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 ~  Abstract
 ~ Introduction
 ~  Materials and Me...
 ~ Results
 ~ Discussion
 ~ Conclusion
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  Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 34  |  Issue : 4  |  Page : 427-432
 

Trend of human brucellosis over a decade at tertiary care centre in North Karnataka


Department of Microbiology, SDM College of Medical Sciences and Hospital, Dharwad, Karnataka, India

Date of Submission08-Jul-2016
Date of Acceptance14-Oct-2016
Date of Web Publication8-Dec-2016

Correspondence Address:
R D Kulkarni
Department of Microbiology, SDM College of Medical Sciences and Hospital, Dharwad, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0255-0857.195372

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 ~ Abstract 

Background: Brucellosis is an important zoonotic disease. India having a major agrarian population is expected to have a higher prevalence. However, due to lack of laboratory facility or awareness among clinicians, the disease is largely underreported. The aim of this study was to know the prevalence and trend of human brucellosis over a decade, in patients attending a teaching hospital in North Karnataka, and to understand their geographical distribution. Materials and Methods: The study was conducted from January 2006 to December 2015 at a tertiary care teaching hospital in North Karnataka. A total of 3610 serum samples were evaluated from suspected cases of brucellosis. All serum samples were initially screened by Rose Bengal plate test, and positive samples were further analysed by Serum agglutination test (SAT) using standard Brucella abortus antigen from Indian Veterinary Research Institute, Izatnagar, Uttar Pradesh, India. A titre above or equal to 1:80 IU/ml was considered as positive. Demographic data such as age, sex and native place of these patients were also analysed. Results: We observed that human brucellosis is present in North Karnataka. The overall seropositivity of brucellosis in suspected cases was 5.1%. The positive titres ranged from 1:80 to 163,840 IU/ml. The majority of the patients were from Gadag, Koppal and Haveri districts of North Karnataka. Conclusion: Our study confirms the presence of human brucellosis in the northern part of Karnataka. Further studies to understand the prevalence of animal brucellosis in these areas will help in implementing prevention measures.


Keywords: Brucella, epididymo-orchitis, Karnataka, neurobrucellosis


How to cite this article:
Patil D P, Ajantha G S, Shubhada C, Jain P A, Kalabhavi A, Shetty P C, Hosamani M, Appannanavar S, Kulkarni R D. Trend of human brucellosis over a decade at tertiary care centre in North Karnataka. Indian J Med Microbiol 2016;34:427-32

How to cite this URL:
Patil D P, Ajantha G S, Shubhada C, Jain P A, Kalabhavi A, Shetty P C, Hosamani M, Appannanavar S, Kulkarni R D. Trend of human brucellosis over a decade at tertiary care centre in North Karnataka. Indian J Med Microbiol [serial online] 2016 [cited 2017 Jan 18];34:427-32. Available from: http://www.ijmm.org/text.asp?2016/34/4/427/195372



 ~ Introduction Top


Human brucellosis is a major bacterial zoonosis reported worldwide. It is caused by bacteria belonging to genus Brucella, which are Gram-negative, nonspore forming and nonencapsulated coccobacilli. More than 500,000 new cases are reported globally every year, and the annual incidence varies from <2 to 500/1,000,000 populations in different geographical regions.[1]

The cause of this disease was obscure until 1887 when Sir David Bruce – a Scottish physician reported numerous small coccal organisms in stained sections of spleen from fatally infected British soldiers stationed at Malta. He isolated and identified the pathogen and called it Micrococcus melitensis.[2]

Brucellosis remains a major debilitating illness, causing severe human disease and high economic losses. It is more prevalent in western parts of Asia, India, Middle Eastern, Southern European and Latin American countries.[3],[4] Brucellosis is a significant and increasing veterinary and public health problem in India. In India, 80% of the population lives in approximately 575,000 villages and thousands of small towns; having close contact with domestic/wild animal population owing to their occupation.[3] Hence, the human population stands at a greater risk of acquiring zoonotic diseases including brucellosis. Although this zoonotic infection has been presumed to be endemic to North Karnataka, it has been reported from only two centres, namely, Belgaum and Bijapur, consistently.[4]

