Comparative Field Trial Effect of *Brucella* spp. Vaccines on Seroconversion in Goats and Their Possible Implications to Control Programs

*Baldomero Molina-Sánchez, David I. Martínez-Herrera, Violeta T. Pardío-Sedas, Ricardo Flores-Castro, José F. Morales-Álvarez and José A. Villagómez-Cortés*

#### **Abstract**

The aim of this study was to determine the seroprevalence of *Brucella* spp. in a goat flock and the seroconversion of three groups of animals vaccinated with Rev-1 (*Brucella melitensis*), RB51, and RB51-SOD (*Brucella abortus*) to estimate the level of protection conferred on susceptible females. Seventy-two animals were used by group. Goats were older than 3 months, seronegative to brucellosis, not vaccinated previously, and kept within positive flocks. Vaccinated animals received 2 mL of product subcutaneously in the neck region. The first block was injected with Rev-1; the second received RB51, and the third group was injected with RB51-SOD. Follow-up sampling was performed at 30, 60, 90, and 365 days postvaccination. The general prevalence of brucellosis for the three groups was 1.2% (95%CI:0.5–2.7). The seroconversion rate by day 30 after vaccination was 77.7% (95%CI:61.9–88.2) for goats vaccinated with Rev-1. At 365 days post vaccination, the percentage of seropositive goats declined to 13.8% (95%CI:6.0–28.6). At day 365 after vaccination, 2.7% (95%CI:0.4–14.1) and 5.5% (95%CI:1.5–18.1) of animals vaccinated with RB51 and RB51-SOD, respectively, became positive. Results show that the seroconversion induced by Brucella abortus RB51 and RB51-SOD vaccines is lower than that by *Brucella melitensis* Rev-1.

**Keywords:** *Brucella*, vaccine, seroprevalence, seroconversion, goat

#### **1. Introduction**

The brucellosis is a highly contagious disease and one of the zoonoses worldwide; most importantly, it is caused by bacteria of the genus *Brucella* [1]. This has been classified by the World Health Organization (WHO) as one of the "top 10" neglected zoonoses, a group of diseases that are simultaneously ongoing threats to human health and a source of perpetuation for poverty [2]. The importance of the disease is enormous but remains under-prioritized worldwide, especially among

**4**

*New Insight into* Brucella *Infection and Foodborne Diseases*

[10] Alavi SM, Alavi L. Treatment of brucellosis: A systematic review of studies in recent twenty years. Caspian Journal of Internal Medicine.

[11] Rajala EL, Cecilia G, Isabel L, Nosirjon S, Sofia B, Ulf M. Prevalence

seropositivity among sheep and goats in a peri-urban region of Tajikistan.

and risk factors for *Brucella*

[12] Alavi SM, Rajabzadeh AR. Comparison of two chemotherapy regimen: Doxycycline-rifampicin and doxycycline cotrimoxazol in the brucellosis patients AHVAZ, IRAN, 2004-2006. Pakistan Journal of Medical Sciences. 2007 (Part-II);**23**(6):889-892

2013;**4**(2):636-641

2016;**48**(3):553-558

[1] Godfroid J, Nielsen K, Saegerman C. Croatian Medical Journal. 2010;**51**:

[2] Abubakar M, Mansoor M, Arshad MJ. Bovine brucellosis: Old and new concepts with Pakistan perspective.

[3] Bano Y, Lone SA. Brucellosis: An economically important infection. Journal of Medical Microbiology & Diagnosis. 2015;**4**:208. DOI: 10.4172/2161-0703.1000208

[4] Pappas G. The changing *Brucella* ecology: Novel reservoirs, new threats. International Journal of Antimicrobial

[5] Gul ST, Khan A. Epidemiology and epizootology of brucellosis: A review. Pakistan Veterinary Journal.

[6] McDermott J, Grace D, Zinsstag J. Economics of brucellosis impact and control in low-income countries. Revue scientifique et technique (International Office of Epizootics). 2013;**32**:249-261

[7] Falade S. Serological response of sheep to *Brucella* melitensis rev. 1 Vaccine. Zoonoses and Public Health.

[9] Ahmad T, Iahtasham K, Saddaf R, Saeed HK, Raheela A. Prevalence of bovine brucellosis in Islamabad and Rawalpindi districts of Pakistan. Pakistan Journal of Zoology.

2016;**49**(3):761-1149. DOI: 10.17582/

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296-305

**References**

the pastoralists and small-scale livestock farmers. The humans can be infected by ingestion of food products such as unpasteurized milk and their derivative products contaminated with the pathogen or by direct interaction with an infected animal or by aerosol inhalation [1, 3].

In small ruminants, the brucellosis is caused by *B. melitensis* [4, 5], the most important agent that induces the disease in humans [6, 7]. The disease often occurs in cattle, sheep, and goat production units; the latter is the most important given its potential role in conveying disease to human. Because brucellosis is a public health problem, its presence and disease control strategies implemented in domestic ruminants affect the occurrence of disease in humans [8, 9]. In small ruminants, the disease is clinically characterized by a decrease in milk production, abortion, loss of weight, fetal death, placental retention, weak offspring, and acute orchitis. In dairy animals, *Brucella* spp. replicates in the mammary gland and supra-mammary lymph nodes, and infected animals continually excrete the pathogen into milk throughout their lives [10, 11].

In underdeveloped countries, vaccination is the main tool used in the control of this disease [12, 13], in particular as a preventive measure in small ruminants, and is considered necessary given the economic and medical consequences of having brucellosis in animals and people infected [14]. The main indicator of brucellosis reduction in animals is a concomitant reduction of human cases [13, 15]. In endemic areas, intensive vaccination with *B. melitensis* Rev. 1 strain in adult and young females has been developed, being the most popular vaccine for the control of brucellosis in small ruminants. The use of a reduced dose rate decreases the presence of vaccine-associated undesirable events, such as postvaccine reactors to conventional tests, abortion, and milk shedding [16]. The vaccination is recommended prior to the first gestation between 3 and 7 months of age to avoid abortion in pregnant animals [17]. When used at a reduced dose, Rev. 1 has shown to protect goats for at least 5 years after vaccination [13, 15]. El Idrissi et al. show that after vaccination, the animals vaccinated with Rev. 1 became positive to rose bengal plate test (RBPT) and complement fixation test (CFT) at 2 weeks, reaching the highest number of seroconverted animals' highest level between 2 and 6 weeks. Thereafter, the percentage of seropositive ewes declined to zero at 14 weeks after challenge. More than 75% of animals were seroconverted 15 days after challenge inoculation [18]. The seroconversion of vaccine is the persistent serological reaction, especially when animals are vaccinated as adults. These persistent serological reactions are mainly against the antigenic O-chain of the lipopolysaccharide present in smooth *Brucella* [19]. Some strains may generate diagnostic interferences in serological test [19, 20], like vaccines containing *Brucella* LPS O antigens that are detected by traditional serodiagnostic tests for brucellosis [21]. It has been reported that the average time from inoculation to seroconversion may range from 2 to 3 weeks in *B. melitensis*-infected goats, from 2 to 4 weeks in *B. abortus*-infected goats, and 3 weeks for the majority of tests evaluated with goats infected with either *Brucella* species [5, 19].

