Human brucellosis in Macedonia - 10 years of clinical experience in endemic region

Case Report: Neurobrucellosis Presenting as Malignancy

Neurobrucellosis, caused by Brucella species, is a zoonotic infection that may involve the central nervous system. Although uncommon, it can manifest as a solitary intracranial mass. We report a case of neurobrucellosis in a 25-year-old woman from Peru who presented with headache, weight loss, and right-side hemiparesis and paresthesia. A contrast-enhanced magnetic resonance imaging scan revealed an intracerebral mass in the left temporal lobe. Serum testing subsequently were positive. Brain biopsy demonstrated non-necrotizing granulomas without malignant cells. Neurobrucellosis should be considered in the differential diagnosis of brain space occupying lesions in endemic countries.

Brucella infection presenting as infective endocarditis complicated by embolic stroke

Brucellosis (undulant fever) is a zoonotic infection caused by Brucella species. It typically presents with fever, malaise, night sweats, and arthralgia. One of its rare complications is infective endocarditis, which occurs in approximately 1.3% of patients and can be further complicated by embolic stroke. This report describes a rare occurrence of Brucella endocarditis presenting as an embolic stroke. A 34-year-old male presented with sudden left-sided weakness and fever. He reported headaches, fever, and generalized weakness in the preceding week. The patient worked on a farm and hence had animal contact. A neurological exam showed left-sided facial weakness, and power of 0/5 and 1/5 in the left upper and lower extremities, respectively. CT scan of the head revealed a right middle cerebral artery (MCA) territory infarct with penumbra and a right MCA occlusion. He underwent a cerebral artery thrombectomy with successful recanalization. However, he continued to have fever and high inflammatory markers. Echocardiography showed aortic valve vegetation and blood cultures grew Brucella melitensis. A multidisciplinary meeting was held to determine the optimal management, which included a course of rifampicin and doxycycline.

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.

Case report of pulmonary brucellosis complicated by pleural effusion

Brucellosis is a bacterial disease and one of the most widespread zoonoses transmitted by an animal. It can affect any organ system, but pulmonary involvement is an unusual presentation according to the literature. We report the case of a 32 -year-old lady from Saudi Arabia who suffered from persistent fever and was found to have lobar pneumonia complicated by parapneumonic effusion. She started empirical antibiotics, and many investigations were done. In the end, after more detail about the patient's circumstances, the presumptive diagnosis of Brucella was made by high serology titer. She was effectively treated with doxycycline and rifampicin and completely recovered. In conclusion, pulmonary brucellosis is infrequent and challengeable in diagnosis but should be knowledge, especially in endemic areas of brucellosis.

Brucella infection-induced hemophagocytic syndrome with subsequent development of the probable vanishing bile duct syndrome: A case report and literature review

Vanishing bile duct syndrome is a rare clinical manifestation, and many clinicians tend to classify vanishing bile duct syndrome as a surgical disease and perform emergency surgery, leading to poor prognosis for patients. In this report, we present a case of a patient initially diagnosed with probable vanishing bile duct syndrome. However, through a meticulous step-by-step investigation, we ultimately determined that the patient was suffering from Brucella infection-induced hemophagocytic syndrome, which contributed to the development of the probable vanishing bile duct syndrome. Once a definitive diagnosis was established, the patient underwent treatment following anti-Brucella and Hemophagocytic lymphohistiocytosis-2004 protocols, leading to an improvement in the patient's condition. We conducted a literature review on brucellosis, and it demonstrated the lack of specificity in diagnosing Brucella infections and the diverse range of clinical manifestations. Failure to arrive at a definitive diagnosis may result in clinical misdiagnosis and delayed treatment, thereby leading to grave consequences.

Recurrent Neurobrucellosis in a Feral Swine Hunter

Brucellosis is a zoonotic infectious disease caused by the bacterial genus Brucella and is most commonly transmitted to humans globally via the consumption of contaminated unpasteurized products. In a significant minority of cases, Brucella has been found to be transmitted by contact with infected swine bodily fluids such as blood. Only a small proportion of all cases of brucellosis affects the central nervous system, and of the four species of Brucella that are known to infect humans, Brucella suis is unusual. Neurologic involvement occurs in a limited proportion of cases and can vary in presentation, ranging from encephalitis to radiculitis or from brain abscess to neuritis. In this case report, we present a 20-year-old male with an eight-day history of headache and neck pain and a high fever that started two days after the onset of the headaches. Three weeks prior, he had hunted, killed, butchered, cooked, and eaten a wild boar in the field. A workup was performed, and blood cultures eventually grew Brucella suis. Although an intensive broad-spectrum antibiotic protocol was implemented, his post-therapy course was complicated. He eventually discontinued his antibiotics after one year.

Predictive factors for focal disease in human brucellosis, an observational cohort study

This retrospective cohort study aimed to identify predictors for focal disease in human brucellosis. The study included patients with brucellosis diagnosed between January 2000 and December 2021. Overall, 247 patients were identified. Focal disease was diagnosed in 64 (25.9%) patients. The most common focal infection was bone and joint in 56 patients (23.4%). Disease duration > 14 days was significantly associated with focal illness [OR = 2.2 (1.08-4.47), p = 0.030], although febrile illness was inversely associated with focal illness this did not reach statistical significance [OR = 0.46 (0.21-1.00), p = 0.050]. Focal brucellosis should be suspected in patients with prolonged illness.