A human being can be infected with brucellosis through various routes, for example, consumption of unboiled or pasteurised milk or contaminated dairy products, microbial inoculation through cuts or abrasions in the skin surface, conjunctival inoculation, inhalation of infectious aerosols, accidental human contact with infected animals and consumption of contaminated meat.[5]

Human brucellosis is often misdiagnosed or underdiagnosed due to overlapping clinical manifestations with many bacterial infections. Undulant fever, weight loss and night sweats are the major symptoms of brucellosis in humans. It is one of the causes of fever of prolonged duration in endemic areas and one of the important causes of pyrexia of unknown origin (PUO).[6],[7] The other common clinical symptoms include weakness, scrotal swelling and pain, lethargy, chills, decreased appetite, arthralgia, myalgia, weight loss, headache, back pain and psychological symptoms.[8]

In animals, the pathogen can cause abortion, infertility, retention of placenta, birth of weak and dead calves and reduced milk yield.[9] Because of the commonality of signs and symptoms with many other infections, laboratory confirmation of suspected case is essential. The laboratory confirmation of human brucellosis is based on bacteriological, serological or molecular methods, each having its own advantages and disadvantages. Although culture remains the gold standard, suggestive clinical picture with positive serology is accepted as a case of brucellosis, especially in the Brucella endemic regions.[10],[11]

Accurate diagnosis of brucellosis is the key to control the spread of this disease. Many serological tests such as Rose Bengal plate test (RBPT), complement fixation test, Coombs test, ELISA and serum agglutination test (SAT) are described for the diagnosis of brucellosis.[12],[13],[14] The molecular diagnosis of human brucellosis can be performed using genus-specific polymerase chain reaction (PCR) assays.[15] Due to the adequate sensitivity, ease of performance, dependability and lower cost, serological tests such as SAT, RBPT and ELISA have high value to screen sera from suspected cases.[16]

The aim of this study was to know the prevalence and trend of human brucellosis over a decade, in patients attending a teaching hospital in North Karnataka, and to understand the distribution of this infection in this region.


 ~ Materials and Methods Top


The study was conducted from January 2006 to December 2015 at a tertiary care teaching hospital in North Karnataka. A total of 3610 serum samples were evaluated from suspected brucellosis cases.

Serum samples were subjected to RBPT according to the manufacturer's guidelines. Formation of agglutinate within 4 min with antigen was recorded as a positive reaction [Figure 1].
Figure 1: Rose Bengal plate test

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All samples showing agglutination were further tested by standard agglutination test (SAT).[17] Standard Brucella abortus plain antigen (phenol killed B. abortus S99) was procured from Indian Veterinary Research Institute (IVRI), Izatnagar, India. The highest serum dilution, at which 50% agglutination was observed, was marked as the end-point for titre. A titre of ≥1:80 IU/ml was considered as positive, as studies or reports on endemic titre for Brucella antibodies are not available from this area. Demographic data such as age, sex and native place of these patients were recorded.

During the study period, we received 23,689 blood samples for culture, of which 43 samples yielded Brucella spp. (BacT/ALERT, bioMerieux India Pvt. Ltd., Delhi). One isolate was recovered from a case of the testicular abscess. We handle all the blood cultures always in biosafety cabinet Class II A2. Moist, tiny, grey colonies showing nonmotile, oxidase and rapid urease positive, acid fast by modified cold Ziehl–Neelsen stain were presumptively identified as Brucella spp.[4],[18] All the suspected Brucella isolates were sent to IVRI, Izatnagar, and all were confirmed as Brucella melitensis, except a few isolates that were lost due to contamination. The isolate from testicular abscess was confirmed by PCR. B. melitensis isolation from the testicular fluid is not uncommon.[4]


 ~ Results Top


Of the 3610 serum samples tested, 189 (5.2%) were positive for brucellosis by SAT. The median age of samples tested positive was 31 years. The male to female ratio was 7:3 (males, 137 and females, 52). The titres ranged from 1:80 to 163,840 IU/ml.

During the same study period, we received a total of 23,689 blood samples for culture and sensitivity. Samples were processed in BacT/ALERT three-dimensional automated blood culture system (bioMerieux India Ltd.). We recovered Brucella from 44 cases and two isolates from testicular abscess. All the isolates were confirmed as B. melitensis by IVRI, Izatnagar, India.