In Mexico, the vaccine RB51 was approved since 1998 as the official one for use in cattle females. The strain has been evaluated in both goat and sheep under controlled conditions with good protection against the experimental challenge with *B. melitensis*, even though protection is lower than that obtained with the Rev. 1 vaccine. Under experimental conditions no abortion occurs. Also, no postvaccination antibodies can be detected by conventional serology. The same findings have been reported after mass goat vaccination with RB51 in Veracruz, Mexico [13, 15].

Nowadays, the homologous overexpression to induce a greater and more effective immune response for the improvement of protective immunity of the vaccines has been developed. This can be achieved by introducing a plasmid within the RB51

**7**

*Comparative Field Trial Effect of* Brucella *spp. Vaccines on Seroconversion in Goats…*

strain with the gene that encodes the antigen expressed, along with appropriate promoters. In mouse (*Balb/c*) it has been shown that the overexpression of Cu/Zn superoxide dismutase (SOD) induces the best protection facing the experimental infection by *B. abortus* indicating that the homologous overexpression can produce a better vaccine RB51 (RB51-SOD) with an equal or better protection than that induced by Rev. 1, against the infection with *B. melitensis* [14, 19, 20]. However, there are no reports in domestic animals on the seroconversion and the vaccine efficacy. Therefore, the aim of this study was to determine the prevalence of *Brucella melitensis* in a goat flock and the seroconversion in animals vaccinated with Rev. 1 *Brucella melitensis*, RB51, and RB51-SOD *Brucella abortus* strains to estimate the

A phase III field trial was performed from September to December 2016 in order to determine the seroprevalence and seroconversion of goat flocks positive to brucellosis in the Xaltepec community municipality of Perote, Veracruz, Mexico, and to evaluate the protection conferred by vaccines with Rev. 1 *Brucella melitensis*,

The experiment was performed in two stages. In the first one, 546 animals from 14 herds with similar management, grazing, feeding, and confinement conditions were used to determine the prevalence of goat brucellosis in Xaltepec. In the second stage, groups required for vaccine evaluation were integrated by randomly selecting animals negative to serological tests meeting the inclusion criteria. Positive animals remained in the herds under field conditions in order to function as a challenge for

Sample size was calculated using Win Episcope Version 2.0 for simple random

sampling, considering the 0.52% prevalence in goats reported in Veracruz by Román-Ramírez et al. of [12], a confidence interval of 95%, and an error margin of 5%. Since each animal had an identification number on its metallic earring, females were randomly assigned to each group and subgroup. For each group, the minimal calculated sample was 72 animals; each group was integrated by a vaccinated subgroup (36) and a not vaccinated or control subgroup (36). Studied groups were integrated by goats older than 3 months, seronegative to brucellosis, and not vaccinated previously and kept within positive flocks. Animals were randomly split into three groups and kept together 8 months in the flock to maintain

Animals in each vaccinated group received 2 mL of vaccine subcutaneously applied in the neck region. The first group was injected with Rev. 1 (*Brucella meli-*

mL. Each group had a control subgroup of unvaccinated animals which received

to 3 × 109

with RB51-SOD (*Brucella abortus*) with a concentration of 3 × 108

2 mL of PSS by subcutaneous injection in the neck region.

CFU/mL, the second received RB51

to 3 × 109

CFU/

CFU/mL, and the third one was injected

*DOI: http://dx.doi.org/10.5772/intechopen.87065*

level of protection conferred on susceptible females.

RB51, and RB51-SOD *Brucella abortus* strains.

**2. Material and methods**

**2.2 Experimental design**

healthy and vaccinated animals.

exposure to *Brucella* spp.

**2.3 Vaccination of animals**

strain (*Brucella abortus*) 3 × 108

*tensis*) strain with a concentration of 1–2 × 109

**2.1 Study design**

*Comparative Field Trial Effect of* Brucella *spp. Vaccines on Seroconversion in Goats… DOI: http://dx.doi.org/10.5772/intechopen.87065*

strain with the gene that encodes the antigen expressed, along with appropriate promoters. In mouse (*Balb/c*) it has been shown that the overexpression of Cu/Zn superoxide dismutase (SOD) induces the best protection facing the experimental infection by *B. abortus* indicating that the homologous overexpression can produce a better vaccine RB51 (RB51-SOD) with an equal or better protection than that induced by Rev. 1, against the infection with *B. melitensis* [14, 19, 20]. However, there are no reports in domestic animals on the seroconversion and the vaccine efficacy. Therefore, the aim of this study was to determine the prevalence of *Brucella melitensis* in a goat flock and the seroconversion in animals vaccinated with Rev. 1 *Brucella melitensis*, RB51, and RB51-SOD *Brucella abortus* strains to estimate the level of protection conferred on susceptible females.

#### **2. Material and methods**

#### **2.1 Study design**

*New Insight into* Brucella *Infection and Foodborne Diseases*

by aerosol inhalation [1, 3].

their lives [10, 11].

the pastoralists and small-scale livestock farmers. The humans can be infected by ingestion of food products such as unpasteurized milk and their derivative products contaminated with the pathogen or by direct interaction with an infected animal or

In small ruminants, the brucellosis is caused by *B. melitensis* [4, 5], the most important agent that induces the disease in humans [6, 7]. The disease often occurs in cattle, sheep, and goat production units; the latter is the most important given its potential role in conveying disease to human. Because brucellosis is a public health problem, its presence and disease control strategies implemented in domestic ruminants affect the occurrence of disease in humans [8, 9]. In small ruminants, the disease is clinically characterized by a decrease in milk production, abortion, loss of weight, fetal death, placental retention, weak offspring, and acute orchitis. In dairy animals, *Brucella* spp. replicates in the mammary gland and supra-mammary lymph nodes, and infected animals continually excrete the pathogen into milk throughout

