weakness, and gastrointestinal complaints were the most common symptoms, and monoarthritis, hepatosplenomegaly, and lymphadenopathy were the most common clinical findings. A considerable number of patients with BB had undetectable/low serum agglutinin titers, suggesting insufficient reliability on serology alone in diagnosis of brucellosis.

Brucella melitensis invades murine erythrocytes during infection

Brucella spp. are facultative intracellular Gram-negative coccobacilli responsible for brucellosis, a worldwide zoonosis. We observed that Brucella melitensis is able to persist for several weeks in the blood of intraperitoneally infected mice and that transferred blood at any time point tested is able to induce infection in naive recipient mice. Bacterial persistence in the blood is dramatically impaired by specific antibodies induced following Brucella vaccination. In contrast to Bartonella, the type IV secretion system and flagellar expression are not critically required for the persistence of Brucella in blood. ImageStream analysis of blood cells showed that following a brief extracellular phase, Brucella is associated mainly with the erythrocytes. Examination by confocal microscopy and transmission electron microscopy formally demonstrated that B. melitensis is able to invade erythrocytes in vivo. The bacteria do not seem to multiply in erythrocytes and are found free in the cytoplasm. Our results open up new areas for investigation and should serve in the development of novel strategies for the treatment or prophylaxis of brucellosis. Invasion of erythrocytes could potentially protect the bacterial cells from the host's immune response and hamper antibiotic treatment and suggests possible Brucella transmission by bloodsucking insects in nature.

Brucella abortus induces apoptosis of human T lymphocytes

Immune evasion is essential for Brucella abortus to survive in the face of robust adaptive CD4+ T cell response. We have previously demonstrated that B. abortus can indirectly inhibit CD4+ T cells by down-regulating MHC-II expression and antigen presentation on macrophages. However, whether B. abortus is able to directly interfere with T lymphocytes is not known. We report here that B. abortus induces apoptosis of human T lymphocytes, even though invasion of T lymphocytes was low and non-replicative. The ability of heat-killed B. abortus to reproduce the same phenomenon suggested that there was a bacterial structural component involved. We demonstrated that a prototypical B. abortus outer membrane lipoprotein (l-Omp19), but not its unlipidated form, induced T lymphocyte apoptosis. Moreover, a synthetic lipohexapeptide that mimics the structure of the protein lipid moiety also induced an increase in T lymphocyte cell death, indicating that the structural component implicated in the phenomenon could be any B. abortus lipoprotein. B. abortus-induced T lymphocyte apoptosis was dependent on the secretion of TNF-α since pre-incubation of T lymphocytes with anti-TNF-α mAb inhibited the apoptosis of the cells. Overall, these results represent a new mechanism whereby B. abortus by directly inhibiting T cell-mediated responses may evade adaptive immune responses.

Subversion of innate immune responses by Brucella through the targeted degradation of the TLR signaling adapter, MAL

Gram-negative bacteria belonging to the Brucella species cause chronic infections that can result in undulant fever, arthritis, and osteomyelitis in humans. Remarkably, Brucella sp. genomes encode a protein, named TcpB, that bears significant homology with mammalian Toll/IL-1 receptor domains and whose expression causes degradation of the phosphorylated, signal competent form of the adapter MyD88-adapter-like (MAL). This effect of TcpB is mediated through its box 1 region and has no effect on other TLR adapter proteins such as MyD88 or TIR-domain containing adapter protein-inducing IFNbeta. TcpB also does not affect a mutant, signal-incompetent form of MAL that cannot be phosphorylated. Interestingly, the presence of TcpB leads to enhanced polyubiquitination of MAL, which is likely responsible for its accelerated degradation. A Brucella abortus mutant lacking TcpB fails to reduce levels of MAL in infected macrophages. Therefore, TcpB represents a unique pathogen-derived molecule that suppresses host innate-immune responses by specifically targeting an individual adapter molecule in the TLR signaling pathway for degradation.

Establishment of systemic Brucella melitensis infection through the digestive tract requires urease, the type IV secretion system, and lipopolysaccharide O antigen

Human brucellosis is caused mainly by Brucella melitensis, which is often acquired by ingesting contaminated goat or sheep milk and cheese. Bacterial factors required for food-borne infection of humans by B. melitensis are poorly understood. In this study, a mouse model of oral infection was characterized to assess the roles of urease, the VirB type IV secretion system, and lipopolysaccharide for establishing infection through the digestive tract. B. melitensis strain 16M was consistently recovered from the mesenteric lymph node (MLN), spleen, and liver beginning at 3 or 7 day postinfection (dpi). In the gut, persistence of the inoculum was observed up to 21 dpi. No inflammatory lesions were observed in the ileum or colon during infection. Mutant strains lacking the ureABC genes of the ure1 operon, virB2, or pmm encoding phosphomannomutase were constructed and compared to the wild-type strain for infectivity through the digestive tract. Mutants lacking the virB2 and pmm genes were attenuated in the spleen (P < 0.05) and MLN (P < 0.001), respectively. The wild-type and mutant strains had similar levels of resistance to low pH and 5 or 10% bile, suggesting that the reduced colonization of mutants was not the result of reduced resistance to acid pH or bile salts. In an in vitro lymphoepithelial cell (M-cell) model, B. melitensis transited rapidly through polarized enterocyte monolayers containing M-like cells; however, transit through monolayers containing only enterocytes was reduced or absent. These results indicate that B. melitensis is able to spread systemically from the digestive tract after infection, most likely through M cells of the mucosa-associated lymphoid tissue.