Geographical distribution

Brucellosis has been reported from Dharwad, Belgaum and Bijapur districts. For the first time, we are reporting cases from Gadag, Haveri and Koppal districts with the positivity rate of 21.1% from Gadag (40/189), 17.4% from Koppal (33/189) and 18.5% from Haveri districts (35/189).


 ~ Discussion Top


Human brucellosis is found to have a significant presence in rural/nomadic communities where people live in close association with animals. India is principally an agrarian country. The farming here is not mechanised, and animals are the integral part of agricultural needs such as plowing. Animal husbandry is the second largest occupation in rural India. Brucellosis is acquired by contact with secretions of infected animals or animal products.[19] Although brucellosis is known to be here for a long time, geographically relevant data are sparse. Brucellosis would probably be found wherever it will be looked for in India. Thus, the majority of the rural Indian population is at an increased risk of acquiring this zoonotic infection. It is shown in Malta and other developed countries that careful monitoring of dairy industry and animal screening programme to remove infected animals will eliminate brucellosis.[10]

Worldwide incidence of human brucellosis in endemic areas varies widely from <0.01 to >200/100,000 population.[20] The true incidence of human brucellosis, however, is unknown for most countries including India. It has been estimated that the true incidence may be 25 times higher than the reported incidence due to misdiagnosis and underreporting.[2] Studies carried out in different parts of the world have demonstrated the seroprevalence of Brucella from 1.8% in Ecuador to 11.1% Mongolia.[21],[22],[23],[24] Reports from our neighbouring countries also show the presence of this condition, for example, Bangladesh; from 2.5% to 18.6% and Pakistan, in occupationally relevant groups as 6.9%.[14],[25]

A search given on PubMed (http://www.ncbi.nlm.nih.gov/pubmed) on 9th May, 2016, with keywords 'Brucellosis India' gave 251 hits. The early reports on brucellosis in India came from North India.[26],[27] The prevalence of brucellosis has been widely reported in different states of India such as Punjab, Orissa, Andhra Pradesh, Rajasthan, Maharashtra, Gujarat, Uttar Pradesh and Goa.[4],[28],[29],[30],[31],[32]

The results of this retrospective study carried over 10 years showed the presence of human brucellosis in districts of North Karnataka, so far underreported [Figure 2]. The seropositivity of brucellosis in suspected cases was found to be 5.1% [Table 1]. Agasthya et al. (2012) used RBPT, SAT and Indirect ELISA to evaluate serum samples from high-risk individuals in Karnataka and found 19.69% samples positive by indirect ELISA.[33] Similarly, Mangalgi et al. observed 4.79%, 4.41% and 4.41% seroprevalence among PUO cases by RBPT, SAT and 2-mercaptoethanol (2-ME), respectively, in Bijapur. Another cross-sectional study by this group in 2015 showed overall positivity rates by RBPT, SAT and 2-ME test as 10.50%, 7.32% and 5.88%, respectively.[34],[35]
Figure 2: North Karnataka districts showing brucellosis. Districts in green: Belgaum and Bijapur already reported to have brucellosis. Districts in red: Dharwad, Gadag, Haveri and Koppal found to have brucellosis

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Table 1: Seropositivity and sex distribution

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All the 189 samples could not be tested for other serological parameters, as the other tests were performed, only when ordered by the clinicians. Of the 189 Brucella positive samples, forty were tested for other serological parameters. The Widal test was most commonly ordered test with Brucella. Thirty-five samples were tested for Widal, of which nine were positive. The other tests ordered were for malaria (19), dengue (15), Weil–Felix (15) and leptospirosis (3). From these tests, only two samples were positive; one for malaria and the other for Weil–Felix test. Thus, of the 189 samples tested, 11 were also positive for additional serological parameters.