In underdeveloped countries, vaccination is the main tool used in the control of this disease [12, 13], in particular as a preventive measure in small ruminants, and is considered necessary given the economic and medical consequences of having brucellosis in animals and people infected [14]. The main indicator of brucellosis reduction in animals is a concomitant reduction of human cases [13, 15]. In endemic areas, intensive vaccination with *B. melitensis* Rev. 1 strain in adult and young females has been developed, being the most popular vaccine for the control of brucellosis in small ruminants. The use of a reduced dose rate decreases the presence of vaccine-associated undesirable events, such as postvaccine reactors to conventional tests, abortion, and milk shedding [16]. The vaccination is recommended prior to the first gestation between 3 and 7 months of age to avoid abortion in pregnant animals [17]. When used at a reduced dose, Rev. 1 has shown to protect goats for at least 5 years after vaccination [13, 15]. El Idrissi et al. show that after vaccination, the animals vaccinated with Rev. 1 became positive to rose bengal plate test (RBPT) and complement fixation test (CFT) at 2 weeks, reaching the highest number of seroconverted animals' highest level between 2 and 6 weeks. Thereafter, the percentage of seropositive ewes declined to zero at 14 weeks after challenge. More than 75% of animals were seroconverted 15 days after challenge inoculation [18]. The seroconversion of vaccine is the persistent serological reaction, especially when animals are vaccinated as adults. These persistent serological reactions are mainly against the antigenic O-chain of the lipopolysaccharide present in smooth *Brucella* [19]. Some strains may generate diagnostic interferences in serological test [19, 20], like vaccines containing *Brucella* LPS O antigens that are detected by traditional serodiagnostic tests for brucellosis [21]. It has been reported that the average time from inoculation to seroconversion may range from 2 to 3 weeks in *B. melitensis*-infected goats, from 2 to 4 weeks in *B. abortus*-infected goats, and 3 weeks for the majority of tests evaluated with goats infected with either *Brucella*

In Mexico, the vaccine RB51 was approved since 1998 as the official one for use in cattle females. The strain has been evaluated in both goat and sheep under controlled conditions with good protection against the experimental challenge with *B. melitensis*, even though protection is lower than that obtained with the Rev. 1 vaccine. Under experimental conditions no abortion occurs. Also, no postvaccination antibodies can be detected by conventional serology. The same findings have been reported after mass goat vaccination with RB51 in Veracruz, Mexico [13, 15].

Nowadays, the homologous overexpression to induce a greater and more effective immune response for the improvement of protective immunity of the vaccines has been developed. This can be achieved by introducing a plasmid within the RB51

**6**

species [5, 19].

A phase III field trial was performed from September to December 2016 in order to determine the seroprevalence and seroconversion of goat flocks positive to brucellosis in the Xaltepec community municipality of Perote, Veracruz, Mexico, and to evaluate the protection conferred by vaccines with Rev. 1 *Brucella melitensis*, RB51, and RB51-SOD *Brucella abortus* strains.

#### **2.2 Experimental design**

The experiment was performed in two stages. In the first one, 546 animals from 14 herds with similar management, grazing, feeding, and confinement conditions were used to determine the prevalence of goat brucellosis in Xaltepec. In the second stage, groups required for vaccine evaluation were integrated by randomly selecting animals negative to serological tests meeting the inclusion criteria. Positive animals remained in the herds under field conditions in order to function as a challenge for healthy and vaccinated animals.

Sample size was calculated using Win Episcope Version 2.0 for simple random sampling, considering the 0.52% prevalence in goats reported in Veracruz by Román-Ramírez et al. of [12], a confidence interval of 95%, and an error margin of 5%. Since each animal had an identification number on its metallic earring, females were randomly assigned to each group and subgroup. For each group, the minimal calculated sample was 72 animals; each group was integrated by a vaccinated subgroup (36) and a not vaccinated or control subgroup (36). Studied groups were integrated by goats older than 3 months, seronegative to brucellosis, and not vaccinated previously and kept within positive flocks. Animals were randomly split into three groups and kept together 8 months in the flock to maintain exposure to *Brucella* spp.

#### **2.3 Vaccination of animals**

Animals in each vaccinated group received 2 mL of vaccine subcutaneously applied in the neck region. The first group was injected with Rev. 1 (*Brucella melitensis*) strain with a concentration of 1–2 × 109 CFU/mL, the second received RB51 strain (*Brucella abortus*) 3 × 108 to 3 × 109 CFU/mL, and the third one was injected with RB51-SOD (*Brucella abortus*) with a concentration of 3 × 108 to 3 × 109 CFU/ mL. Each group had a control subgroup of unvaccinated animals which received 2 mL of PSS by subcutaneous injection in the neck region.

#### **2.4 Sample collection**

Follow-up sampling was performed at 30, 60, 90, and 365 days post vaccination by blood sampling collected from the jugular vein in vacutainer tubes without anticoagulant (BD Vacutate, Oxford, UK). Each tube was identified with the number in the animal earring. Tubes containing blood samples were placed in a tilt position about 2 hours at room temperature allowing the separation of serum from the blood package. Later, tubes were placed into coolers at 4°C and transported to the laboratory and then were centrifuged at 1000 × *g* 10 minutes at room temperature. Finally, the serum was stored in sterile vials at −20°C until analysis.

#### **2.5 Serological testing**

Serum samples were analyzed by series using the following tests: 3% RBPT as screening and simple radial immunodifusion test (SRD) as confirmatory [5, 22].

RBPT was used as a screening test on the serum samples collected for the presence of *Brucella* agglutinins. Equal volumes of test serum and B. *abortus* antigen strain 1119-3 at 3% and pH of 3.6 (Aba Test Tarjeta 3%) (National Producer of Veterinary Biologics PRONABIVE) were added and mixed. This test has shown 98% sensitivity and 100% specificity. This test gives presumptive results.

SRD was used as a confirmatory test, and the antigen was used at a concentration of 1 mg/mL on agarose gel prepared with a glycine buffer solution and native hapten obtained from *B. melitensis* 16 M strain (produced at CENID Microbiology Animal, INIFAP). The test has shown 96% sensitivity and 80–100% specificity for the differential diagnosis between goats infected with *Brucella* spp. and those vaccinated with the Rev. 1 strain.

#### **2.6 Analyses of data**

Seroconversion produced during the observation period was calculated. Differences between groups and the significance of association were calculated by chi square (*Xi2* ), and the degree of association was estimated using relative risk (RR) [23]. In those cases that frequency of positive animals to tests was 0.0%, confidence interval was calculated according to Campbell et al. [24].

#### **3. Results**

The results of initial seroprevalence of brucellosis in goat flocks at Xaltepec are shown in **Tables 1** and **2**. The seroprevalence in the three groups determined by the 3% RBPT as presumptive test resulted in 22.1, 26.1, and 16.0% (95%CI: 16.5–28.9, 19.9–33.2, and 11.1–22.3, respectively).

The serum positive goats were confirmed with SRD, and the prevalence reduced to 0.5, 1.1, and 2.2% (95%CI: 0.3–3.4, 0.1–4.3, and 0.7–5.9, respectively). Thus, a general prevalence of 1.2% (95%CI: 0.5–2.7) was observed.