Influence and prediction of meteorological factors on brucellosis in a northwest region of China

This paper aims to study the cumulative lag effect of meteorological factors on brucellosis incidence and the prediction performance based on Random Forest model. The monthly number of brucellosis cases and meteorological data from 2015 to 2019 in Yongchang of Gansu Province, northwest China, were used to build distributed lag nonlinear model (DLNM). The number of brucellosis cases of lag 1 month and meteorological data from 2015 to 2018 were used to build RF model to predict the brucellosis incidence in 2019. Meanwhile, SARIMA model was established to compare the prediction performance with RF model according to R² and RMSE. The results indicated that the population had a high incidence risk at temperature between 5 and 13 °C and lag between 0 and 18 days, sunshine duration between 225 and 260 h and lag between 0 and 1 month, and atmosphere pressure between 789 and 793.5 hPa and lag between 0 and 18 days. The R² and RMSE of train set and test set in RF model were 0.903, 1.609, 0.824, and 2.657, respectively, and the R² and RMSE in SARIMA model were 0.530 and 7.008. This study found significant nonlinear and lag associations between meteorological factors and brucellosis incidence. The prediction performance of RF model was more accurate and practical compared with SARIMA model.

Methodological choices in brucellosis burden of disease assessments: A systematic review

BACKGROUND

Foodborne and zoonotic diseases such as brucellosis present many challenges to public health and economic welfare. Increasingly, researchers and public health institutes use disability-adjusted life years (DALYs) to generate a comprehensive comparison of the population health impact of these conditions. DALYs calculations, however, entail a number of methodological choices and assumptions, with data gaps and uncertainties to accommodate. Thisreview identifies existing brucellosis burden of disease studies and analyzes their methodological choices, assumptions, and uncertainties. It supports the Global Burden of Animal Diseases programme in the development of a systematic methodology to describe the impact of animal diseases on society, including human health.

METHODS/PRINCIPAL FINDINGS

A systematic search for brucellosis burden of disease calculations was conducted in pre-selected international and grey literature databases. Using a standardized reporting framework, we evaluated each estimate on a variety of key methodological assumptions necessary to compute a DALY. Fourteen studies satisfied the inclusion criteria (human brucellosis and quantification of DALYs). One study reported estimates at the global level, the rest were national or subnational assessments. Data regarding different methodological choices were extracted, including detailed assessments of the adopted disease models. Most studies retrieved brucellosis epidemiological data from administrative registries. Incidence data were often estimated on the basis of laboratory-confirmed tests. Not all studies included mortality estimates (Years of Life Lost) in their assessments due to lack of data or the assumption that brucellosis is not a fatal disease. Only two studies used a model with variable health states and corresponding disability weights. The rest used a simplified singular health state approach. Wide variation was seen in the duration chosen for brucellosis, ranging from 2 weeks to 4.5 years, irrespective of the whether a chronic state was included.

CONCLUSION

Available brucellosis burden of disease assessments vary widely in their methodology and assumptions. Further research is needed to better characterize the clinical course of brucellosis and to estimate case-fatality rates. Additionally, reporting of methodological choices should be improved to enhance transparency and comparability of estimates. These steps will increase the value of these estimates for policy makers.

Epidemiological Characteristics and Clinical Manifestations of Brucellosis and Q Fever Among Humans from Northeastern Inner Mongolia

Objective

To investigate the distribution, epidemiology, and clinical symptoms of brucellosis and Q fever in northeastern Inner Mongolia.

Methods

In this study, 64 townships of Bairin left flag and Alukerqin flag, Jarud flag and Horqin right front flag in four counties with frequent brucellosis and Q fever were selected. Epidemiological characteristics, clinical features, and exposure to risk factors were identified and descriptively analyzed in patients from these areas.

Results

There were 367 brucellosis cases in the four regions and 78 positive cases of Q-fever infection. In addition, 24 cases of brucellosis and Q-fever co-infection were identified, with a co-infection rate of 1.13%. Brucellosis and Q fever were mainly concentrated in the 30–65 and 40–55 age groups. For brucellosis, the difference between age groups was statistically significant (χ² = 29.121, P < 0.05). The sex distribution for brucellosis was 225 men (61.31%) and 142 women (38.69%), and 45 men (57.69%) and 33 women (42.31%) had Q fever. Those with brucellosis and Q fever were mainly farmers, accounting for 79.19% and 78.38% of the total number, respectively. Of the 367 cases of brucellosis infection, the main symptoms were joint pain (52.59%), fatigue (47.14%), lower back pain (38.96%), fever (33.24%), hyperhidrosis (28.88%), and muscle pain (20.44%). Of the 78 cases of Q-fever infection, the main symptoms were joint pain (35.90%), fatigue (30.77%), lower back pain (26.92%), fever (21.79%), and hyperhidrosis (17.95%). Muscle pain also accounted for 12.82%.

Conclusion

Occupational distribution suggests that we should strengthen the protection measures against diseases infected through animal husbandry. Among the clinical symptoms, fever, hyperhidrosis and fatigue were associated with brucellosis, while fever, headache, and fatigue were significantly associated with Q fever.

Immune Thrombocytopenic Purpura and Its Rare Association With a Brucella Infection: A Case Report

Although several factors such as viral and bacterial pathogens, and drugs have been widely reported to be associated with immune thrombocytopenic purpura (ITP), brucellosis is an unusual cause of this disorder. Here, we describe a patient with brucellosis with fever and purpura as the first manifestation of her illness due to immune-mediated severe thrombocytopenia. In this case, ITP responded well to the anti-Brucella treatment with platelet recovery within three days.

