Therapeutic options for human brucellosis

Poxviruses as Agents of Biological Warfare: The Importance of Ensuring Ethical Standards for Research with Viruses

Historically, biological agents have been used to target various populations. One of the earliest examples could be the catastrophic effect of smallpox in Australia in the eighteenth century (as alleged by some historians). Modern biological techniques can be used to both create or provide protection against various agents of biological warfare. Any microorganism (viruses, bacteria, and fungi) or its toxins can be used as biological agents. Minnesota Department of Health has listed Smallpox (variola major) as a category A bioterrorism agent, even though it has been eradicated in 1980 through an extensive vaccination campaign. Category A agents are considered the highest risk to public health. Laboratory-associated outbreaks of poxviruses could cause unprecedented occupational hazards. Only two WHO-approved BSL-4 facilities in the United States and Russia are allowed to perform research on the variola virus. So, poxviruses present themselves as a classical case of a dual-use dilemma, since research with them can be used for both beneficial and harmful purposes. Although the importance of ethics in scientific research requires no further elaboration, ethical norms assume greater significance during experimentation with poxviruses. In this chapter, we will update the readers on the sensitive nature of conducting research with poxviruses, and how these viruses can be a source of potential biological weapons. Finally, specified ethical guidelines are explored to ensure safe research practices in virology.

Hepatobiliary Brucellosis: Brucella Bacteremia Presenting with Refractory Hepatobiliary Infection

Brucellosis often presents with common and nonspecific symptoms such as fever, malaise, and arthralgia but can also involve primary organs. Intra-abdominal involvement is rare. We report a case of hepatobiliary brucellosis presenting as a refractory hepatobiliary infection in a healthy young adult with no underlying rheumatologic disease or history of exposure to risk factors. Detection of Brucella in the blood led to a shift in the patient's management and consequently her recovery.

Ocular Involvement of Brucellosis: A Pooled Analysis Study

AIM

Brucellosis may affect the eye to varying degrees. The aim of this study was to investigate the ocular involvement of brucellosis and highlight key points.

MATERIAL AND METHODS

Published literature in English language on the ocular involvement of brucellosis within last 30 years was evaluated. The PubMed international database was screened using certain keywords.

RESULTS

The study included 27 publications evaluating a total of 159 cases. The most common types of ocular involvement were uveitis (52.2%) and conjunctivitis (17.6%). Most cases had concomitant systemic brucellosis (27.7%), and the most commonly used diagnostic method was a serological test (92.4%). Of all the patients, 37.1% recovered with sequelae.

CONCLUSION

Brucellosis may cause a wide range of ophthalmic manifestations, and an overlooked or late diagnosis may also lead to the development of sequelae or loss of vision. A routine ophthalmologic examination should be performed in all patients with systemic brucellosis.

A proposed management classification for spinal brucellosis from India

INTRODUCTION

The myriad presentation of osteoarticular brucellosis make the patient seek the help of general practitioners, orthopaedic and rheumatology specialists. Moreover, the lack of disease-specific symptomatology is the leading cause of the delay in diagnosing osteoarticular brucellosis. Given the increasing number of spinal brucellosis cases across the country, no literature is presented on the systematic management of spinal brucellosis. However, with our experience, we formulated a classification for managing spinal brucellosis.

METHODS

A single-centred prospective observational study was conducted with 25 confirmed cases of spinal brucellosis. Patients were analysed and graded clinically, serologically, and radiologically and were managed with antibiotics for 10-12 weeks, and if necessary, stabilisation and fusion were done based on the treatment classification devised. All patients were followed up to ensure disease clearance at serial follow-up with relevant investigations.

RESULTS

The mean age of the study participants was 52.16 ± 12.53 years. According to spondylodiscitis severity code (SSC) grading, four patients belong to grades 1, 12 to grade 2 and 9 to grade 3 at presentation. Erythrocyte sedimentation rate (p = 0.02), c-reactive protein (p < 0.001), Brucella agglutination titers (p < 0.001), and radiological outcomes improved statistically by six months. The treatment duration was individualised according to the patient's response to the treatment, with a mean time of 11.42 ± 2.66 weeks. The mean follow-up period was 14.42 ± 8 months.