**Tables 3–6** show the seroconversion rate in goats vaccinated with *Brucella* strain determined by RBPT at 30, 60, 90, and 365 days after vaccination. At 30 days after vaccination, the 77.7% (95%CI: 61.9–88.2) of goats vaccinated with Rev. 1 strain became positive to RBPT. Thereafter, 60 and 90 days post vaccination the percentage of seropositive goats declined to 72.2% (95%CI: 56.0–84.1) and 63.8% (95%CI: 47.5–77.5), respectively. At 365 days, 13.8% of vaccinated animals remained as seropositive to RBPT. Only two animals vaccinated with RB51 and RB5-SOD, respectively, were positive to RBPT at 30, 60, and 90 days after vaccination with

**9**

*Brucella* strains [20].

*Comparative Field Trial Effect of* Brucella *spp. Vaccines on Seroconversion in Goats…*

Rev. 1 185 41 22.1 16.5–28.9 RB51 180 47 26.1 19.9–33.2 RB51-SOD 181 29 16.0 11.1–22.3 **Total 546 117 21.4 18.1–25.1**

*Seroprevalence of brucellosis rate by RBPT in goat flocks of Xaltepec municipality Perote, Veracruz, Mexico.*

Rev. 1 41 1 0.5 0.3–3.4 RB51 47 2 1.1 0.1–4.3 RB51-SOD 29 4 2.2 0.7–5.9 **Total 117 7 1.2 0.5–2.7**

*Seroprevalence of brucellosis rate by SRD in goat flocks of Xaltepec municipality Perote, Veracruz, Mexico.*

Rev 1 Vaccinated 36 28 a 77.7 61.9–88.2

RB51 Vaccinated 36 1 a 2.7 0.4–14.1

RB51-SOD Vaccinated 36 2 a 5.5 1.5–18.1

Control 36 4 b 11.1 4.4–25.3

Control 36 0 a 0.0 0.0–0.09

Control 36 0 a 0.0 0.0–0.09

**Group/subgroup N Time after vaccination (days)**

**Positive Seroprevalence (%) 95%CI**

**Positive Seroprevalence (%) 95%CI**

**30 Positive Seroconversion rate (%) 95%CI**

**Strain Sample size RBPT**

**Strain Sample size SRD**

a prevalence of 2.7% and 5.5% (95%CI: 0.4–14.1 and 1.5–18.1, respectively). At 365 days post vaccination, only 11.1% of vaccinated animals with RB51 remained reacting; there were no seroreactors to RB51-SOD strain by RBPT. Meanwhile, animals vaccinated with RB51 and RB51-SOD did not produce anti-O side-chain antibodies as measured by RBPT. Non-vaccinated control goats were seronegative. The seroconversion of a vaccine is the persistent serological reaction, especially when animals are vaccinated as adults; these persistent serological reactions are mainly against the antigenic O-chain of the lipopolysaccharide present in smooth

*Seroconvertion rates determined by RBPT at 30 days after vaccination of goats with Rev-1, RB51, and RB51-*

*Different superscripts indicate statistical difference by column (P< 0.01).*

*SOD strains in Xaltepec, Perote, Veracruz, Mexico.*

**Tables 7–10** show positive animals to RBPT that were confirmed with the SRD at 30, 60, 90, and 365 days after vaccination. Only 2.7% (95%CI: 0.4–14.1) of goats

*DOI: http://dx.doi.org/10.5772/intechopen.87065*

**Table 1.**

**Table 2.**

**Table 3.**

*Comparative Field Trial Effect of* Brucella *spp. Vaccines on Seroconversion in Goats… DOI: http://dx.doi.org/10.5772/intechopen.87065*


**Table 1.**

*New Insight into* Brucella *Infection and Foodborne Diseases*

the serum was stored in sterile vials at −20°C until analysis.

sensitivity and 100% specificity. This test gives presumptive results.

Follow-up sampling was performed at 30, 60, 90, and 365 days post vaccination by blood sampling collected from the jugular vein in vacutainer tubes without anticoagulant (BD Vacutate, Oxford, UK). Each tube was identified with the number in the animal earring. Tubes containing blood samples were placed in a tilt position about 2 hours at room temperature allowing the separation of serum from the blood package. Later, tubes were placed into coolers at 4°C and transported to the laboratory and then were centrifuged at 1000 × *g* 10 minutes at room temperature. Finally,

Serum samples were analyzed by series using the following tests: 3% RBPT as screening and simple radial immunodifusion test (SRD) as confirmatory [5, 22]. RBPT was used as a screening test on the serum samples collected for the presence of *Brucella* agglutinins. Equal volumes of test serum and B. *abortus* antigen strain 1119-3 at 3% and pH of 3.6 (Aba Test Tarjeta 3%) (National Producer of Veterinary Biologics PRONABIVE) were added and mixed. This test has shown 98%

SRD was used as a confirmatory test, and the antigen was used at a concentration of 1 mg/mL on agarose gel prepared with a glycine buffer solution and native hapten obtained from *B. melitensis* 16 M strain (produced at CENID Microbiology Animal, INIFAP). The test has shown 96% sensitivity and 80–100% specificity for the differential diagnosis between goats infected with *Brucella* spp. and those

Seroconversion produced during the observation period was calculated. Differences between groups and the significance of association were calculated by

(RR) [23]. In those cases that frequency of positive animals to tests was 0.0%,

The results of initial seroprevalence of brucellosis in goat flocks at Xaltepec are shown in **Tables 1** and **2**. The seroprevalence in the three groups determined by the 3% RBPT as presumptive test resulted in 22.1, 26.1, and 16.0% (95%CI: 16.5–28.9,

The serum positive goats were confirmed with SRD, and the prevalence reduced to 0.5, 1.1, and 2.2% (95%CI: 0.3–3.4, 0.1–4.3, and 0.7–5.9, respectively). Thus, a

**Tables 3–6** show the seroconversion rate in goats vaccinated with *Brucella* strain

determined by RBPT at 30, 60, 90, and 365 days after vaccination. At 30 days after vaccination, the 77.7% (95%CI: 61.9–88.2) of goats vaccinated with Rev. 1 strain became positive to RBPT. Thereafter, 60 and 90 days post vaccination the percentage of seropositive goats declined to 72.2% (95%CI: 56.0–84.1) and 63.8% (95%CI: 47.5–77.5), respectively. At 365 days, 13.8% of vaccinated animals remained as seropositive to RBPT. Only two animals vaccinated with RB51 and RB5-SOD, respectively, were positive to RBPT at 30, 60, and 90 days after vaccination with

confidence interval was calculated according to Campbell et al. [24].

general prevalence of 1.2% (95%CI: 0.5–2.7) was observed.