Brucellosis: A Rare Cause of Febrile Neutropenia in a Child

We report a case of brucellosis-induced severe neutropenia in a 2-year-old girl who presented with a 2-week history of fever. On clinical examination, the patient was febrile with mild aphthous stomatitis. However, her general condition was stable, and systemic examination did not show involvement of any other organ. Laboratory test results revealed severe neutropenia, mild anemia, and an elevated serum C-reactive protein level. Flow cytometry of peripheral blood leukocytes revealed no malignancy, and blood film morphology was unremarkable except for mild microcytosis and hypochromia. Antineutrophil antibody and Coombs test results were negative. We administered intravenous cefuroxime; however, therapy was switched to meropenem plus clarithromycin because fever persisted for 5 days, despite treatment. On the 10th day after admission, Brucella serology tests showed positive results, and trimethoprim-sulfamethoxazole plus rifampicin therapy was prescribed for 8 weeks. The fever defervesced, and the child was discharged in a good state of health. Neutropenia persisted for several months but gradually resolved. Neutropenia, defined as an absolute neutrophil count (ANC) < 1.5 cells × 10 9 /L beyond the first year of life, is a benign transient condition associated with an intercurrent infection (usually viral illnesses or infections) in immunocompetent children. However, severe neutropenia (ANC < 0.5 × 10 9 /L) associated with fever necessitates hospitalization and administration of broad-spectrum antibiotics to avoid the high risk of sepsis, particularly in children. Brucellosis is rarely associated with hematologic abnormalities such as neutropenia. Early diagnosis of hematologic complications of brucellosis is essential for prompt initiation of specific and aggressive treatment.

Laboratory and clinical predictors of focal involvement and bacteremia in brucellosis

Early diagnosis of organ involvement and bacteremia in brucellosis increases treatment success and may prevent poor clinical outcomes. This study aimed to investigate the predictors of focal involvement and bacteremia in patients with brucellosis. A total of 139 brucellosis patients aged 16 years and older were included in the study. Patients with and without organ involvement and bacteremic and non-bacteremic patients were compared separately. Low back pain, lymphadenomegaly, absence of fever on admission, ESR, AST, and neutrophil-lymphocyte ratio (NLR) were predictors of focal involvement (OR: 2.604; 3.167; 7.224; 1.039; 1.032; 1.738, respectively). The AUC value of ESR was 0.669 (0.573-0.765, p = 0.002) with the cutoff point > 30 mm/h (sensitivity 89.74% and specificity 37.00%) in predicting focal involvement in patients with brucellosis. Myalgia and headache (OR: 2.970; 2692) were defined as clinical predictors of Brucella bacteremia. Focal involvement should be considered in patients with brucellosis in the absence of myalgia and fever, presence of low back pain, and sedimentation > 30 mm/h. Brucella bacteremia should be considered regardless of fever, especially in patients with myalgia and headache in endemic areas.

Facing the Human and Animal Brucellosis Conundrums: The Forgotten Lessons

Brucellosis is a major zoonotic disease caused by Brucella species. Historically, the disease received over fifty names until it was recognized as a single entity, illustrating its protean manifestations and intricacies, traits that generated conundrums that have remained or re-emerged since they were first described. Here, we examine confusions concerning the clinical picture, serological diagnosis, and incidence of human brucellosis. We also discuss knowledge gaps and prevalent confusions about animal brucellosis, including brucellosis control strategies, the so-called confirmatory tests, and assumptions about the primary-binding assays and DNA detection methods. We describe how doubtfully characterized vaccines have failed to control brucellosis and emphasize how the requisites of controlled safety and protection experiments are generally overlooked. Finally, we briefly discuss the experience demonstrating that S19 remains the best cattle vaccine, while RB51 fails to validate its claimed properties (protection, differentiating infected and vaccinated animals (DIVA), and safety), offering a strong argument against its current widespread use. These conundrums show that knowledge dealing with brucellosis is lost, and previous experience is overlooked or misinterpreted, as illustrated in a significant number of misguided meta-analyses. In a global context of intensifying livestock breeding, such recurrent oversights threaten to increase the impact of brucellosis.

Epidemiology and time series analysis of human brucellosis in Tebessa province, Algeria, from 2000 to 2020

BACKGROUND

Brucellosis runs rampant endemically with sporadic outbreaks in Algeria. The present study aimed to provide insights into the epidemiology of brucellosis and compare the performance of some prediction models using surveillance data from Tebessa province, Algeria.

STUDY DESIGN

A retrospective study.

METHODS

Seasonal autoregressive integrated moving average (SARIMA), neural network autoregressive (NNAR), and hybrid SARIMA-NNAR models were developed to predict monthly brucellosis notifications. The prediction performance of these models was compared using root mean square error (RMSE), mean absolute error (MAE), and mean absolute percentage error (MAPE).

RESULTS

Overall, 13 670 human brucellosis cases were notified in Tebessa province from 2000-2020 with a male-to-female ratio of 1.3. The most affected age group was 15-44 years (56.2%). The cases were reported throughout the year with manifest seasonality. The annual notification rate ranged from 30.9 (2013) to 246.7 (2005) per 100 000 inhabitants. The disease was not evenly distributed, rather spatial and temporal variability was observed. The SARIMA (2,1,3) (1,1,1)12, NNAR (12,1,6)12, and SARIMA (2,0,2) (1,1,0)12-NNAR (5,1,4)12 were selected as the best-fitting models. The RMSE, MAE, and MAPE of the SARIMA and SARIMA-NNAR models were by far lower than those of the NNAR model. Moreover, the SARIMA-NNNAR hybrid model achieved a slightly better prediction accuracy for 2020 than the SARIMA model.

CONCLUSION

As evidenced by the obtained results, both SARIMA and hybrid SARIMA-NNAR models are suitable to predict human brucellosis cases with high accuracy. Reasonable predictions, along with mapping brucellosis incidence, could be of great help to veterinary and health policymakers in the development of informed, effective, and targeted policies, as well as timely interventions.

Venous thrombosis, peripheral aneurysm formation, and fever in a feral pig hunter with Brucellosis

Brucellosis is a systemic bacterial zoonotic disease with potential endovascular complications including endocarditis, although multifocal vasculopathy is rare. Moreover, swine-associated human infections are less common since brucellosis was eradicated in commercial swine in U.S. states and territories. However, feral swine continue to serve as a reservoir for Brucella suis. We describe the case of a feral swine hunter who presented with fever and respiratory symptoms and was diagnosed with pulmonary embolus. Blood cultures revealed growth of Brucella, later confirmed as Brucella suis. Despite initial appropriate antimicrobial therapy, he maintained fever with worsening knee pain, and magnetic resonance imaging and two-dimensional echocardiography subsequently confirmed the presence of a thrombosed popliteal artery aneurysm and mitral valve vegetation, respectively. To our knowledge, this is the first report of contemporaneous venous and arterial thromboembolism attributable to B. suis infection.