CONCLUSION

High index of suspicion of patients from endemic regions, proper clinical assessment, serological evaluation, radiological assessment, appropriate decision-making (medical/surgical) in treatment, and regular follow-up were the key to successful comprehensive management of spinal brucellosis.

Human descending aorta injury caused by brucellosis: A case report

BACKGROUND

Brucellosis is one of the most common zoonotic diseases in the world. Although cardiovascular complications of human brucellosis account for only 3% of morbidity, they are the leading cause of death. Peripheral vascular disease due to brucellosis is rare and under-reported in the literature.

CASE PRESENTATION

Two patients with previous brucellosis, both of whom had been treated with anti-brucellosis, were admitted to vascular surgery for thoracic aortic ulcer and abdominal aortic pseudoaneurysm, respectively, with positive IgG antibody to brucellosis and negative IgM antibody to brucellosis, tube agglutination test, and blood culture. These 2 patients were successfully treated with aortic stent-graft implantation and followed up for 8 and 10 weeks without complications.

CONCLUSIONS

Chronic damage to human blood vessels by brucellosis may not disappear with brucellosis treatment, and peripheral blood vessels should be examined annually in people previously diagnosed with brucellosis. Clinicians in related departments should pay attention to peripheral vascular complications of brucellosis.

Antibiotic persistence of intracellular Brucella abortus

Background

Human brucellosis caused by the facultative intracellular pathogen Brucella spp. is an endemic bacterial zoonosis manifesting as acute or chronic infections with high morbidity. Treatment typically involves a combination therapy of two antibiotics for several weeks to months, but despite this harsh treatment relapses occur at a rate of 5–15%. Although poor compliance and reinfection may account for a fraction of the observed relapse cases, it is apparent that the properties of the infectious agent itself may play a decisive role in this phenomenon.

Methodology/Principal findings

We used B. abortus carrying a dual reporter in a macrophage infection model to gain a better understanding of the efficacy of recommended therapies in cellulo. For this we used automated fluorescent microscopy as a prime read-out and developed specific CellProfiler pipelines to score infected macrophages at the population and the single cell level. Combining microscopy of constitutive and induced reporters with classical CFU determination, we quantified the protective nature of the Brucella intracellular lifestyle to various antibiotics and the ability of B. abortus to persist in cellulo despite harsh antibiotic treatments.

Conclusion/Significance

We demonstrate that treatment of infected macrophages with antibiotics at recommended concentrations fails to fully prevent growth and persistence of B. abortus in cellulo, which may be explained by a protective nature of the intracellular niche(s). Moreover, we show the presence of bona fide intracellular persisters upon antibiotic treatment, which are metabolically active and retain the full infectious potential, therefore constituting a plausible reservoir for reinfection and relapse. In conclusion, our results highlight the need to extend the spectrum of models to test new antimicrobial therapies for brucellosis to better reflect the in vivo infection environment, and to develop therapeutic approaches targeting the persister subpopulation.

Brucellosis is a zoonosis endemic to many low- and middle-income countries around the world. Therapies recommended by the WHO are comprised of at least two antibiotics for several weeks, sometimes months. Relapses are frequent despite these harsh treatments. The underlying reasons for these relapses, besides reinfection and non-compliance to treatment, are unknown. Our study shows that Brucella abortus can form so called “persisters” in rich broth but also inside macrophages. This small bacterial subpopulation survives antibiotic treatment and resumes growth after removal of the antibiotics and could therefore serve as a reservoir for relapses in human brucellosis. Furthermore, we show that the intracellular lifestyle of Brucella has protective properties against recommended antibiotics as observed for other intracellular pathogens, highlighting the necessity to develop new infection models to assess antibiotic efficacy.