Testing for Brucella infections started in this institute in the year 2006. It needs a mention that tests for brucellosis were initiated by the Department of Microbiology rather than receiving requests from the Clinical Departments. Initially, clinicians of this area used to consider the diagnosis of Brucella a rare possibility. Dharwad district was yet ignored for the presence of brucellosis. In the year 2006, only forty samples were received to rule out brucellosis, and eight of them turned positive. This provided evidence for the presence of brucellosis here, and awareness among clinicians about this infection was kindled. Year after year, the number of samples from suspected cases of brucellosis continued to rise [Table 2]. Dharwad as well as the neighbouring districts - Koppal, Haveri and Gadag were not bold on the Brucella map of Karnataka. Since our institute is a premier tertiary care centre in North Karnataka, we cater to these neighbouring districts also. Our experience over last 10 years has revealed the presence of human brucellosis in these three neighbouring districts with Dharwad and helped sensitise the clinicians from these districts about the presence of brucellosis. The animal husbandry and agricultural practices of all the North Karnataka are alike. Therefore, it is important for the laboratories from other neighbouring districts such as Bellary, Raichur, Gulbarga, Bidar and Karwar to take an initiative to provide evidence for the presence of infections in these areas to sensitise the clinical fraternity.
Table 2: Year-wise distribution of cases

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The median age of the patients with brucellosis in this study was 31 years and males outnumbered females [Table 1]. Although brucellosis affects all age groups,[36] in this study, young adults were most commonly found to be affected. A similar observation has been made by other workers. The youngest case was 3 years old and the eldest was 75 years old.[37],[38]

The affliction of various organs by Brucella infection is known. Clinical manifestations and severity of symptoms may vary depending on geographic areas with respect to pathogenic species of Brucella and the host.[39] All 189 Brucella-positive cases at this institute presented with a history of fever, followed by fever with chills and rigors, low backache and scrotal pain and swelling [Table 3]. Night sweats are said to be a characteristic feature of brucellosis, however, during the present study, only one case presented with complaints of night sweats.[2] The overall clinical picture of brucellosis in our study is very similar to that reported by other studies.[2],[4],[40]
Table 3: Clinical presentation and complications

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The clinical features in human brucellosis are protean and therefore, a number of infectious and noninfectious diseases may mimic brucellosis clinically.[2]

The most common localised complication of brucellosis is a joint infection which may affect large- or medium-sized peripheral joints, sacroiliac joints or spine.[33],[40]

Patients presenting with lower backache in our study were diagnosed with one or other orthopaedic complications such as spondylitis, synovitis and arthritis. All the positive cases diagnosed as chronic brucellosis with epididymo-orchitis complained of scrotal pain or swelling.

[Table 3] shows the complications observed in all the seropositive cases.

Two cases were clinically diagnosed as neurobrucellosis. One case presented with a history of fever and altered sensorium since 5 days, and the other case presented with acute onset of schizophrenia without any history of psychiatric illness or family history of schizophrenia. In both the cases, Brucella antibodies in blood as well as in cerebrospinal fluid (CSF) were seen in high titres. From both the cases, CSF could not be obtained for culture. The case presenting with acute schizophrenia yielded B. melitensis from the blood. Neurobrucellosis is a known complication of this infection. Selective nerve palsies, responding favourably to anti-Brucella treatment, have been observed (personal communication, Dr. B.V. Peerapur). It may present as meningitis, meningoencephalitis or encephalitis.[4] However, acute schizophrenia apparently related to Brucella infection has never been reported.

Of the 189 diagnosed cases, 140 cases received antibiotic treatment with doxycycline 1 g twice a day and rifampicin 600 mg daily for 6 weeks. All 189 cases were discharged as improved. A limitation of this study was incomplete information about the contact of the cases with animals. We also did not perform sensitivity testing for the isolates. The need for an enquiry from clinicians and hearty liaison between the clinicians and microbiologists cannot be overemphasised even in endemic areas to diagnose human brucellosis accurately.[2],[4],[39]


 ~ Conclusion Top


Our experience over 10 years suggests that brucellosis is present in Dharwad and neighbouring districts of North Karnataka, i.e., Gadag, Koppal and Haveri. For an occupational condition such as brucellosis, knowledge of risk factors among farmers and general population is vital in control and prevention programmes. Adequate epidemiologically relevant information such as animal contact from patients must be gathered which will be helpful for the control of this public health problem. Accurate diagnosis followed by recommended anti-Brucella therapy is curative.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 ~ References Top

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    Figures

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    Tables

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