), and the degree of association was estimated using relative risk

**2.4 Sample collection**

**2.5 Serological testing**

vaccinated with the Rev. 1 strain.

19.9–33.2, and 11.1–22.3, respectively).

**2.6 Analyses of data**

chi square (*Xi2*

**3. Results**

**8**

*Seroprevalence of brucellosis rate by RBPT in goat flocks of Xaltepec municipality Perote, Veracruz, Mexico.*


#### **Table 2.**

*Seroprevalence of brucellosis rate by SRD in goat flocks of Xaltepec municipality Perote, Veracruz, Mexico.*


#### **Table 3.**

*Seroconvertion rates determined by RBPT at 30 days after vaccination of goats with Rev-1, RB51, and RB51- SOD strains in Xaltepec, Perote, Veracruz, Mexico.*

a prevalence of 2.7% and 5.5% (95%CI: 0.4–14.1 and 1.5–18.1, respectively). At 365 days post vaccination, only 11.1% of vaccinated animals with RB51 remained reacting; there were no seroreactors to RB51-SOD strain by RBPT. Meanwhile, animals vaccinated with RB51 and RB51-SOD did not produce anti-O side-chain antibodies as measured by RBPT. Non-vaccinated control goats were seronegative. The seroconversion of a vaccine is the persistent serological reaction, especially when animals are vaccinated as adults; these persistent serological reactions are mainly against the antigenic O-chain of the lipopolysaccharide present in smooth *Brucella* strains [20].

**Tables 7–10** show positive animals to RBPT that were confirmed with the SRD at 30, 60, 90, and 365 days after vaccination. Only 2.7% (95%CI: 0.4–14.1) of goats


**Table 4.**

*Seroconvertion rates determined by RBPT at 60 days after vaccination of goats with Rev-1, RB51, and RB51- SOD strains in Xaltepec, Perote, Veracruz, Mexico.*


#### **Table 5.**

*Seroconvertion rates determined by RBPT at 90 days after vaccination of goats with Rev-1, RB51, and RB51- SOD strains in Xaltepec, Perote, Veracruz, Mexico.*


*Different superscripts indicate statistical difference by column (P< 0.01).*

#### **Table 6.**

*Seroconvertion rates determined by RBPT at 365 days after vaccination of goats with Rev-1, RB51, and RB51- SOD strains in Xaltepec, Perote, Veracruz, Mexico.*

vaccinated with Rev. 1 became positive during the first three samplings, but this situation did not persist until at 365 days post vaccination as expected. Also, goats vaccinated with RB51 and RB51-SOD during the first 90 days post vaccination expressed

**11**

*\*w.d.= without data*

*\*w.d.= without data*

**Table 7.**

*\*w.d.= without data*

**Table 9.**

*SOD strains in Xaltepec, Perote, Veracruz, Mexico.*

*SOD strains in Xaltepec, Perote, Veracruz, Mexico.*

*SOD strains in Xaltepec, Perote, Veracruz, Mexico.*

**Table 8.**

*Comparative Field Trial Effect of* Brucella *spp. Vaccines on Seroconversion in Goats…*

**Group/subgroup Time after vaccination (days)**

Rev 1 Vaccinated 1/28 2.7 0.49–14.1

RB51 Vaccinated 0/1 0.0 0.0–0.79

RB51-SOD Vaccinated 0/2 0.0 0.0–0.66

**Group/subgroup Time after vaccination (days)**

*Seroconversion rates determined by SRD at 30 days after vaccination of goats with Rev-1, RB51, and RB51-*

Rev 1 Vaccinated 1/27 2.7 0.49–14.1

RB51 Vaccinated 0/1 0.0 0.0–0.79

RB51-SOD Vaccinated 0/2 0.0 0.0–0.66

*Seroconversion rates determined by SRD at 60 days after vaccination of goats with Rev-1, RB51, and RB51-*

Rev 1 Vaccinated 1/23 2.7 0.49–14.1

RB51 Vaccinated 0/1 0.0 0.0–0.79

RB51-SOD Vaccinated 0/2 0.0 0.0–0.66

**Group/subgroup Time after vaccination (days)**

**60 Positive Prevalence rate (%) 95%CI**

**30 Positive Prevalence rate (%) 95%CI**

**90 Positive Prevalence rate (%) 95%CI**

Control 0/4 0.0 0.0–0.49

Control 0/4 0.0 0.0–0.49

Control 0/0 w.d.\* w.d.\*

Control 0/0 w.d.\* w.d.\*

Control 0/0 w.d.\* w.d.\*

Control 0/0 w.d.\* w.d.\*

Control 0/4 0.0 0.0–0.49

Control 0/0 w.d.\* w.d.\*

Control 0/0 w.d.\* w.d.\*

antibodies that were detected with the RBPT test but were negative to the SRD test; however, at 365 days, an animal in the RB51 strain group was identified as seropositive (2.7%, 95%CI: 0.4–14.1). It is noteworthy that serological samples that underwent

*Seroconversion rates determined by SRD at 90 days after vaccination of goats with Rev-1, RB51, and RB51-*

*DOI: http://dx.doi.org/10.5772/intechopen.87065*

*Comparative Field Trial Effect of* Brucella *spp. Vaccines on Seroconversion in Goats… DOI: http://dx.doi.org/10.5772/intechopen.87065*


#### **Table 7.**

*New Insight into* Brucella *Infection and Foodborne Diseases*

*Different superscripts indicate statistical difference by column (P< 0.01).*

*SOD strains in Xaltepec, Perote, Veracruz, Mexico.*

**Table 4.**

**Group/subgroup N Time after vaccination (days)**

Rev 1 Vaccinated 36 27 a 72.2 56.0–84.1

RB51 Vaccinated 36 1 a 2.7 0.4–14.1

RB51-SOD Vaccinated 36 2 a 5.5 1.5–18.1

*Seroconvertion rates determined by RBPT at 60 days after vaccination of goats with Rev-1, RB51, and RB51-*

Rev 1 Vaccinated 36 23 a 63.8 47.5–77.5

RB51 Vaccinated 36 1 a 2.7 0.4–14.1

RB51-SOD Vaccinated 36 2 a 5.5 1.5–18.1

**Group/subgroup N Time after vaccination (days)**

Control 36 4 b 11.1 4.4–25.3

Control 36 0 a 0.0 0.0–0.09

Control 36 0 a 0.0 0.0–0.09

Control 36 4 b 11.1 4.4–25.3

Control 36 0 a 0.0 0.0–0.09

Control 36 0 a 0.0 0.0–0.09

**60 Positive Seroconversion rate (%) 95%CI**

**90 Positive Seroconversion rate (%) 95%CI**

**365 Positive Seroconversion rate (%) 95%CI**

**10**

**Table 6.**

**Table 5.**

vaccinated with Rev. 1 became positive during the first three samplings, but this situation did not persist until at 365 days post vaccination as expected. Also, goats vaccinated with RB51 and RB51-SOD during the first 90 days post vaccination expressed