Brucellosis causing bone marrow aplasia in an 11-year-old patient with complete recovery after treatment

Brucellosis is one of the most prevalent zoonotic infections in the Middle East. The disease may present with a range of symptoms from a simple febrile illness to severe invasive infections affecting different organ systems (meningitis, osteomyelitis). In this paper we present an eleven-year-old girl who was diagnosed with “idiopathic bone marrow aplasia” and planned for hematopoietic stem cell transplant (HSCT), when pre-transplant work-up showed high brucella titers. The patient was started on doxycycline, rifampin and gentamicin initially, with discontinuation of the latter 3 weeks into therapy. She recovered completely after 8 months of treatment.

Neurobrucellosis: Brief Review

BACKGROUND

Brucella are small, nonmotile, intracellular, and aerobic gram-negative bacteria. Of the 10 species that currently form the genus Brucella, 5 were shown to be pathogenic in humans.

REVIEW SUMMARY

The epidemiology, clinical manifestations, diagnosis and imaging, and treatment of neurobrucellosis will be reviewed.Brucellosis's transmission to humans occurs by direct contact with contaminated animals. Older patients are at increased risk of nervous system involvement in brucellosis. Brucella spp. can lead to central nervous system involvement through direct damage via invasion of neural tissue or indirect damage caused by endotoxins or immune inflammatory reactions elicited by the presence of the bacteria in the body. Patients can have general nonspecific symptoms in addition to neurological and psychiatric symptoms. There are 4 diagnostic criteria for the diagnosis of neurobrucellosis, which include signs and symptoms suggestive of neurobrucellosis, a positive finding of Brucella spp. in the cerebrospinal fluid (CSF), and/or a positive titer of antibodies targeting brucella in the CSF, lymphocytosis with high protein levels and low glucose levels in CSF, and imaging findings (either cranial magnetic resonance imaging or computed tomography) peculiar to neurobrucellosis. For the treatment, a combined therapy is favored over monotherapy for the eradication of Brucella. Moreover, a multirouted therapy has been associated with increased treatment efficacy. The prognosis of neurobrucellosis is dependent on patients' clinical presentation: brucellar meningitis is associated with a good prognosis, whereas diffuse central nervous system involvement is associated with the development of long-term sequelae.

CONCLUSIONS

Neurobrucellosis affects patients globally and in endemic areas. Neurologists should familiarize themselves with its clinical presentation, diagnosis, and treatment to provide optimal care for their patients.

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.

Complicated Brucellosis With Multisystem Involvement: Two Case Reports

Brucellosis is a zoonotic infection caused by facultative intracellular bacteria of the genus Brucella. The ability of the organism to invade both phagocytic and non-phagocytic cells and survive in the intracellular environment makes brucellosis a systemic infection that can affect various organs of the body. Complications of brucellosis occur when the infection involves one or more focal body sites. Early identification of complications of brucellosis and initiation of appropriate treatment is the key to a better outcome.

Here we present two cases of complicated brucellosis, both having multiple body site involvement.

Brucellar reproductive system injury: A retrospective study of 22 cases and review of the literature

Objective

We aimed to describe the clinical characteristics and prognosis of 22 patients with Brucella-induced reproductive system injury.

Methods

We assessed 22 patients with reproductive system injury between 2010 and 2018 at The First Affiliated Hospital of Xinjiang Medical University.

Results

The disease is predominant in men. Male patients had orchitis, erectile dysfunction, prostatitis, and urethral stricture, while female patients had vaginitis and cervicitis. Some patients had laboratory abnormalities and liver injury. Patients received combination therapy of rifampicin and doxycycline. Doxycycline combined with levofloxacin or moxifloxacin was administered to patients with rifampicin intolerance. All patients had received antibiotic therapy for at least 6 weeks. One patient was lost to follow-up, one patient relapsed because of osteoarthropathy, and one patient had dysuria resulting from chronic prostatitis. The clinical symptoms resolved in the other patients, and the overall patient prognosis was good.

Conclusion

Clinicians should pay attention to brucellosis-induced reproductive system damage. The two-drug regimen of rifampicin+doxycycline is recommended for these patients. Doxycycline combined with levofloxacin or moxifloxacin should be used in patients with brucellosis-induced reproductive system damage who have rifampicin intolerance. The treatment course should be at least 6 weeks.

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INTRODUCTION

Brucellosis, the most common zoonosis globally, is considered a major public health problem.

OBJECTIVE

A retrospective study was carried out over 21&#160;years (1998-2018) to determine the epidemiological features of human brucellosis in the province of El-Oued (south-eastern Algeria).

RESULTS

1,832 confirmed cases of human brucellosis were reported during the study period, with an average incidence rate of around 12.26&#160;cases per 100,000&#160;inhabitants. The annual distribution of the incidence was characterized by an increasing trend and a strong fluctuation&#160;; its values ranged between 2.27 and 24.96 per 100,000 inhabitants. The monthly distribution showed that the highest incidence rates were recorded from mid-February to July, with a peak of 2.74&#160;cases per 100,000&#160;inhabitants in April.Human brucellosis has affected all municipalities. The highest incidence rate was observed in border municipalities such as Ben&#160;Guecha and Oum Tiour (89.76 and 66.14 per inhabitants, respectively).The incidence in the male population was higher than that of the&#160;female at 14.63 versus 9.83 per 100,000&#160;inhabitants, respectively, noting that it increases with age. Individuals over 65&#160;years are the most at risk, with an incidence rate of 22.32 per 100,000&#160;inhabitants.