Brucellosis of the Spine in Children-An Analysis of 5 Children From an Endemic Setting

BACKGROUND

Brucellosis of the spine is quite common among adults in endemic regions. The incidence of brucellosis of the spine affecting children is very rare. This article describes the clinical characteristics, diagnosis, management and outcome of children with brucellosis of the spine. It also aims to create awareness among all health care professionals, especially spine surgeons, regarding this rare entity.

METHODS

This was a retrospective study of children aged less than 15 years who were diagnosed and treated for brucellosis of the spine. Confirmed cases of brucellosis in children who had completed a full course of a triple-drug regimen as per Centers for Disease Control and Prevention (CDC) guidelines were included. Outcome analysis included both clinical and radiological measures. Clinical measures included pain, neurological status, and return to school. Resolution of the abscess and sclerosis of the involved vertebra were taken as the radiological measure.

RESULTS

A total of 5 children (4 boys and 1 girl) with an average age of 10 years, ranging from 6 to 14 years, fulfilled the inclusion criteria. The mean follow-up period was 32 months. All children presented with fever, back pain, and constitutional symptoms. Two of them had neurological deficits, and posttreatment, they improved to near normal neurological status. Only 1 child with an epidural abscess compressing the lumbar canal required surgical intervention. All the children were treated with a triple-drug regimen. Longer duration of treatment (14 months) was given for 2 children with history of relapse. All children were healed of the disease without any sequalae or relapse.

CONCLUSIONS

Blood culture and standard agglutination tests are mandatory for the diagnosis of brucellosis. Children tolerated the triple-drug regimen well. Prolonged duration of treatment was required for children with relapse. Health education to all treating health care professionals and parents is of paramount importance for treatment and control of this endemic disease.

Epidemiological assessment of 5598 brucellosis inpatients in Spain (1997-2015)

Brucellosis remains one of the main zoonoses worldwide. Epidemiological data on human brucellosis in Spain are scarce. The objective of this study was to assess the epidemiological characteristics of inpatient brucellosis in Spain between 1997 and 2015. A retrospective longitudinal descriptive study was performed. Data were requested from the Health Information Institute of the Ministry of Health and Equality, which provided us with the Minimum Basic Data Set of patients admitted to the National Health System. We also obtained data published in the System of Obligatory Notifiable Diseases. A total of 5598 cases were registered. The period incidence rate was 0.67 (95% CI 0.65-0.68) cases per 100 000 person-years. We observed a progressive decrease in the number of cases and annual incidence rates. A total of 3187 cases (56.9%) came from urban areas. The group most at risk comprised men around the fifth decade of life. The average (±s.d.) hospital stay was 12.6 days (±13.1). The overall lethality rate of the cohort was 1.5%. The number of inpatients diagnosed with brucellosis decreased exponentially. The group of patients with the highest risk of brucellosis in our study was males under 45 years of age and of urban origin. The lethality rate has reduced to minimum values. It is probable that hospital discharge records could be a good database for the epidemiological analysis of the hospital management of brucellosis and offer a better information collection system than the notifiable diseases system (EDO in Spanish).

The Characteristics, Prevalence, and Risk Factors of Drug-Induced Liver Injury Among Brucellosis Inpatients in Xinjiang, China

Background: We investigated the prevalence, demographic and clinical features, and risk factors associated with drug-induced liver injury (DILI) during the treatment of brucellosis inpatients in a retrospective study. Methods: We collected the clinical data of 782 brucellosis inpatients admitted at the Shawan County People's Hospital, Xinjiang, from 2015-2019. All cases were re-evaluated using the international consensus of DILI criteria and RUCAM rating scale. 71 patients were confirmed as DILI cases and compared with 523 other patients with normal liver function. Results: It was indicated that DILI occurred with a prevalence of about 9.08% among brucellosis inpatients receiving drug therapy. Hepatocellular injury was the most common type of DILI (61.97%, 95% confidence interval [CI] 50.34-72.37), followed by mixed (23.94%, 95% CI 15.52-35.04) and cholestatic types (14.08%, 95% CI 7.83-24.02). In addition, 13.64% of the hepatocellular DILI cases fulfilled Hy's law criteria and only two cases (2.82%) progressed to severe DILI. Most patients adopted the combination of rifampicin, antipyretic analgesics, anti-infective agents, and traditional Chinese medicine for the treatment of brucellosis, with all the 71 patients taking rifampicin as the drug of choice. Multivariable logistic regression analyses indicated that obesity, regular alcohol intake, and decreased serum albumin were the independent risk factors of DILI in patients with brucellosis after adjusting for gender, age, and ethnicity. Conclusion: DILI occurred in a minority of inpatients diagnosed with brucellosis receiving rifampicin-based therapeutic regimen. In addition, obesity, alcohol abuse, and decreased serum albumin were valuable predictors of the risk of DILI in patients with brucellosis.