Brucellosis: a re-emerging zoonosis

Brucellosis, especially caused by Brucella melitensis, remains one of the most common zoonotic diseases worldwide with more than 500,000 human cases reported annually. The bacterial pathogen is classified by the CDC as a category (B) pathogen that has potential for development as a bio-weapon. Brucella spp. are considered as the most common laboratory-acquired pathogens. The geographical distribution of brucellosis is constantly changing with new foci emerging or re-emerging. The disease occurs worldwide in both animals and humans, except in those countries where bovine brucellosis has been eradicated. The worldwide economic losses due to brucellosis are extensive not only in animal production but also in human health. Although a number of successful vaccines are being used for immunization of animals, no satisfactory vaccine against human brucellosis is available. When the incidence of brucellosis is controlled in the animal reservoirs, there is a corresponding and significant decline in the incidence in humans.

A 24-year study of the epidemiology of human brucellosis in a health-care system in Eastern Saudi Arabia

OBJECTIVE

The aim of the study was to examine the epidemiology of human brucellosis in a helath-care system in Eastern Saudi Arabia.

METHODS

All cases of human brucellosis from 1983 to 2007 were analyzed.

RESULTS

In the study period, there were 913 patients with brucellosis in the Saudi Aramco health-care system. There were 608 males and 305 females with a male to female ratio of (2:1). The annual incidence rate per 100,000 populations increased from 13 to 70 in 1983 and 1987, respectively, then decreased to 9 in 2006. The age of the patients ranged from 1 to 83 years with a mean age of 35.8+/-17.9 years and a median of 36 years. Of the total patients, 195 (21%) and 155 (17%) cases occurred in those between 20-30 and 31-40 years of age, respectively. Children (< or =10 years of age) constituted 5% of all the patients. The adjusted rate per 100,000 population showed that the highest rate was in those 40-49 years of age (100/100,000) and the lowest rate was in patients less than 10 years of age (2.9/100,000). The number of cases was highest in April to June (n=361; 39.5%) and the lowest reported cases were in January. Of the 219 patients whom their families had animals, 125 (57.1%) had camels, 49 (22.4%) had sheep, 24 (11%) had goats, and 21 (9.6%) had cows. Blood cultures were positive in 80.7% (201/247) of cases. There was no association between age group and the rate of positive blood culture (P value=0.244). The titer of brucella serology was 1:320 in 34.3%, 1:640 in 31%, 1:1280 in 24.7%, > or =1:2560 in 10%. The higher brucella titers were associated with higher rate of positive cultures (P value=0.0002).

CONCLUSION

There was a decrease in the incidence of brucellosis over the study period. The highest incidence was in patients 40-49 years of age. Continued surveillance and efforts are needed to further decrease the cases of brucellosis.

Development and characterization of mouse models of infection with aerosolized Brucella melitensis and Brucella suis

There is a need to identify vaccines that can protect against Brucella, a potential bioterrorism agent. We have developed mouse models of infection with aerosolized Brucella melitensis and Brucella suis and demonstrated their utility for the evaluation of vaccines using the model live B. melitensis vaccine strain Rev.1.

Evaluation of recombinant invasive, non-pathogenic Eschericia coli as a vaccine vector against the intracellular pathogen, Brucella

Background

There is no safe, effective human vaccine against brucellosis. Live attenuated Brucella strains are widely used to vaccinate animals. However these live Brucella vaccines can cause disease and are unsafe for humans. Killed Brucella or subunit vaccines are not effective in eliciting long term protection. In this study, we evaluate an approach using a live, non-pathogenic bacteria (E. coli) genetically engineered to mimic the brucellae pathway of infection and present antigens for an appropriate cytolitic T cell response.

Methods

E. coli was modified to express invasin of Yersinia and listerialysin O (LLO) of Listeria to impart the necessary infectivity and antigen releasing traits of the intracellular pathogen, Brucella. This modified E. coli was considered our vaccine delivery system and was engineered to express Green Fluorescent Protein (GFP) or Brucella antigens for in vitro and in vivo immunological studies including cytokine profiling and cytotoxicity assays.

Results

The E. coli vaccine vector was able to infect all cells tested and efficiently deliver therapeutics to the host cell. Using GFP as antigen, we demonstrate that the E. coli vaccine vector elicits a Th1 cytokine profile in both primary and secondary immune responses. Additionally, using this vector to deliver a Brucella antigen, we demonstrate the ability of the E. coli vaccine vector to induce specific Cytotoxic T Lymphocytes (CTLs).

Conclusion

Protection against most intracellular bacterial pathogens can be obtained mostly through cell mediated immunity. Data presented here suggest modified E. coli can be used as a vaccine vector for delivery of antigens and therapeutics mimicking the infection of the pathogen and inducing cell mediated immunity to that pathogen.