CONCLUSION

Along with strengthening preventive measures in the population, eliminating brucellosis in animals is the most effective method to protect humans against infection.

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.

Brucella, a bacterium with multiple ways of causing infection

Brucellosis is a zoonotic infection caused by the intracellular gram-negative bacterium Brucella. It is the most common zoonosis worldwide, and its transmission is classically associated with consumption of unpasteurized animal products. However, other mechanisms of transmission include contact of the skin or mucous membranes with infected animal tissue. We present a case of a patient who had more than one possible route of infection.

Brucellar epididymo-orchitis: a retrospective study of 25 cases

Objective: Brucellosis is a multisystemic disease which may affect all organs. Epididymo-orchitis is the most common form of genitourinary involvement. The aim of this study was to present our eight-year experience regarding the management of patients with brucellar epididymo-orchitis (BEO).Materials and method: The medical records of male brucellosis patients treated in two centers, between 2010 and 2018 were analyzed retrospectively. The diagnosis of epididymo-orchitis was made when the patients had scrotal pain, swelling, and enlarged tender testicles and/or epididymis on clinical examination. Brucellosis was diagnosed with a positive standard tube agglutination test or a positive blood culture.Results: Brucellosis was diagnosed in 996 male patients. Of these patients, 25 had a diagnosis of BEO (2.5%). All BEO patients suffered from enlarged painful testicles, however, testicular complaints were the only presentation symptoms in three of them. All patients received medical treatment alone except one patient with testicular abscess who underwent surgical drainage besides medical treatment. All patients recovered completely and no relapses have been detected during six-month follow-up.Conclusion: Patients with epididymo-orchitis should be investigated for brucellosis especially in endemic regions. To our knowledge, BEO patients may present with isolated testicular symptoms that make a diagnostic challenge.

Acute Thyroiditis Associated with Brucellosis: A Case Report

Brucella thyroiditis represents an extremely rare focal form of brucellosis. In this case report we describe a 55 years old male, diagnosed with brucellosis and peripheral arthritis with subsequent development of acute thyroiditis. The symptoms duration consistent with brucellosis started two weeks before establishing the diagnosis. Only a day after diagnosis and initiation of antibrucellar treatment, acute non-suppurative thyroiditis suddenly manifested. Thyroiditis was diagnosed with clinical inspection and confirmed by ultrasound investigation. With the appropriate antibrucellar treatment, complete cure of thyroid affection was reached in ten days and the patient remained well during the follow-up period of two and a half years. In conclusion, in brucellosis endemic regions brucellosis should be included in the diagnostic consideration in patients with acute non-suppurative thyroiditis. Early recognition and adequate treatment of brucella thyroiditis results in favorable outcome.

Economic and health burden of brucellosis in Kazakhstan

Brucellosis is a widespread zoonotic disease considered as an emerging and re-emerging disease with a resulting threat of public health and animal health. Official reports document an animal incidence in Kazakhstan of about 0.6% per year, and the country still registers high number of human cases annually . The main objective of this paper was to evaluate the distribution and economic impact of brucellosis in Kazakhstan. We analysed human disease incidence data obtained from the Government Sanitary & Epidemiological Service with the aim to estimate the burden of disease in terms of disability-adjusted life years (DALYs). We also estimated the economic impact in terms of monetary losses. Additionally, we mapped the geographical distribution of the disease throughout Kazakhstan. In total, 1,334 human cases of brucellosis were registered in 2015 in Kazakhstan that resulted in 713 DALYs. Around $21 million was spent on compensation for animals that had to be slaughtered due to brucellosis, and an additional $24 million was spent on testing animals. Animal brucellosis and human brucellosis occur throughout the whole country, some trends of which are reviewed in this paper. We estimated the burden of the disease and explored possible explanation for high human incidence rates. This paper is the first to estimate the human burden of disease and the economic costs in Kazakhstan. Both of these are substantial.

The influence of illness duration before diagnosis on clinical characteristics and outcome in human brucellosis

Our study assesses the influence of illness duration before establishing the diagnosis of brucellosis and initiating therapy on patients' main clinical characteristics and outcome in an endemic area. The medical files of 297 patients with brucellosis were retrospectively analysed. They were divided into four groups according to illness duration before initiating therapy: <10 days; 11-30 days; 31-90 days; and >90 days. There were significant differences in the occurrences of fever (P = 0.019), focal forms (P = 0.026), spondylitis (P = 0.034) and therapeutic failures (P = 0.006) between the groups. Duration of >30 days before treatment initiation is responsible for more serious clinical presentation and outcome, whereas illness duration of >90 days further worsens the clinical progression in human brucellosis.

Brucella Seroprevalence in a High-Risk Population in Greece: A Cross-Sectional Study

Introduction

Brucellosis is a zoonosis with high occupational risk. However, seroprevalence of Brucella antibodies among occupational groups is not known, since studies in endemic countries are rare.

Methods

A cross-sectional seroprevalence study was conducted among livestock farmers in an endemic region in Greece. A low-risk group of individuals that just moved in the region was used as controls. Rose Bengal, Wright standard tube agglutination (STA) tests, and specific IgG and IgM antibodies using ELISA were evaluated; differences and odds ratios were calculated. Results were compared with studies from other endemic regions.

Results

100 livestock farmers and family members and 34 first-year students were enrolled. Rose Bengal results were 18% positive versus 0% (p=0.007); Wright STAs for Brucella melitensis were 8% versus 2.9% (p=0.448) and for Brucella abortus they were 2% versus 2.9% (p=0.588). ELISA IgG was positive in 8% of farmers versus 2.9% of students (p=0.448). Parallel testing with Rose Bengal and ELISA IgG was positive in 3% versus 0% (p=0.571). No significant odds ratios were calculated for Wright STAs and ELISA IgG.

Conclusions

Healthy livestock farmers may present with positive Rose Bengal test but this translates to true seroprevalence in only a small proportion. Livestock farmers have no significant seroprevalence that may obscure diagnosis of acute brucellosis in clinical settings.