Canine Brucellosis: An Update

Canine brucellosis is an infectious and zoonotic disease caused by Brucella canis, which has been reported worldwide, and is a major public health concern due to close contact between dogs and humans. In dogs, canine brucellosis manifests with abortion outbreaks, reproductive failure, enlargement of lymph nodes, and occasionally affects the osteoarticular system, although the occurrence of asymptomatic infections in dogs are not uncommon. In humans, the disease is associated with a febrile syndrome, commonly with non-specific symptoms including splenomegaly, fatigue, and weakness. Infection of dogs occurs mostly by the oronasal route when in contact with contaminated tissues such as aborted fetuses, semen, urine, and vaginal secretions. In humans, contact with contaminated fluids from infected dogs is an important source of infection, and it is an occupational risk for veterinarians, breeders, laboratory workers, among other professionals who deal with infected animals or biological samples. The diagnosis in dogs is largely based on serologic methods. However, serologic diagnosis of canine brucellosis remains very challenging due to the low accuracy of available tests. Molecular diagnostic methods have been increasingly used in the past few years. Treatment of infected dogs is associated with a high frequency of relapse, and should be employed only in selected cases. Currently there are no commercially available vaccines for prevention of canine brucellosis. Therefore, development of novel and improved diagnostic methods as well as the development of efficacious and safe vaccination protocols are needed for an effective control of canine brucellosis and its associated zoonotic risk.

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.

A new candidate vaccine for human brucellosis based on influenza viral vectors: a preliminary investigation for the development of an immunization schedule in a guinea pig model

BACKGROUND

A new candidate vector vaccine against human brucellosis based on recombinant influenza viral vectors (rIVV) subtypes H5N1 expressing Brucella outer membrane protein (Omp) 16, L7/L12, Omp19 or Cu-Zn SOD proteins has been developed. This paper presents the results of the study of protection of the vaccine using on guinea pigs, including various options of administering, dose and frequency. Provided data of the novel vaccine candidate will contribute to its further movement into the preclinical stage study.

METHODS

General states of guinea pigs was assessed based on behavior and dynamics of a guinea pig weight-gain test. The effectiveness of the new anti-brucellosis vector vaccine was determined by studying its protective effect after conjunctival, intranasal and sublingual administration in doses 10⁵ EID₅₀, 10⁶ EID₅₀ and 10⁷ EID₅₀ during prime and boost vaccinations of animals, followed by challenge with a virulent strain of B. melitensis 16 M infection. For sake of comparison, the commercial B. melitensis Rev.1 vaccine was used as a control. The protective properties of vaccines were assessed by quantitation of Brucella colonization in organs and tissues of infected animals and compared to the control groups.

RESULTS

It was observed a gradual increase in body weight of guinea pigs after prime and booster immunization with the vaccine using conjunctival, intranasal and sublingual routes of administration, as well as after using various doses of vaccine. The most optimal way of using the vaccine has been established: double intranasal immunization of guinea pigs at a dose of 10⁶ EID₅₀, which provides 80% protection of guinea pigs from B. melitensis 16 M infection (P < 0.05), which is comparable to the results of the effectiveness of the commercial B. melitensis Rev.1 vaccine.

CONCLUSIONS

We developed effective human vaccine candidate against brucellosis and developed its immunization protocol in guinea pig model. We believe that because of these studies, the proposed vaccine has achieved the best level of protection, which in turn provides a basis for its further promotion.