*Seroconvertion rates determined by RBPT at 365 days after vaccination of goats with Rev-1, RB51, and RB51-*

*Different superscripts indicate statistical difference by column (P< 0.01).*

*Different superscripts indicate statistical difference by column (P< 0.01).*

*SOD strains in Xaltepec, Perote, Veracruz, Mexico.*

*SOD strains in Xaltepec, Perote, Veracruz, Mexico.*

**Group/subgroup N Time after vaccination (days)**

*Seroconvertion rates determined by RBPT at 90 days after vaccination of goats with Rev-1, RB51, and RB51-*

Rev 1 Vaccinated 36 5 a 13.8 6.0–28.6

RB51 Vaccinated 36 4 a 11.1 4.4–25.3

RB51-SOD Vaccinated 36 0 a 0.0 0.0–0.09

Control 36 9 a 25.0 13.7–41.0

Control 36 9 a 25.0 13.7–41.0

Control 36 7 a 19.4 9.7–35.0

*Seroconversion rates determined by SRD at 30 days after vaccination of goats with Rev-1, RB51, and RB51- SOD strains in Xaltepec, Perote, Veracruz, Mexico.*


#### **Table 8.**

*Seroconversion rates determined by SRD at 60 days after vaccination of goats with Rev-1, RB51, and RB51- SOD strains in Xaltepec, Perote, Veracruz, Mexico.*


#### **Table 9.**

*Seroconversion rates determined by SRD at 90 days after vaccination of goats with Rev-1, RB51, and RB51- SOD strains in Xaltepec, Perote, Veracruz, Mexico.*

antibodies that were detected with the RBPT test but were negative to the SRD test; however, at 365 days, an animal in the RB51 strain group was identified as seropositive (2.7%, 95%CI: 0.4–14.1). It is noteworthy that serological samples that underwent


#### **Table 10.**

*Seroconversion rates determined by SRD at 365 days after vaccination of goats with Rev-1, RB51, and RB51- SOD strains in Xaltepec, Perote, Veracruz, Mexico.*

the confirmatory test (SRD) correspond to animals that had a positive result to the screening test (RBPT); hence, the original sample size was not decreased.

#### **4. Discussion**

Goat herds in the present study had similar conditions of feeding, handling, and confinement. Each group was exposed to animals infected with *Brucella* spp. Overall seroprevalence in the herds under study was 21.4% (95%CI: 18.1–25.1) with 3% RBST as screening and 1.2% (95%CI: 0.5–2.7) by SRD as the confirmatory one. These seroprevalences are similar to those found by Román-Ramírez et al. in 14 municipalities in the central area of the state of Veracruz, Mexico, that were 18.18% (95%CI: 15.15–21.64) by RBST and 0.52% (95%CI: 0.13–1.65) by SDR tests [12]. However, the seroprevalence is also greater than 9.8% reported by Solorio-Rivera et al. (95%CI: 8.8–10.7) [5] using RBST test in goat herds of the state of Michoacán, Mexico. This shows that the herds located in the community of Xaltepec, municipality of Perote, Veracruz, Mexico, have animals that could be exposed to brucellosis and the conditions of management provide an opportunity for the perpetuating the infection.

The permanent vaccination program for goat herds has been operating in the area since 1994 achieving the requirements for the control phase according to the Official Mexican Standard (NOM-041-ZOO-1995) National Campaign against brucellosis in animals. These findings may suggest that the vaccine used is not protecting all animals, the vaccine is not properly managed or injected, or vaccination is not timely applied, resulting in the possibility of maintaining infection in the animals. Furthermore, the animal may not develop the infection, but the immune response capability is then detected by the diagnostic screening test without being a truly infected animal. As a result, the recognized agglutination serological tests (RSBT) leads to diagnostic confusion determining infected animals to remain in the herds. Hence, it is necessary to evaluate the vaccine strain to be used in the brucellosis control programs, since the results shown in **Table 1** demonstrate that more than 50% of the animals reacted to the screening test, but are not infected as shown by the SRD test (**Tables 7**–**9**), which possess a greater sensitivity. This situation determines the need to invest in confirmatory tests [25–29].

When vaccinated groups of goats were evaluated by the RSBT, animals vaccinated with Rev. 1 strain had a seroconversion rate of 77.7% (95%CI: 61.9–88.2),

**13**

[28, 29, 32].

*Comparative Field Trial Effect of* Brucella *spp. Vaccines on Seroconversion in Goats…*

72.2% (95%CI: 56.0–84.1), 63.8% (95%CI: 47.5–77.5), and 13.8% (95%CI: 6.0– 28.6) at 30, 60, 90, and 365 days post vaccination, respectively (**Tables 3–6**). This agrees with Blasco et al. [7] who pointed out that vaccination with a full dose (1 ×

 CFU/mL) may cause diagnostic interference and inconvenience to rely on vaccination as the only alternative for brucellosis eradication programs in goat herds [7, 27]. RBST-positive animals were confirmed by the SRD test, and only one animal resulted positive, representing 2.7% (95%CI: 0.4–14.1) (**Tables 7–9**). This indicates that the vaccine did not protect or that the animal was infected prior to vaccination, despite being negative at initial screening. Vaccinated animals were not challenged at a controlled dose of *Brucella melitensis*, since the challenge was through a natural exposure to the infected animals, which were kept in confinement with the vaccinated animals, to allow exposed vaccinated animals to become infected as occurring in the normal management situation in the regional produc-

As observed in **Tables 3–5**, animals vaccinated with the RB51 and RB51-SOD strains, 2.7% (95%CI: 0.4–14.1) and 5.5% (95%CI: 1.5–18.1), respectively, reacted to the RBST during the evaluation period. However, when analyzed by the SRD for confirmation, all animals were negative. RB51 strain is officially used for vaccination only in bovine females; it is a rough mutant strain derived from *B. abortus* 2308 smooth strain, so it does not induce response of anti-LPS antibodies. It has the advantage of allowing conventional serological tests to be used for brucellosis diagnosis in animals, and its use is considered safe in small ruminants [31]. Fosgate et al. carried out a study in water buffalo males and females which were vaccinated subcutaneously with RB51 at a concentration of 1.0–3.4 × 1010 UFC/mL, to evaluate the serological performance by agglutination tests [31]. Animals were challenged in a herd with an initial *Brucella* spp. prevalence of 56%. Out of the vaccinated animals, 2/32 (6.2%) reacted in different samplings in at least one serological test (STAT, SPAT, and/or BPAT). Authors conclude that the proportion of vaccinated animals that became positive to brucellosis in this field trial was greater than the corresponding proportion in the control group emphasizing that vaccination does not stop the seroconversion effect on the herds challenged with a field strain. Furthermore, the RB51 vaccine did not prevent seroconversion of the animals. Therefore, infected animals were able to process the agent and maintain such a condition that it could react to the diagnostic test by IgM production by stimulation of the O-type side chains of the field strain, although the animal was not infected

El Idrissi et al. compared the vaccine efficacy of Rev. 1 and RB51 strains in sheep.

