Brucellosis (overview) A23.9

Marston 1861; Bruce 1887

Worldwide notifiable anthropozoonoses caused by infection with brucella (mainly Brucella (B.) melitensis, B. abortus, B. suis, B. ovis). After the stage of bacteremia with undulating fever, development of granulomatous inflammation, especially in the lymph nodes, spleen and liver, as well as arthritis of the ileosacral, intervertebral and hip joints.

Brucella are small, gram-negative, non-flagellated rod bacteria. A distinction is made between 3 species that cause clinically very similar clinical pictures:

• Brucella abortus (causative agent of M. Bang = Febris undulans bovina): The main host is cattle (causes a febrile general infection).
• Brucella melitensis (causative agent of Malta fever = Mediterranean fever, Febris mediterranea, Febris undulans melitensis, Bruce septicemia, wave fever): Main hosts are sheep and goats.
• Brucella suis (porcine brucellosis = brucellosis suis): The main host is the pig.
• Brucella canis (canine brucellosis); main hosts are dogs

B. abortus: Occurs worldwide, especially in temperate and tropical areas where cattle are bred. Brucellosis affects certain occupational groups (farmers, shepherds, hunters, butchers, veterinarians (notifiable occupational disease - BK no. 3102)). In Germany <50 cases/year. Mostly imported cases (mainly from Turkey).

Brucella melitensis: Mediterranean region, Africa, South America.

B. suis: North America.

Incubation period 2-6 weeks. A prodromal stage with uncharacteristic general symptoms is followed by the stage of bacteremia with typical, but not obligatory, wave-like temperature spikes (undulating fever): fever slowly rising to 38-40 °C over 5-7 days, followed by an equally slow decline. These attacks can recur for weeks to months. In addition, hepatosplenomegaly, headache, aching limbs, possibly gastrointestinal symptoms. Extremely varied, more or less generalized exanthema may occur on the skin, macular, papular, pustular, psoriasiform, haemorrhagic, erythema-exudativum-multiforme-like.

In the subsequent stage of organ manifestation, formation of granulomas in lymph nodes, liver, bones and other organs. Rarely in the skin as uncharacteristic, ulcerating nodules, plate-like infiltrates, ecthyma-like efflorescences.

Therapy of choice: Doxycycline 200mg/day p.o. + Rifampicin 600-900mg/day p.o. over 6 weeks

Alternative: Combination of tetracycline (e.g. tetracycline Wolff) 2 g/day for 3-6 weeks and streptomycin (e.g. strepto-fatol) 1 g/day i.v. or i.m. for 2 weeks. For mild infections monotherapy with tetracyclines is sufficient.

Alternatively: Doxycycline 2 times/day 100 mg p.o. instead of tetracycline.

In children under 12 years of age: Trimethoprim/Sulfamethoxazol (e.g. Cotrimox-Wolff Saft 1/2-2 measuringsl. depending on age) for 4 weeks. Combination of this therapy with rifampicin (e.g. Eremfat) 10-15 mg/kg bw/day p.o. is recommended. Treatment with rifampicin alone is not recommended due to rapid development of resistance.

With therapy in the acute phase (start of therapy during the first 3 months) the chances of recovery are 90-100%, later 60-80%.

If therapy is started late, it is often not possible to eliminate the pathogens completely; chronic, long lasting courses with recurrent flare-ups of the disease are possible. In approx. 5% of the treated cases, relapses due to persistent sensitive pathogens occur, so that a new therapy attempt with the existing regime may be possible (antibiogram!).

There is an obligation to report laboratory evidence by name.

1. Ariza J et al (1992) Treatment of human brucellosis with doxycycline plus rifampicin or doxycycline plus streptomycin. A randomized, double-blind study. Ann Internal Med 117: 25-30
2. Bang B (1897) The etiology of infectious discarding. Z Veterinary Medicine 1: 241-278
3. Bruce D (1887) Note on the discovery of a microorganism in Malta fever. Practitioner (London) 39: 161-170
4. Marston JA (1861) Report on fever (Malta). Royal Army Med Dept Rep 3: 486-521
5. Mazokopakis E et al (2003) Acute brucellosis presenting with erythema nodosum. Eur J Epidemiol 18: 913-915
6. McLean DR et al (1992) Neurobrucellosis: clinical and therapeutic features. Clin Infect Dis 15: 582-590
7. Metin A et al (2001) Cutaneous findings encountered in brucellosis and review of the literature. Int J Dermatol 40: 434-438
8. Milionis H et al (2000) Cutaneous manifestations in brucellosis: case report and review of the literature. Infection 28: 124-126
9. Weil Y et al (2003) Brucella prosthetic joint infection: a report of 3 cases and a review of the literature. Clin Infect Dis 36: e81-86