Scenario of pathogenesis and socioeconomic burden of human brucellosis in Saudi Arabia

Brucellosis is considered a prevailing endemic infectious disease in the Kingdom of Saudi Arabia and represents a health problem with socio-economic burden. There are two main Brucella species that cause human brucellosis; Brucella abortus, and Brucella melitensis. The clinical features range from asymptomatic to the acute symptoms of fever, joint pain, muscle pain, headache, nausea/vomiting, anorexia and malaise in addition to the subsequent complications that might occur. The endemicity of brucellosis might be explained due to obstacles in controlling the importation of animals for slaughtering during Hajj periods and for several other predisposing factors. The distribution of the disease is all over the country and the most prevalent part is the south followed by north and then the east and central parts. However, in the complexity of brucellosis control measures, there are several activities which have been implemented to tackle the disease such as mass vaccination of animals, regulating importation of slaughter animals, and improving public awareness. This review provides a detailed description of the status of brucellosis in Saudi Arabia, which includes epidemiology, clinical characteristics, virulence and pathophysiology, and prevention of the disease.

Brucellosis

Brucellosis is a common Zoonosis affecting half a million people annually. The most common mode of infection is by consuming unpasteurized milk or milk products. The general manifestations are those of fever with generalized symptoms. The nervous system is affected in 4-7% of cases. The manifestations are protean and include meningo-encephalitis as well as peripheral nervous system involvement. The diagnosis relies on culture, which is cumbersome and can be falsely negative. Agglutination tests for the various species of the organism are the mainstay for diagnosis. Treatment is for 3-6 months with combination therapy including Doxycycline, Rifampicin and ceftriaxone. The main issue is prevention and better animal husbandry.

Hepatic Brucelloma Diagnosis and Long-Term Treatment, France

We report a case of hepatic brucelloma in France. This diagnosis may be suspected in any patient who has a liver abscess after traveling to a brucellosis-endemic area. Brucella spp. may be detected by PCR in the liver tissue or suppuration. Abscess drainage and prolonged antimicrobial therapy help achieve healing.

Osteoarticular manifestations of human brucellosis: A review

Brucellosis is a common global zoonotic disease, which is responsible for a range of clinical manifestations. Fever, sweating and musculoskeletal pains are observed in most patients. The most frequent complication of brucellosis is osteoarticular involvement, with 10% to 85% of patients affected. The sacroiliac (up to 80%) and spinal joints (up to 54%) are the most common affected sites. Spondylitis and spondylodiscitis are the most frequent complications of brucellar spinal involvement. Peripheral arthritis, osteomyelitis, discitis, bursitis and tenosynovitis are other osteoarticular manifestations, but with a lower prevalence. Spinal brucellosis has two forms: focal and diffuse. Epidural abscess is a rare complication of spinal brucellosis but can lead to permanent neurological deficits or even death if not treated promptly. Spondylodiscitis is the most severe form of osteoarticular involvement by brucellosis, and can have single- or multi-focal involvement. Early and appropriate diagnosis and treatment of the disease is important in order to have a successful management of the patients with osteoarticular brucellosis. Brucellosis should be considered as a differential diagnosis for sciatic and back pain, especially in endemic regions. Patients with septic arthritis living in endemic areas also need to be evaluated in terms of brucellosis. Physical examination, laboratory tests and imaging techniques are needed to diagnose the disease. Radiography, computed tomography, magnetic resonance imaging (MRI) and bone scintigraphy are imaging techniques for the diagnosis of osteoarticular brucellosis. MRI is helpful to differentiate between pyogenic spondylitis and brucellar spondylitis. Drug medications (antibiotics) and surgery are the only two options for the treatment and cure of osteoarticular brucellosis.