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.

Pediatric brucellosis. An update review for the new millennium

Brucellosis remains the most common bacterial zoonotic infection in many countries worldwide. Despite being long recognized and controllable, the disease still causes substantial morbidity, affecting especially the young population. The aim of this review is to provide insight to the epidemiology, etiology, clinical features, diagnosis, and management of childhood brucellosis.

Acute liver failure complication of brucellosis infection: a case report and review of the literature

Background

Brucellosis is one of the most widespread zoonoses worldwide. It can affect any organ system, particularly the gastrointestinal system, but there is no report of acute liver failure as a brucellosis complication.

Case presentation

We present a case of acute liver failure secondary to brucellosis infection. A 75-year-old Hispanic man presented to a University Hospital in Chía, Colombia, with a complaint of 15 days of fatigue, weakness, decreased appetite, epigastric abdominal pain, jaundice, and 10 kg weight loss. On examination in an emergency room, abdomen palpation was normal with hepatosplenomegaly and the results of a liver function test were elevated. The diagnosis of brucellosis was confirmed by epidemiological contact and positive Rose Bengal agglutination with negative enzyme-linked immunosorbent assay immunoglobulin M for Brucella. He was then treated with doxycycline plus trimethoprim/sulfamethoxazole, with a favorable clinical outcome.

Conclusions

The clinical presentation of brucellosis can be very imprecise because it can affect any organ system; however, there is no report of acute liver failure as a brucellosis complication. This is the first reported case in the Colombian literature of acute liver failure due to brucellosis. We found this case to be of interest because it could be taken into account for diagnosis in future appearances and we described adequate treatment and actions to be taken at presentation.

A single-tube approach for in vitro diagnostics using diatomaceous earth and optical sensor

Versatile, simple and efficient sample preparation is desirable for point-of-care testing of emerging diseases such as zoonoses, but current sample preparation assays are insensitive, labour-intensive and time-consuming and require multiple instruments. We developed a single-tube sample preparation approach involving direct pathogen enrichment and extraction from human specimens using diatomaceous earth (DE). Amine-modified DE was used to directly enrich a zoonotic pathogen, Brucella, in a large sample volume. Next, a complex of amine-modified DE and dimethyl suberimidate was used for nucleic acid extraction from the enriched pathogen. Using our single-tube approach, the pathogen can be enriched and extracted within 60min at a level of 1 colony formation unit (CFU) from a 1ml sample volume in the same tube. The performance of this approach is 10-100 times better than that of a commercial kit (102 to 103CFU/ml) but does not require a large centrifuge. Finally, we combined the single-tube approach with a bio-optical sensor for rapid and accurate zoonotic pathogen detection in human urine samples. Using the combination system, Brucella in human urine can be efficiently enriched (~ 8-fold) and the detection limit is enhanced by up to 100 times (1CFU/ml bacteria in urine) compared with the commercial kit. This combined system is fast and highly sensitive and thus represents a promising approach for disease diagnosis in the clinical setting.

Characteristics of liver function in brucellosis patients with liver injury: A retrospective evaluation of 254 cases

AIM

To summarize the characteristics of liver function in brucellosis patients with liver injury.

METHODS

The clinical and laboratory data of 254 brucellosis patients with liver injury treated at the First Hospital of Jilin University were retrospectively evaluated.

RESULTS

The age of the 254 patients ranged from 2 to 80 years. All of the patients were diagnosed according to the 2012 brucellosis guidelines. Among the 254 patients, the majority had an increase in alanine transaminase (ALT) and aspartate transaminase (AST) levels < 3 times, an increase in γ-glutamyl transferase > 3 times, slightly elevated alkaline phosphatase, and normal total bilirubin. The disease duration was shorter in the abnormal liver function group than in the normal liver function group, but the highest temperature was higher in the abnormal liver function group. All patients were treated according to the World Health Organization recommendations. The time to fever relief in the two groups had no significant difference, but white blood cells, C-reactive protein, and erythrocyte sedimentation rate were higher in patients with normal liver function than in those without. Of 31 patients with abnormal liver function who were followed, no treatment failure occurred, but five had relapse. In the 44 patients with normal liver function who were randomly followed, three had treatment failure and six had recurrence. There was no significant difference between the two groups in the recurrence rate (P = 0.764). Total bilirubin was higher in patients with viral hepatitis than in those without.

CONCLUSION

Brucella infection can cause varying degrees of liver dysfunction, and ALT or AST increase is usually not more than 3 times. Occasionally, patients may develop severe liver injury, but systemic inflammatory is slight. After a short period of treatment, liver function returns to normal in most cases. Liver injury is more severe in those also having viral hepatitis.

Epidemiological and Clinical Features of People with Malta Fever in Iran: A Systematic Review and Meta-Analysis

Objectives

Numerous studies have reported the epidemiological and clinical features of Malta fever incidence in Iran. Review and synthesis of the related literature through meta-analysis can provide an appropriate measurement for aforementioned indices. Therefore, the present study aimed to determine the epidemiological and clinical features of people with Malta fever in Iran.

Methods

The required documents were obtained through searching national and international databases. In each study, standard deviation of the indices was calculated using binomial distribution formulas. Finally, the heterogeneity index was determined between studies using Cochran (Q) and I² tests.

Results

Combining the results of 47 articles in the meta-analysis indicated that 57.6% (55.02–60.1%) and 42.3% (49.8–44.9%) of the patients were male and female, respectively. Most of the patients lived in rural areas; 68.4% (63.6–73.2%) compared to 31.4% (26.7–36.3%). In addition, 20.8% (17.4–24.2%) of the patients were ranchers and farmers, 16.9% (14.5–19.4%) were students, and 31.6% (27–36.2%) were housewives. Of the patients studies, 50.5% (35.6–65.2%) experienced contact with animals and 57.1% (46.4–67.9%) used unpasteurized dairy products. Fever, joint pain, and sweating were detected among 65.7% (53.7–77.8%) and 55.3% (44.4–66.2%), respectively.

