human to human transmission of brucella...

Human to humantransmission of Brucella

melitensisPATRICE VIGE ANT MD FRCPC, JACK MEN DEL SON MD MS FRCPC, MARK A MIL LER MD MSc FRCPC

B RUCEL LO SIS CAN BE TRANS MIT TED FROM ANI MALS TO HU -mans in many ways: in ges tion of in fected meat or un -

pas teur ized dairy prod ucts; di rect con tact of bro ken skin ormu cous mem brane with in fected ani mal tis sues; and in ha la -tion of in fec tious aero sols. Ex cept for pos si ble cases of trans -mis sion af ter blood trans fu sion, par enteral drug use and bone mar row trans plant (1), brucel lo sis is still con sid ered not to betrans mis si ble from per son to per son via close con tact (2).How ever, a few cases of Brucella me lit en sis in fec tion inspouses of pa tients with se ro logi cally or culture- proven

brucel lo sis have been re ported in the past dec ade (3-6). Wede scribe a well docu mented case of trans mis sion of B me lit -en sis bio type 3 to a spouse, which adds to the grow ing evi -dence of in ter hu man trans mis si bil ity of this in fec tion.

CASE PRES EN TA TIONA 49- year- old mar ried man was ad mit ted to hos pi tal in May

1991 with a four- week his tory of fe ver to 40°C, chills and nightsweats. He also no ticed a dry cough, some non spe cific lower

CASE RE PORT

Department of Microbiology, SMBD-Jewish General Hospital, McGill University, Montreal, QuebecCorresondence and reprints: Dr Jack Mendelson, Department of Microbiology, SMBD-Jewish General Hospital, McGill University, 3755

Côte Ste-Catherine Road, Montreal, Quebec H3T 1E2. Telephone (514) 340-8294, Fax (514) 340-7546Received for publication September 8, 1994. Accepted January 30, 1995

P VIGE ANT, J MEN DEL SON, M MIL LER. Hu man to hu man trans mis sion of Brucella me lit en sis. Can J In fect Dis1995;6(3):153- 155. Hu man brucel lo sis is ac quired mainly through con tact with in fected ani mal tis sues, in ges tion of un -pas teur ized dairy prod ucts or in fected aero sols. Per son to per son trans mis sion is still con sid ered un cer tain. The case of a woman di ag nosed with proven brucel lo sis af ter her hus band suf fered a re lapse of bac tere mia with Brucella me lit en sisbio type 3, which was origi nally ac quired abroad by eat ing goat cheese, is de scribed. It was pos tu lated that per son toper son spread of brucel lo sis is a likely mode of trans mis sion in this case.

Key Words: Brucella me lit en sis, Brucel lo sis

Transmission interhumaine de Brucella melitensisRÉS UMÉ : La brucel lose hu maine s’ac quiert prin ci pa le ment lors d’un con tact avec des tis sus ani maux con tami nés, par l’in ges tion de pro duits laitiers non pas teur isés ou par des aé ro sols in fectés. La trans mis sion d’une per sonne à l’autreest en core jugée douteuse. Le cas d’une femme chez qui une brucel lose a été di ag nos tiquée après que son mari aitsubi une re chute de bacté riémie à Brucella me lit en sis de bio type 3 qu’il avait origi nel le ment ac quise à l’étranger, lorsd’une in ges tion de fromage de chèvre est dé crit ici. Il a été pos tulé que la propa ga tion en tre hu mains de la brucel loseétait un mode de trans mis sion en vis age able dans ce cas.