Brucella infection in a child with progressive familial intrahepatic cholestasis type 2 who had undergone liver transplantation

Brucellosis is considered the most widespread zoonosis in the world. In endemic regions of brucellosis, childhood brucellosis includes up to one-third of all cases of human brucellosis. Brucellosis constitutes a public health problem in Turkey. A boy aged 12 yr who had PFIC2 had undergone deceased-donor liver transplantation in 2008 at the age of seven. The boy presented with fatigue, fever, and pain in the right leg and hip and was admitted to the hospital. Brucella melitensis grew in the blood culture, and the SAT was positive at a titer of 1:640. The patient was treated with oral doxycycline and rifampicin for eight wk. After treatment, the patient recovered and his blood cultures became negative. The patient's mother also had a high Brucella agglutination titer of 1:320 positive and was treated in the internal medicine department with spiramycin and doxycycline. Brucella infection should be suspected in liver transplant recipients with fever of unknown origin, especially in recipients who live in an endemic area.

Human Brucella canis Infection and Subsequent Laboratory Exposures Associated with a Puppy, New York City, 2012

Human Brucella canis infection incidence is unknown. Most identified cases are associated with pet dogs. Laboratory-acquired infections can occur following contact with Brucella spp. We identified a paediatric B. canis case, the source and other exposed persons. A 3-year-old New York City child with fever and dyspnoea was hospitalized for 48 h for bronchiolitis. After her admission, blood culture grew B. canis, she was prescribed anti-microbials and recovered. B. canis was also isolated from blood of the child's pet dog; these isolates were genetically similar. The dog originated from an Iowa breeding facility which was quarantined after identification of the dog's infection. Additionally, 31 laboratory workers were exposed and subsequently monitored for symptoms; 15 completed post-exposure prophylaxis. To our knowledge, this is the first report strongly suggesting B. canis zoonotic transmission to a child in the United States, and highlights the need for coordinated control policies to minimize human illness.

Brucella arteritis: clinical manifestations, treatment, and prognosis

Brucellosis is the most common bacterial zoonosis, and causes a considerable burden of disease in endemic countries. Cardiovascular involvement is the main cause of mortality due to infection with Brucella spp, and most commonly manifests as endocarditis, peripheral and cerebrovascular aneurysms, or arterial and venous thromboses. We report a case of brucellosis presenting as bacteraemia and aortic endarteritis 18 years after the last known exposure to risk factors for brucella infection. The patient was treated with doxycycline, rifampicin, and gentamicin, and underwent surgical repair of a penetrating aortic ulcer, with a good clinical recovery. We review the signs and symptoms, diagnostic approach, prognosis, and treatment of brucella arteritis. We draw attention to the absence of consensus about the optimum therapy for vascular brucellosis, and the urgent need for additional studies and renewed scientific interest in this major pathogen.

A new aurora in anaplastic thyroid cancer therapy

Anaplastic thyroid cancers (ATC) are among the most aggressive human neoplasms with a dire prognosis and a median survival time of few months from the diagnosis. The complete absence of effective therapies for ATC renders the identification of novel therapeutic approaches sorely needed. Chromosomal instability, a feature of all human cancers, is thought to represent a major driving force in thyroid cancer progression and a number of mitotic kinases showing a deregulated expression in malignant thyroid tissues are now held responsible for thyroid tumor aneuploidy. These include the three members of the Aurora family (Aurora-A, Aurora-B, and Aurora-C), serine/threonine kinases that regulate multiple aspects of chromosome segregation and cytokinesis. Over the last few years, several small molecule inhibitors targeting Aurora kinases were developed, which showed promising antitumor effects against a variety of human cancers, including ATC, in preclinical studies. Several of these molecules are now being evaluated in phase I/II clinical trials against advanced solid and hematological malignancies. In the present review we will describe the structure, expression, and mitotic functions of the Aurora kinases, their implications in human cancer progression, with particular regard to ATC, and the effects of their functional inhibition on malignant cell proliferation.

