1 بسم الله الرحمن الرحيم Clinical Manifestations of Brucellosis Shahid Beheshti University of medical sciences April 2007 By: Hatami H. MD. MPH

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بسم الله الرحمن الرحيمبسم الله الرحمن الرحيمClinical Manifestations

of BrucellosisShahid Beheshti University of

medical sciences

April 2007

By: Hatami H. MD. MPH

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Clinical classificationClinical classification1) Subclinical illness1) Subclinical illness

2) Acute disease2) Acute disease

3) Subacute disease3) Subacute disease

4) Localized disease4) Localized disease

5) Relapsing disease5) Relapsing disease

6) Chronic disease6) Chronic disease

7) Brucellosis like reaction7) Brucellosis like reaction

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• ChildrenChildren in endemic areas in endemic areas frequently have subclinical frequently have subclinical illnessillness

• Subclinical cases outnumber Subclinical cases outnumber clinically evident cases of clinically evident cases of brucellosis, brucellosis, by 12 to 1by 12 to 1

1- Subclinical illness1- Subclinical illness

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• Incubation period : several weeks to Incubation period : several weeks to months (months (1-3 weeks1-3 weeks))

• May occur as a May occur as a mild, transientmild, transient illness illness or as an or as an explosive, toxicexplosive, toxic disease disease

• 50% of patients have an 50% of patients have an abruptabrupt onsetonset

• Symptoms are Symptoms are proteanprotean and and nonspecificnonspecific

2&3- Acute & subacute2&3- Acute & subacute

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Over 90% of patients experience :Over 90% of patients experience :

• MalaiseMalaise

• ChillsChills

• SweatsSweats

• FatigueFatigue

• WeaknessWeakness

• FeverFever


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More than 50% of patients have :More than 50% of patients have :

• MyalgiaMyalgia

• AnorexiaAnorexia

• Weight lossWeight loss


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Fewer patients complain of :Fewer patients complain of :

• ArthralgiaArthralgia

• CoughCough

• Testicular painTesticular pain

• DysuriaDysuria

• Ocular painOcular pain

• Visual blurringVisual blurring


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• HeadacheHeadache, occipital or frontal, occipital or frontal

• Intense Intense back painback pain

• Pain in the Pain in the armsarms and and legslegs

• SweatsSweats, typically drenching, typically drenching

• Shaking chillsShaking chills, before or after , before or after sweatssweats

• Extreme Extreme prostrationprostration


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• LassitudeLassitude is a prominent symptom is a prominent symptom

• Chest painChest pain worse on breathing worse on breathing

• PalpitationPalpitation due to an arrhythmia due to an arrhythmia

• Abdominal painAbdominal pain with constipation with constipation


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• ConfusionConfusion with with nightmaresnightmares and and somnambulismsomnambulism

• Symptoms especially lassitude, may Symptoms especially lassitude, may persist for many weeks or monthspersist for many weeks or months

• ConvalescenceConvalescence may be slow may be slow


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• FeverFever often grater than 39-40ºc often grater than 39-40ºc occurs in 95%occurs in 95%

• UndulatingUndulating or or intermittentintermittent fever fever pattern is unusualpattern is unusual

• A relative A relative pulse-temperature pulse-temperature deficitdeficit may occur may occur


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• SplenomegalySplenomegaly (10-75%) (10-75%)

• LymphadenopathyLymphadenopathy (14%) (14%)

• Axillary, cervical, and Axillary, cervical, and supraclavicular locations are most supraclavicular locations are most frequentfrequent

• HepatomegalyHepatomegaly is less frequent is less frequent


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Symptoms of acute brucellosis in Symptoms of acute brucellosis in patients admitted in Loghman hospitalpatients admitted in Loghman hospital

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Laboratory changesLaboratory changes• Serologic responseSerologic response

• Mild anemiaMild anemia

• LymphopeniaLymphopenia

• LymphocytosisLymphocytosis

• ThrombocytopeniaThrombocytopenia

• PancytopeniaPancytopenia


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• May localize in almost May localize in almost any organany organ

• Most common in Most common in bonebone, CNS, , CNS, heartheart, , spleenspleen, , testestestes, , liverliver, , gallbladdergallbladder, , kidneykidney, , prostateprostate . . . . . .

• May occur simultaneously at multiple May occur simultaneously at multiple sitessites

• Most often appear in association with a Most often appear in association with a more chronic course of illnessmore chronic course of illness

4- Localized disease4- Localized disease

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• Up to Up to 10%,10%, after antimicrobial therapy after antimicrobial therapy

• Due to Due to intracellularintracellular location location

• Occur most frequently Occur most frequently within monthswithin months after initial infectionafter initial infection

5- Relapsing disease5- Relapsing disease

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• May occur as long as May occur as long as 2 years after2 years after apparently successful treatmentapparently successful treatment

• It is sometimes It is sometimes precipitatedprecipitated by another by another infection or by traumainfection or by trauma

• Both relapses and re-infections tend to Both relapses and re-infections tend to be be mildermilder than the initial episode than the initial episode

5- Relapsing disease5- Relapsing disease

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May be manifested as :May be manifested as :• An insidious onsetAn insidious onset

• Recurrent relapsesRecurrent relapses

• Localized diseaseLocalized disease

• Persistent illnessPersistent illness

6- Chronic brucellosis6- Chronic brucellosis

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• A duration grater than 1 yearA duration grater than 1 year

• May caused by May caused by inadequate treatmentinadequate treatment

• Symptoms are Symptoms are not associatednot associated with with clinical, microbiologic and serologic clinical, microbiologic and serologic evidence of active diseaseevidence of active disease


