Brucellosis Clinical Findings and Treatment
The optimal treatment for brucellosis is a six-week regimen of doxycycline (100 mg twice daily) combined with either streptomycin (15 mg/kg daily) for 2-3 weeks or rifampicin (600-900 mg daily) for six weeks, with the doxycycline-streptomycin combination showing superior efficacy. 1, 2, 3
Clinical Manifestations
- Fever with temperature swings is the hallmark symptom, often accompanied by profuse sweating, especially at night 3
- Headaches are frequently reported and can be severe 3
- Systemic symptoms affecting multiple organs and tissues are common 4
- The clinical presentation is highly variable and nonspecific, making laboratory confirmation essential 5
Diagnosis
- Diagnosis can be made through multiple methods:
- Blood cultures (gold standard) - modern automated systems can detect acute cases within 5-7 days 5
- Serological tests - though they lack specificity, they remain a diagnostic cornerstone in resource-poor countries 5
- Nucleic acid amplification assays (PCR) - combine high sensitivity and specificity but may remain positive long after clinical recovery 5
Complications
- Musculoskeletal involvement is the most common complication 4
- Neurobrucellosis can cause meningitis and other neurological complications 3
- Endocarditis is a rare but potentially fatal complication with high mortality 3, 4
- Epididymo-orchitis occurs in a small percentage of cases 6
- Brucellar spondylitis (spinal involvement) may require extended treatment beyond the standard 6 weeks 2, 3
First-Line Treatment Options
Doxycycline-Streptomycin combination:
Doxycycline-Rifampicin combination:
Doxycycline-Gentamicin combination:
Second-Line Treatment Options
- Trimethoprim-Sulfamethoxazole (TMP-SMX): 800+160 mg twice daily for 6 weeks 1
- Quinolone-containing regimens (ofloxacin or ciprofloxacin) should be reserved as second or third agents 1
- For brucellosis in pregnancy, TMP-SMX alone or in combination with rifampicin is recommended 3
Treatment for Complicated Brucellosis
- For brucellar spondylitis, aminoglycoside-containing regimens may be superior to rifampicin-containing ones 2, 3
- Treatment duration may need to be extended beyond the standard 6 weeks for focal disease 2, 3
- Brucellar endocarditis requires aggressive management with empirical antimicrobials and often surgical intervention 2, 3
Treatment Monitoring and Outcomes
- Relapse rates range from 5-15% even with appropriate treatment 1, 2
- Relapses are usually mild and can be treated with the same regimens 1, 2
- Total treatment duration is typically 6 weeks for uncomplicated cases 1, 2
Public Health Considerations
- In regions where brucellosis and tuberculosis coexist, consider the implications of using rifampicin, as this may contribute to mycobacterial resistance 1, 2
- Avoid consumption of unpasteurized dairy products 3, 6
- Use appropriate personal protective equipment when handling potentially infected animals 3
- Follow proper laboratory safety protocols when handling Brucella specimens 3
Special Considerations
- For patients over 60 years of age, reduced dosage of streptomycin should be used due to increased risk of toxicity 7
- Brucella is highly contagious and can enter through mucous membranes such as the conjunctiva, oropharynx, respiratory tract and skin abrasions 8
- As few as 10-100 organisms are sufficient to constitute an infectious aerosol dose for humans 8