Immunogenic response induced by wzm and wzt gene deletion mutants from Brucella abortus S19

Brucellosis is an infectious disease affecting humans and animals worldwide. Effective methods of control include inducing immunity in animals by vaccination and elimination. Brucella abortus S19 is one of the popular vaccines for control of cattle brucellosis, as it has low virulence. In this paper, allelic exchange plasmids of wzm and wzt genes were constructed and partially knocked out to evaluate the effects on the induction of immunity to Brucella abortus S19 mutants. Cytokine secretion in vitro, INF-γ induction in vivo and antibody dynamics were evaluated. These data suggested that the immunity-eliciting ability of the wzm and wzt gene deletion mutants was similar, although reduced compared with the S19 strain. The results demonstrated that the wzt gene may be more important in the regulation of the induction of immunity than the wzm gene.

Review of brucellosis cases from laboratory exposures in the United States in 2008 to 2011 and improved strategies for disease prevention

Five laboratory-acquired brucellosis (LAB) cases that occurred in the United States between 2008 and 2011 are presented. The Centers for Disease Control and Prevention (CDC) reviewed the recommendations published in 2008 and the published literature to identify strategies to further prevent LAB. The improved prevention strategies are described.

A literature review of laboratory-acquired brucellosis

Brucellosis is a bacterial zoonotic disease which has been associated with laboratory-acquired infections. No recent reviews have addressed the characteristics of laboratory-acquired brucellosis (LAB). English-language literature was reviewed to identify reports of laboratory exposures to Brucella spp. and LAB cases between 1982 and 2007. Evaluation of 28 case reports identified 167 potentially exposed laboratory workers, of whom 71 had LAB. Nine reports were identified that summarized an additional 186 cases of LAB. Only 18 (11%) exposures were due to laboratory accidents, 147 (88%) exposures were due to aerosolization of organisms during routine identification activities, and the circumstances of 2 (1%) exposures were unknown. Brucella melitensis was the causative agent in 80% (135/167) of the exposures. Workers with high-risk exposures were 9.3 times more likely to develop LAB than workers with low-risk exposures (95% confidence interval [CI], 3.0 to 38.6; P < 0.0001); they were also 0.009 times likelier to develop LAB if they took antimicrobial PEP than if they did not (95% CI, 0 to 0.042; P < 0.0001). The median incubation period in case and summary reports was 8 weeks (range 1 to 40 weeks). Antimicrobial PEP is effective in preventing LAB. The incubation period may be used to identify appropriate serological and symptom surveillance time frames for exposed laboratory workers.

Doxycycline-rifampin versus doxycycline-rifampin-gentamicin in treatment of human brucellosis

This prospective, non-randomized trial, compared the efficacy and tolerance of a doxycycline-rifampin regimen, administered for 45 days, versus doxycycline-rifampin given for 45 days plus gentamicin for the first 7–10 days, in the treatment of human brucellosis. Of 238 patients that were initially included in the study, 181 were finally evaluated. Ninety-four were treated with the doxycycline-rifampin and 87 with the doxycycline-rifampin-gentamicin regimens. In the doxycycline-rifampin group: relapses were noted in 13 (13.8%) patients; therapeutic failures in five (5.3%); and mild adverse effects in 28 (29.8%). In the doxycycline-rifampin-gentamicin group: four (4.6%) relapsed; and five (5.7%) therapeutic failures were registered. Mild adverse effects were registered in 29 (33.3%) patients. The doxycycline-rifampin-gentamicin regimen demonstrated a significantly lower relapse rate compared to the doxycycline-rifampin combination ( P = 0.034). We conclude that adding gentamicin for the first 7–10 days to the standard oral doxycycline-rifampin regimen can decrease the rate of relapses.

Comparison of doxycycline-streptomycin, doxycycline-rifampin, and ofloxacin-rifampin in the treatment of brucellosis: a randomized clinical trial

BACKGROUND

Traditional regimens for the treatment of brucellosis are associated with significant relapse rates. The aim of this study was to compare the efficacy of ofloxacin plus rifampin (OFX-RIF) versus doxycycline plus streptomycin (DOX-STR) and doxycycline plus rifampin (DOX-RIF) regimens in the treatment of brucellosis.