CAN J INFECT DIS VOL 6 NO 3 MAY/JUNE 1995 153

ab domi nal dis com fort and weight loss of 3 kg. These symp -toms de vel oped two weeks af ter his re turn from Ger many and Syria. The pa ti ent’s last meal in Syria in cluded un pas teur izedgoat cheese. The physi cal ex ami na tion was nor mal, with atem pera ture of 36.9°C, ex cept for rhon chi over the left lung.The labo ra tory re sults re vealed a to tal leu ko cyte count of6.3x109/L with 46% neu tro phils and 48% lym pho cytes, nor -mal elec tro lytes and cre ati nine, and mildly ele vated liver en -zymes (as par tate ami no trans fe rase 53 U/L, al anineami no trans fe rase 53 U/L, lac tate de hy dro ge nase 465 U/L),with nor mal bili ru bin. The uri naly sis was nor mal, urine cul turewas nega tive and the chest x- ray showed atelec ta sis at theright base. An ab domi nal ul tra sound dem on strated sple no -megaly. Af ter three days of in cu ba tion, the two sets of bloodcul tures that were drawn three days be fore ad mis sion, cul -tured in NR 6 and NR 7 blood cul ture bot tles and read in thenon ra dio met ric BAC TEC 640 ap pa ra tus (Bec ton Dick in son)re vealed Gram- negative coc co ba cilli. The pa tient was ini tiallytreated with cef tri ax one. In view of per sis tent daily fe ver(maxi mum 39.7°C) and the pos si bil ity of brucel lo sis, ri fampin450 mg bid and doxycy cline 100 mg bid by mouth were added af ter two days of par enteral cef tri ax one. Two days later, thepa ti ent’s tem pera ture re turned to nor mal and he was dis -charged from the hos pi tal on the same oral medi ca tion only.The blood iso lates were sub se quently iden ti fied as B me lit en -sis bio type 3 by the pro vin cial pub lic health labo ra tory.

The pa tient com pleted one month of treat ment and wasas ymp to matic for seven months when the same symp toms(fe ver, chills) re curred. He de nied any fur ther travel or in ges -tion of un pas teur ized dairy prod uct since the first epi sode.Blood cul tures were again posi tive for B me lit en sis bio type 3.Car diac echo gra phy was nor mal. He was given the sametreat ment as be fore for two months and re mained well 12months af ter fin ish ing the treat ment.

The pa ti ent’s wife de vel oped high daily fe vers (39 to 40°C), chills and head aches two months af ter her hus band’s re cur -rence, and her blood cul tures also yielded B me lit en sis bio -type 3 af ter four days’ in cu ba tion. For the pre vi ous threeyears, she did not travel out side North Amer ica. She ate some cav iar im ported from Iran one week be fore her ill ness, but itwas cul tured and found not to har bour Brucella spe cies. Sheoc ca sion ally ate pas teur ized cheese from an Ara bic shop inMont real. She had regu lar sex ual in ter course with her hus -band over that pe riod and did not use a bar rier method of birth con trol. She was simi larly treated with doxy cycline and ri -fampin and did well in sub se quent follow- up vis its.

DIS CUS SIONThe most likely source of the hus band’s dis ease was the

goat cheese eaten in Syria. We be lieve that the sec ond epi -sode was a re cur rence rather than a re in fec tion be cause thepa tient did not travel to an en demic area af ter the first epi sode and no other risk fac tors were iden ti fied. Moreo ver, though asix- week regi men of doxycy cline and ri fampin is now con sid -ered the treat ment of choice by the World Health Or gani za -tion, a fail ure rate of 14% is ex pected (7). The in dex casere ceived only four weeks of treat ment, with which Ar iza et al

(8) docu mented a fail ure rate as high as 38.8%. It is there foreplau si ble to at trib ute the pa ti ent’s re cur rence to a less thanop ti mal du ra tion of ther apy, which proba bly should not be less than six weeks. There doesn’t seem to be a uni ver sally ac -cepted stan dard of follow- up for pa tients with brucella otherthan ob serv ing the pa tient for re cur rence of symp toms, whichcan oc cur, as in the pres ent case, many months af ter the ini -tial epi sode.

The pa ti ent’s wife’s dis ease started two months af ter herhus band’s re cur rence, which would be the ex pected in cu ba -tion pe riod if the dis ease was ac quired from him then. TheQue bec pro vin cial pub lic health labo ra tory, which main tainssur veil lance of all brucella iso lates and se rol ogy, re ported nocases of brucella in fec tion in the prov ince of Que bec otherthan in trav el lers or im mi grants ar riv ing from an en demiccoun try, sug gest ing that the cheese bought from the Ara bicshop was an un likely source. Moreo ver, that cheese was pas -teur ized and other peo ple at home ate it with out be com ing ill.Since the hus band did not con sume cav iar be fore he re lapsed and all three blood iso lates were bio chemi cally iden ti cal, it isun likely that the cav iar was the source of in fec tion, es pe ciallyif one con sid ers that cul tures were nega tive for brucella.