Considering seroconversion, they conclude that after vaccination, all sheep vaccinated with Rev. 1 were positive to RBPT and complement fixation test (CFT) at 2 weeks, reaching their maximum between 2 and 6 weeks [7]. Then the percentage decreased and was zero 14 weeks after challenge. Animals vaccinated with RB51 did not produce anti-O side-chain antibodies, as measured by RBPT and CFT. After exposure to challenge, anti-O side-chain antibodies, measured by RBPT, were

Out of the animals vaccinated with RB51-SOD strain, 2/36 were seroconverted, representing 5.5% (95%CI: 1.5–18.1) (**Tables 3–5**). The animals that underwent the confirmatory test (SRD) were negative as shown in **Tables 7–9**. The above indicates that animals established an immune memory response generating the production of immunoglobulins detectable by the screening test, but they were not infected [34]. Olsen et al. [32] evaluated the RB51-SOD strain in bisons, which was less effective than RB51 in protecting against abortion and uterine infection in this species [32–34]. In the present study, some animals of the goat groups of *B. abortus* strains RB51 and RB51-SOD were positive only to

detected in the serum of vaccinated animals and controls [19].

*DOI: http://dx.doi.org/10.5772/intechopen.87065*

tion systems in Mexico [14, 30].

10<sup>9</sup>

*Comparative Field Trial Effect of* Brucella *spp. Vaccines on Seroconversion in Goats… DOI: http://dx.doi.org/10.5772/intechopen.87065*

72.2% (95%CI: 56.0–84.1), 63.8% (95%CI: 47.5–77.5), and 13.8% (95%CI: 6.0– 28.6) at 30, 60, 90, and 365 days post vaccination, respectively (**Tables 3–6**). This agrees with Blasco et al. [7] who pointed out that vaccination with a full dose (1 × 10<sup>9</sup> CFU/mL) may cause diagnostic interference and inconvenience to rely on vaccination as the only alternative for brucellosis eradication programs in goat herds [7, 27]. RBST-positive animals were confirmed by the SRD test, and only one animal resulted positive, representing 2.7% (95%CI: 0.4–14.1) (**Tables 7–9**). This indicates that the vaccine did not protect or that the animal was infected prior to vaccination, despite being negative at initial screening. Vaccinated animals were not challenged at a controlled dose of *Brucella melitensis*, since the challenge was through a natural exposure to the infected animals, which were kept in confinement with the vaccinated animals, to allow exposed vaccinated animals to become infected as occurring in the normal management situation in the regional production systems in Mexico [14, 30].

As observed in **Tables 3–5**, animals vaccinated with the RB51 and RB51-SOD strains, 2.7% (95%CI: 0.4–14.1) and 5.5% (95%CI: 1.5–18.1), respectively, reacted to the RBST during the evaluation period. However, when analyzed by the SRD for confirmation, all animals were negative. RB51 strain is officially used for vaccination only in bovine females; it is a rough mutant strain derived from *B. abortus* 2308 smooth strain, so it does not induce response of anti-LPS antibodies. It has the advantage of allowing conventional serological tests to be used for brucellosis diagnosis in animals, and its use is considered safe in small ruminants [31]. Fosgate et al. carried out a study in water buffalo males and females which were vaccinated subcutaneously with RB51 at a concentration of 1.0–3.4 × 1010 UFC/mL, to evaluate the serological performance by agglutination tests [31]. Animals were challenged in a herd with an initial *Brucella* spp. prevalence of 56%. Out of the vaccinated animals, 2/32 (6.2%) reacted in different samplings in at least one serological test (STAT, SPAT, and/or BPAT). Authors conclude that the proportion of vaccinated animals that became positive to brucellosis in this field trial was greater than the corresponding proportion in the control group emphasizing that vaccination does not stop the seroconversion effect on the herds challenged with a field strain. Furthermore, the RB51 vaccine did not prevent seroconversion of the animals. Therefore, infected animals were able to process the agent and maintain such a condition that it could react to the diagnostic test by IgM production by stimulation of the O-type side chains of the field strain, although the animal was not infected [28, 29, 32].

El Idrissi et al. compared the vaccine efficacy of Rev. 1 and RB51 strains in sheep. Considering seroconversion, they conclude that after vaccination, all sheep vaccinated with Rev. 1 were positive to RBPT and complement fixation test (CFT) at 2 weeks, reaching their maximum between 2 and 6 weeks [7]. Then the percentage decreased and was zero 14 weeks after challenge. Animals vaccinated with RB51 did not produce anti-O side-chain antibodies, as measured by RBPT and CFT. After exposure to challenge, anti-O side-chain antibodies, measured by RBPT, were detected in the serum of vaccinated animals and controls [19].

Out of the animals vaccinated with RB51-SOD strain, 2/36 were seroconverted, representing 5.5% (95%CI: 1.5–18.1) (**Tables 3–5**). The animals that underwent the confirmatory test (SRD) were negative as shown in **Tables 7–9**. The above indicates that animals established an immune memory response generating the production of immunoglobulins detectable by the screening test, but they were not infected [34]. Olsen et al. [32] evaluated the RB51-SOD strain in bisons, which was less effective than RB51 in protecting against abortion and uterine infection in this species [32–34]. In the present study, some animals of the goat groups of *B. abortus* strains RB51 and RB51-SOD were positive only to

*New Insight into* Brucella *Infection and Foodborne Diseases*

the confirmatory test (SRD) correspond to animals that had a positive result to the

*Seroconversion rates determined by SRD at 365 days after vaccination of goats with Rev-1, RB51, and RB51-*