METHODS

Two hundred and nineteen patients with brucellosis were enrolled in a randomized clinical trial; 28 cases were withdrawn because they did not attend the follow-up. Out of 191 patients with brucellosis, 64 received OFX-RIF, 62 received DOX-RIF, and 65 patients received DOX-STR regimens. All patients were assessed during the period of therapy in the second, fourth, and sixth weeks by clinical course and were also followed up clinically and serologically for 6 months after the cessation of therapy.

RESULTS

The highest clinical response (95.4%) was observed in the DOX-STR group (p=0.009). The results of multivariate analysis indicate that treatment with DOX-STR had the least therapeutic failures among the three groups (p=0.033). Adverse reactions were seen in 16.8% of patients, but there was no significant difference among the three groups (p=0.613). The lowest relapse rate (4.6%) was observed in the DOX-STR group (p=0.109).

CONCLUSIONS

We conclude that the DOX-STR combination should remain the first-line regimen for the treatment of brucellosis in our region; we recommend DOX-RIF and OFX-RIF combinations as the second-line regimens.

Protective live oral brucellosis vaccines stimulate Th1 and th17 cell responses

Zoonotic transmission of brucellosis often results from exposure to Brucella-infected livestock, feral animals, or wildlife or frequently via consumption of unpasteurized milk products or raw meat. Since natural infection of humans often occurs by the oral route, mucosal vaccination may offer a means to confer protection for both mucosal and systemic tissues. Significant efforts have focused on developing a live brucellosis vaccine, and deletion of the znuA gene involved in zinc transport has been found to attenuate Brucella abortus. A similar mutation has been adapted for Brucella melitensis and tested to determine whether oral administration of ΔznuA B. melitensis can confer protection against nasal B. melitensis challenge. A single oral vaccination with ΔznuA B. melitensis rapidly cleared from mice within 2 weeks and effectively protected mice upon nasal challenge with wild-type B. melitensis 16M. In 83% of the vaccinated mice, no detectable brucellae were found in their spleens, unlike with phosphate-buffered saline (PBS)-dosed mice, and vaccination also enhanced the clearance of brucellae from the lungs. Moreover, vaccinated gamma interferon-deficient (IFN-γ(-/-)) mice also showed protection in both spleens and lungs, albeit protection that was not as effective as in immunocompetent mice. Although IFN-γ, interleukin 17 (IL-17), and IL-22 were stimulated by these live vaccines, only RB51-mediated protection was codependent upon IL-17 in BALB/c mice. These data suggest that oral immunization with the live, attenuated ΔznuA B. melitensis vaccine provides an attractive strategy to protect against inhalational infection with virulent B. melitensis.

Towards a Brucella vaccine for humans

There is currently no licensed vaccine for brucellosis in humans. Available animal vaccines may cause disease and are considered unsuitable for use in humans. However, the causative pathogen, Brucella, is among the most common causes of laboratory-acquired infections and is a Center for Disease Control category B select agent. Thus, human vaccines for brucellosis are required. This review highlights the considerations that are needed in the journey to develop a human vaccine, including animal models, and includes an assessment of the current status of novel vaccine candidates.

A current review of targeted therapeutics for ovarian cancer

Difficult to detect, ovarian cancer typically presents at an advanced stage. Significant progress has been achieved in the treatment of ovarian cancer with therapeutics focused on DNA replication or cell division. However, despite sensitivity to induction chemotherapy the majority of patients will develop recurrent disease. Conventional agents for recurrent disease offer little in terms of long-term responses. Various targeted therapeutics have been explored in the management of ovarian cancer. These include monoclonal antibodies to epidermal growth factor receptors, small molecule tyrosine kinase inhibitors, monoclonal antibodies directed at the vascular endothelial growth factor (bevacizumab), and the small tyrosine kinase inhibitors that target the vascular endothelial growth factor receptor. Recently, several other agents have come forth as potential therapeutic agents in the management of ovarian cancer. These include monoclonal antibodies to the folate receptor, triple angiokinase inhibitors, PARP inhibitors, aurora kinase inhibitors, inhibitors of the Hedgehog pathway, folate receptor antagonists, and MTOR inhibitors.

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.