Conclusion

The present study revealed that the frequency of male patients with brucellosis was considerably more than that of female patients. The number of patients with Malta fever in rural areas was significantly more than in urban areas. High-risk behavior, unprotected contact with animals, and using unpasteurized dairy products were among the most significant factors affecting Malta fever incidence in Iran. Fever, joint pain, and sweating were detected among most of the patients with Malta fever.

Testicular infection in brucellosis: Report of 34 cases

BACKGROUND/PURPOSE

To present clinical and laboratory features, treatment options, and outcome in patients with brucellar testicular infection and to compare them with analogous in brucellar patients without testicular involvement.

METHODS

Thirty four brucellar patients with testicular infection treated in two general hospitals in the Republic of Macedonia, during the period 1998-2009, were retrospectively analyzed. Their clinical and laboratory characteristics were compared with analogous in 364 male brucellar patients without testicular infection, who were treated at the same hospitals during the same time period.

RESULTS

Brucellar testicular infection was evident in 34 (8.5%) out of 398 male patients with brucellosis. The median age of the patients was 46.5 years. In all patients testicular involvement was presented as an acute form with a median duration of 5 days (range, 2-14 days) prior to diagnosis. Twenty-three of the patients had at least one other simultaneous focal infection. After starting with the treatment testicular infection lasted a median 10 days, range 7-21 days. Brucellar patients with testicular infection when compared with other brucellar patients more frequently manifested fever (97% vs. 61%), concomitant spondylitis (32% vs. 16%), and urinary system involvement (12% vs. 2%). Also, the relapse rate in patients with testicular involvement was significantly higher (24% vs. 9%).

CONCLUSION

In endemic regions brucellosis should be taken into consideration in any patient with testicular infection. Brucellar testicular involvement is usually characterized with a severe acute clinical presentation and a high percentage of relapses which entails the need of timely recognition and proper treatment duration of at least 60 days.

Clinical characteristics of human brucellosis in patients with various monoarticular involvements

The aim of the study was to determine the main demographic, epidemiological, clinical characteristics, and outcome in patients with various types of brucellar monoarticular involvement. Retrospectively, we analyzed medical histories of 331 patients with brucellar monoarticular involvement who were treated at the infectious diseases departments in Prilep, Shtip, and Veles, Republic of Macedonia, during the period 1990-2012. Their data were compared accordingly to the affected joint (sacroiliac, hip, knee, ankle, wrist, and shoulder).Patients with shoulder arthritis were significantly the oldest (mean ± standard deviation [SD] 46.0 ± 14.5 years) whereas sacroiliitis and hip arthritis were present predominantly in younger patients (mean ± SD 28.7 ± 14.1 and 28.3 ± 18.3 years, respectively) (p = 0.014). Shoulder arthritis duration was significantly the longest (mean ± SD 24.5 ± 12.4 days), and wrist arthritis duration was significantly the shortest (mean ± SD 4.1 ± 2.5 days) (p < 0.001), before establishing the diagnosis of brucellosis. With appropriate treatment, the need for restitution of the joint impairment was significantly longer when sacroiliitis and hip arthritis were present (mean ± SD 32.8 ± 23.0 and 24.6 ± 12.5 days, respectively) (p < 0.001). The relapses were noted in 14.5, 14, 16.5, 5.5, 6, and 5.5 % of the patients with sacroiliitis, hip-, shoulder-, knee-, ankle-. and wrist arthritis, respectively. In endemic areas, brucellosis should be included in the differential diagnostic consideration in patients with monoarticular involvement. Knee-, ankle-, and wrist arthritis seem to be more benign and with appropriate treatment result in short duration and satisfactory outcome. On the other hand, the involvement of sacroiliac, hip-, and shoulder joint deserves more serious approach due to longer arthritis duration and higher frequency of relapses.

Childhood brucellosis: Review of 317 cases

OBJECTIVE

To describe the main epidemiological, clinical, and laboratory features, treatment options and outcome in children with brucellosis.

METHODS

Retrospectively evaluated data were obtained from 317 pediatric patients with brucellosis that were treated at the University Clinic for Infectious Diseases and Febrile Conditions in Skopje, during the period from 1989 to 2011. The medical records and follow-up protocols were used for evaluation.

RESULTS

Childhood brucellosis composed 317 (18.7%) of 1691 patients with brucellosis. The patients were median 9 years old, ranging from 7 months to 14 years, and 201 (63.4%) were males. Family history was present in 197 (62.1%), and direct contact with animals occurred in 140 (44.2%) of the children. The dominant manifestations were fever in 248 (78.2%), joint pain in 228 (71.9%) and hepatomegaly in 216 (68.1%). Organ affection was present in 206 (65.0%) of the patients. One hundred and six (33.4%) of the patients were treated with combination composed of two, and 211 (66.6%) with three antimicrobial agents. Relapses were registered in 21 (6.6%), and therapeutic failures in 3 (0.9%) of the children.

CONCLUSIONS

In endemic regions childhood brucellosis represents a significant part of human cases. Wide spectrum of clinical manifestations, frequent affection of various organ systems and possibility of relapses show that brucellosis could be a serious disease in this age group. The presence of fever, joint pain, sweating, and affection of various systems in children from endemic regions should alert pediatricians for the possibility of brucellosis.

Lymphadenopathy and fever in a chef during a stay in Europe

This case illustrates a rare presentation (as lymphadenopathy and fever) of one of the most common zoonotic diseases worldwide--brucellosis--in a 22-year-old Brazilian male (a chef) who had recently returned to Brazil after having lived in and traveled around Europe for one year. The histopathology, clinical history, and response to treatment were all consistent with a diagnosis of brucellosis, which was confirmed by PCR in a urine sample. We also review some aspects of brucellosis, such as the clinical features, diagnosis, and management.