A re view of the Eng lish lan guage medi cal lit era ture from1976 to 1993 yielded four ad di tional cases of pos si ble hu manto hu man trans mis sion via non par enteral ex po sure. In threeof these, the in dex case in fec tions were labo ra tory ac quired(3,4,6), and ei ther the in dex case or the spouse grew B me lit -en sis bio type 2 or 3 from blood, their coun ter part be ing di ag -nosed se ro logi cally (3,4) or by blood cul ture (6). In the fourthre port (5), the pa tient was thought to have ac quired brucel lo -sis from an un de fined source while vis it ing Spain with his girl -friend. She be came sick nine months af ter her com pan ion’sdis ease, which ex ceeds the maxi mum re ported in cu ba tionpe riod. In view of the ab sence of other risk fac tors to ex plainher dis ease, per son to per son trans mis sion was pos tu lated.

Sex ual trans mis sion of brucel lo sis, though not docu -mented in hu mans, seems to be a likely mecha nism of in fec -tion. In hu mans, geni tou ri nary com pli ca tions such asepididymo- orchitis and prosta ti tis are seen in cases of brucel -lo sis (9), and seed ing of these or gans could per haps play arole in trans mis sion of the dis ease from per son to per son. Inthe cases re viewed in an other re port cited above, one of thepart ners had clini cal evi dence of uni lat eral epidi dymi tis (5).Our pa tient did not have any clini cal evi dence of ei therepidi dymo- orchitis or prosta ti tis and his uri naly sis was nor -mal. Nev er the less, B me lit en sis has been iso lated from thesperm of a pa tient with out clini cal or chi tis (10).

In con clu sion, we be lieve that hu man to hu man trans mis -sion of B me lit en sis oc curs, and that sex ual trans mis sionproba bly plays a role. Pro spec tive stud ies evalu at ing the rateof brucella se ro con ver sion in spouses of in dex cases areneeded to es ti mate the true in ci dence of such an event. In ad -di tion, given the se ri ous ness of the dis ease and the pre sented evi dence, it would be pru dent to in struct sexu ally ac tive pa -tients with brucel lo sis to use a bar rier method un til ther apy iscom pleted.

VIGE ANT et al

154 CAN J INFECT DIS VOL 6 NO 3 MAY/JUNE 1995

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3. Ruben B, Wong P, Band JD, Colville J. Person-to-persontransmission of Brucella melitensis. Lancet 1991;337:14-5.

4. Goosens H, Marcellis L, DeKeyser P, Butzler JP. Brucellamelitensis: person-to-person transmission? Lancet 1983;i:773.

5. Lindberg J, Larsson P. Transmission of Brucella melitensis.Lancet 1991;337:848-9.

6. Stantic-Pavlinic M, Cec V, Mehle J. Brucellosis in spouses andthe possibility of interhuman infection. Infection 1983;11:313-4.

7. Ariza J, Gudiol F, Pallares R, et al. Treatment of humanbrucellosis with doxycycline plus rifampin or doxycycline plusstreptomycin. Ann Intern Med 1992;117:25-30.

8. Ariza J, Gudiol F, Pallares R , Rufffi G, Fernandez-Viladrich P.Comparative trial of rifampin-doxycycline versustetracycline-streptomycin in the therapy of human brucellosis.Antimicrob Agents Chemother 1985;28:548-51.

9. Mikolitch DJ, Boyce JM. Brucella species. In: Mandell GL,Douglas RG, Bennett JE, eds. Principles and Practice ofInfectious Diseases, 3rd edn. New York: Churchill Livingstone,1990:1735-42.

10. Vandercam B, Zech F, de Cooman S, Bughin C, Gigi J, WautersG. Isolation of Brucella melitensis from human sperm. Eur JMicrobiol Infect Dis 1990;9:303-4.

CAN J INFECT DIS VOL 6 NO 3 MAY/JUNE 1995 155

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