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• Persistent Persistent fatiguefatigue

• MalaiseMalaise and and insomniainsomnia

• Recurrent Recurrent depressiondepression

• Vague Vague painpain & inertia & inertia

• Sexual Sexual impotenceimpotence


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• The onsetThe onset may be : may be :

- Insidious- Insidious

- Follows an acute attack- Follows an acute attack

• It may be due to It may be due to untreateduntreated or or inadequatelyinadequately treated disease treated disease

• Story of recurring flu with Story of recurring flu with lassitude, headache, pain, sweatslassitude, headache, pain, sweats


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• Frontal or retroorbital Frontal or retroorbital headacheheadache

• Low back Low back painpain is common, and is common, and unassociatedunassociated with radiological with radiological evidence of spondylitisevidence of spondylitis


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• Limb pain or stiffness is more often Limb pain or stiffness is more often muscularmuscular than articular than articular

• SweatsSweats occur especially on effort occur especially on effort and also at nightand also at night

• TemperatureTemperature is usually normal is usually normal


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• Recurrent Recurrent exposureexposure to brucellae in to brucellae in seropositiveseropositive persons may cause persons may cause hypersensitivityhypersensitivity reactions reactions

• These reactions can mimic These reactions can mimic brucellosis and manifested with brucellosis and manifested with chillschills and fever within minutes to and fever within minutes to hours and last 24-48 hourshours and last 24-48 hours

7- Brucellosis like reaction7- Brucellosis like reaction

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• Patients with chronic brucellosis may Patients with chronic brucellosis may also be hypersensitive to brucella also be hypersensitive to brucella antigen.antigen.

• Persons hypersensitive to brucellar Persons hypersensitive to brucellar antigen need not be suffering from antigen need not be suffering from chronic brucellosischronic brucellosis

• Distinction must be made between Distinction must be made between chronic brucellosis and chronic brucellosis and hypersensitivityhypersensitivity

7- Brucellosis like reaction7- Brucellosis like reaction

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• Br. AbortusBr. Abortus infection are much milder infection are much milder and run a shorter courseand run a shorter course

• Br. MelitensisBr. Melitensis infection may be very infection may be very persistent, lasting over one year or persistent, lasting over one year or moremore

• Br. SuisBr. Suis causes suppurating causes suppurating complications and a chroniccomplications and a chronic

state of debility state of debility

Clinical differencesClinical differences

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تم�اس پوس�ت ي�ا ملتحم�ه ب�ا واكس�ن تم�اس پوس�ت ي�ا ملتحم�ه ب�ا واكس�ن 1919زن�ده ض�عيف ش�ده ح�اوي س�ويه زن�ده ض�عيف ش�ده ح�اوي س�ويه

بروس��ال در ارتب��اط ب��ا واكنش ه��اي بروس��ال در ارتب��اط ب��ا واكنش ه��اي مختلفي در ميزب��ان ب��وده اس��ت مختلفي در ميزب��ان ب��وده اس��ت بط��وري ك��ه بعض��ي از تم��اس بط��وري ك��ه بعض��ي از تم��اس يافتگ��ان، دچ��ار هيچ گون��ه ن��اراحتي يافتگ��ان، دچ��ار هيچ گون��ه ن��اراحتي موض�عي ي�ا سيس�تميكي نش�ده ان�د موض�عي ي�ا سيس�تميكي نش�ده ان�د ولي س��اير تم��اس يافتگ��ان، بنح��و ولي س��اير تم��اس يافتگ��ان، بنح��و ش�ايعي دچ�ار واكنش موض�عي ف�وري ش�ايعي دچ�ار واكنش موض�عي ف�وري ي��ا بيم��اري سيس��تميك ش��بيه ب��ه ي��ا بيم��اري سيس��تميك ش��بيه ب��ه عف�ونت ناش�ي از س�ويه ه�اي ط�بيعي عف�ونت ناش�ي از س�ويه ه�اي ط�بيعي

بروسال آبورتوس، گرديده اند.بروسال آبورتوس، گرديده اند.

بروسلوز ناشى از تلقيح بروسلوز ناشى از تلقيح واكسن حيوانىواكسن حيوانى

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واكنش ه�اي موض�عي، ب�ه نح�و ش�ايعي واكنش ه�اي موض�عي، ب�ه نح�و ش�ايعي در اف�ردي ظ�اهر ميش�ود ك�ه س�ابقه در اف�ردي ظ�اهر ميش�ود ك�ه س�ابقه ب�اليني ابتالء ب�ه بروس�لوز ي�ا ش�واهد ب�اليني ابتالء ب�ه بروس�لوز ي�ا ش�واهد س��رولوژيك دال ب��ر ابتالء قبلي ب��ه س��رولوژيك دال ب��ر ابتالء قبلي ب��ه اين بيم�اري ي�ا س�ابقه تم�اس قبلي اين بيم�اري ي�ا س�ابقه تم�اس قبلي

1919ب�ا واكس�ن س�اخته ش�ده از س�ويه ب�ا واكس�ن س�اخته ش�ده از س�ويه را ذكر ميكنند.را ذكر ميكنند.

بروسلوز ناشى از تلقيح بروسلوز ناشى از تلقيح واكسن حيوانىواكسن حيوانى

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1 بسم الله الرحمن الرحيم Clinical Manifestations of Brucellosis Shahid Beheshti University of medical sciences April 2007 By: Hatami H. MD. MPH