Retrospective and prospective perspectives on zoonotic brucellosis

Members of the genus Brucella are pathogenic bacteria exceedingly well adapted to their hosts. The bacterium is transmitted by direct contact within the same host species or accidentally to secondary hosts, such as humans. Human brucellosis is strongly linked to the management of domesticated animals and ingestion of their products. Since the domestication of ungulates and dogs in the Fertile Crescent and Asia in 12000 and 33000 ya, respectively, a steady supply of well adapted emergent Brucella pathogens causing zoonotic disease has been provided. Likewise, anthropogenic modification of wild life may have also impacted host susceptibility and Brucella selection. Domestication and human influence on wild life animals are not neutral phenomena. Consequently, Brucella organisms have followed their hosts’ fate and have been selected under conditions that favor high transmission rate. The “arm race” between Brucella and their preferred hosts has been driven by genetic adaptation of the bacterium confronted with the evolving immune defenses of the host. Management conditions, such as clustering, selection, culling, and vaccination of Brucella preferred hosts have profound influences in the outcome of brucellosis and in the selection of Brucella organisms. Countries that have controlled brucellosis systematically used reliable smooth live vaccines, consistent immunization protocols, adequate diagnostic tests, broad vaccination coverage and sustained removal of the infected animals. To ignore and misuse tools and strategies already available for the control of brucellosis may promote the emergence of new Brucella variants. The unrestricted use of low-efficacy vaccines may promote a “false sense of security” and works towards selection of Brucella with higher virulence and transmission potential.

Liver involvement in patients with brucellosis: results of the Marmara study

Brucellosis is a zoonotic disease that primarily affects the reticuloendothelial system. But, the extent of liver damage in due course of the disease is unclear. This study included 325 brucellosis patients with significant hepatobiliary involvement identified with microbiological analyses from 30 centers between 2000 and 2013. The patients with ≥5 times of the upper limit of normal for aminotransferases, total bilirubin level ≥2 mg/dl or local liver lesions were enrolled. Clinical hepatitis was detected in 284 patients (87.3 %) and cholestasis was detected in 215 (66.1 %) patients. Fatigue (91 %), fever (86 %), sweating (83 %), arthralgia (79 %), and lack of appetite (79 %) were the major symptoms. Laboratory tests showed anemia in 169 (52 %), thrombocytopenia in 117 (36 %), leukopenia in 81 (25 %), pancytopenia in 42 (13 %), and leukocytosis in 20 (6 %) patients. The most commonly used antibiotic combinations were doxycycline plus an aminoglycoside (n = 73), doxycycline plus rifampicin (n = 71), doxycycline plus rifampicin and an aminoglycoside (n = 27). The duration of ALT normalization differed significantly in three treatment groups (p < 0.001). The use of doxycycline and an aminoglycoside in clinical hepatitis showed better results compared to doxycycline and rifampicin or rifampicin, aminoglycoside, doxycycline regimens (p < 0.05). However, the length of hospital stay did not differ significantly between these three combinations (p > 0.05). During the follow-up, treatment failure occurred in four patients (1 %) and relapse was seen in three patients (0.9 %). Mortality was not observed. Hepatobiliary involvement in brucellosis has a benign course with suitable antibiotics and the use of doxycycline and an aminoglycoside regimen seems a better strategy in select patients.

Public Health Aspects of Human Brucellosis in the Republic of Macedonia

Background: The Republic of Macedonia is an endemic area where brucellosis is a dominant zoonosis with high morbidity and enormous economic loss.Aim: To determine the incidence rate, prevalence rate and development tendency of infected people with brucellosis in R. Macedonia in the period from 01.01.1999 to 31.12.2009, to register and analyse the epidemiological characteristics of the infected with brucellosis according to gender, age and regional distribution.Materials and methods: The data about the infected people with brucellosis were taken from the register of individual cases as well as monthly and annual reports for infectious diseases prepared by the Institute for Public Health of Republic of Macedonia.Results:  According to the survey the highest number of incidence of human brucellosis in R. Macedonia was found in 2008, 23.94/100,000 people, and the lowest number of infected people was in 2009, about 13.99/100,000 people. Human brucellosis has a decreasing tendency.Conclusion: Human brucellosis remains a public health problem in Republic of Macedonia.

Epidemiological, laboratory, diagnostic and public health aspects of human brucellosis in western Iran

OBJECTIVE

To determine brucellosis's epidemiologic, laboratory, diagnostic and public health features considering brucellosis is endemic in Azna County, western Iran.

METHODS

This descriptive cross-sectional study was investigated on 43 patients with brucellosis in Azna County. The subjects were the patients with symptoms correspondent with brucellosis and positive Wright and 2ME tests. A questionnaire about demographic, epidemiological and laboratory findings was filled in. Afterwards, patients were treated using usual antimicrobial drugs regimen. The collected data were analyzed by SPSS software version 16.

RESULTS

Forty-three subjects were found to be positive in laboratory tests. Incidence of Brucellosis was 59.31 per hundred thousand population. About 34.9% of patients were female and 65.1% male. Nearly 95.2 % of human cases were living in rural and 4.8 % in urban areas. Around 20.9% of patients had history of animal contact. The commonest transmission was unpasteurized dairy products (79.1%). The most contagious seasons were summer and spring (60.3%). The most common age group was 15-24 (27.9%), and about 60.5% of the patients were between 15-44 years old. Disease was more common among housewives (30.2%) and farmers (20.9%). The majority of the patients had Wright test titre=1:320 (54.1%) and 2ME test titre=1:160 (56.1%) in serological titration. Doxycycline with Rifampin was used for treatment of the greatest of patients (60.4%).

CONCLUSIONS

In order to control this zoonotic disease, close cooperation of health and veterinary organizations is necessary.