Goat herds in the present study had similar conditions of feeding, handling, and confinement. Each group was exposed to animals infected with *Brucella* spp. Overall seroprevalence in the herds under study was 21.4% (95%CI: 18.1–25.1) with 3% RBST as screening and 1.2% (95%CI: 0.5–2.7) by SRD as the confirmatory one. These seroprevalences are similar to those found by Román-Ramírez et al. in 14 municipalities in the central area of the state of Veracruz, Mexico, that were 18.18% (95%CI: 15.15–21.64) by RBST and 0.52% (95%CI: 0.13–1.65) by SDR tests [12]. However, the seroprevalence is also greater than 9.8% reported by Solorio-Rivera et al. (95%CI: 8.8–10.7) [5] using RBST test in goat herds of the state of Michoacán, Mexico. This shows that the herds located in the community of Xaltepec, municipality of Perote, Veracruz, Mexico, have animals that could be exposed to brucellosis and the conditions of management provide an opportunity for the perpetuating

The permanent vaccination program for goat herds has been operating in the area since 1994 achieving the requirements for the control phase according to the Official Mexican Standard (NOM-041-ZOO-1995) National Campaign against brucellosis in animals. These findings may suggest that the vaccine used is not protecting all animals, the vaccine is not properly managed or injected, or vaccination is not timely applied, resulting in the possibility of maintaining infection in the animals. Furthermore, the animal may not develop the infection, but the immune response capability is then detected by the diagnostic screening test without being a truly infected animal. As a result, the recognized agglutination serological tests (RSBT) leads to diagnostic confusion determining infected animals to remain in the herds. Hence, it is necessary to evaluate the vaccine strain to be used in the brucellosis control programs, since the results shown in **Table 1** demonstrate that more than 50% of the animals reacted to the screening test, but are not infected as shown by the SRD test (**Tables 7**–**9**), which possess a greater sensitivity. This situation

When vaccinated groups of goats were evaluated by the RSBT, animals vaccinated with Rev. 1 strain had a seroconversion rate of 77.7% (95%CI: 61.9–88.2),

determines the need to invest in confirmatory tests [25–29].

screening test (RBPT); hence, the original sample size was not decreased.

**Group/subgroup Time after vaccination (days)**

Rev 1 Vaccinated 0/5 0.0 0.0–0.43

RB51 Vaccinated 1/4 2.7 0.49–14.1

RB51-SOD Vaccinated 0/0 w.d.\* w.d.\*

**365 Positive Prevalence rate (%) 95%CI**

Control 0/9 0.0 0.0–0.29

Control 1/9 2.7 0.49–14.1

Control 1/7 2.7 0.49–14.1

**12**

**4. Discussion**

*\*w.d.= without data*

*SOD strains in Xaltepec, Perote, Veracruz, Mexico.*

**Table 10.**

the infection.

the screening test, which could be discarded by SRD test that identified them as negative to brucellosis [28, 29, 31, 33, 34].

The RB51-SOD strain was obtained from *B. abortus* 2308 in order to generate the overexpression of a protective periplasmic antigen of the protective antigen known as Cu/Zn SOD, which causes the immune cell response by T-helper-type Th1 lymphocytes, and protection against the strain of *B. abortus* 2308, which has been demonstrated in murine models [26, 29, 31–33]. Despite the favorable outcome in mice, Dorneles et al. [33] pointed out that the potential use of RB51-SOD under field conditions is very limited, although satisfactory results have been obtained. It is important to consider that the response observed in the mice might not reflect the protection achieved in the natural hosts after vaccination. Moreover, to generate a strong and protective immune response that mimic natural infection is a complex challenge. However, the current study in goats allowed to evaluate the RB51-SOD strain and to know part of its satisfactory performance in the field, since the newly developed vaccines have only evaluated in murine models [28–30]. Contrary to the Rev. 1 vaccine, current study demonstrates that the RB51-SOD strain does not induce seroconversion in goats.

#### **5. Conclusion**

When evaluating the Rev. 1, RB51, and RB51-SOD vaccine strains, seroconversion in animals vaccinated with Rev. 1 strain was higher than that shown by the strains RB51 and RB51-SOD by conventional serological tests in infected herds during the evaluated period. Therefore, vaccination with Rev. 1 originates the need to perform confirmatory tests causing an increase in diagnosis costs. According to results of the present study, the RB51-SOD vaccine represents an alternative for controlling one of the most important worldwide zoonosis in goats. However, further studies are required to evaluate the performance of immune response, vaccine safety, and efficacy at field level.

#### **Acknowledgements**

We thank the state committee for the promotion and protection of livestock of Veracruz and the product system goats of Veracruz. This work was supported by SEP-PRODEP research grant project [DSA/I103.5/I5/14220] "Support for the integration of thematic networks of academic collaboration."

**15**

**Author details**

Veracruz, México

Baldomero Molina-Sánchez1

Ricardo Flores-Castro2

*Comparative Field Trial Effect of* Brucella *spp. Vaccines on Seroconversion in Goats…*

, David I. Martínez-Herrera1

1 Facultad de Medicina Veterinaria y Zootecnia, Universidad Veracruzana, Veracruz,

(CENID-Microbiología), Instituto Nacional de Investigaciones Forestales, Agrícolas

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

, José F. Morales-Álvarez2

2 Centro Nacional de Investigación Disciplinaria Microbiología

y Pecuarias, Santa Fé, Ciudad de México, México

\*Address all correspondence to: dmartinez@uv.mx

provided the original work is properly cited.

\*, Violeta T. Pardío-Sedas1

and José A. Villagómez-Cortés1

,

*DOI: http://dx.doi.org/10.5772/intechopen.87065*

#### **Conflict of interest**

The authors have no conflict of interest to declare.

*Comparative Field Trial Effect of* Brucella *spp. Vaccines on Seroconversion in Goats… DOI: http://dx.doi.org/10.5772/intechopen.87065*

#### **Author details**

*New Insight into* Brucella *Infection and Foodborne Diseases*

negative to brucellosis [28, 29, 31, 33, 34].

induce seroconversion in goats.

safety, and efficacy at field level.

**Acknowledgements**

**Conflict of interest**

**5. Conclusion**

the screening test, which could be discarded by SRD test that identified them as

The RB51-SOD strain was obtained from *B. abortus* 2308 in order to generate the overexpression of a protective periplasmic antigen of the protective antigen known as Cu/Zn SOD, which causes the immune cell response by T-helper-type Th1 lymphocytes, and protection against the strain of *B. abortus* 2308, which has been demonstrated in murine models [26, 29, 31–33]. Despite the favorable outcome in mice, Dorneles et al. [33] pointed out that the potential use of RB51-SOD under field conditions is very limited, although satisfactory results have been obtained. It is important to consider that the response observed in the mice might not reflect the protection achieved in the natural hosts after vaccination. Moreover, to generate a strong and protective immune response that mimic natural infection is a complex challenge. However, the current study in goats allowed to evaluate the RB51-SOD strain and to know part of its satisfactory performance in the field, since the newly developed vaccines have only evaluated in murine models [28–30]. Contrary to the Rev. 1 vaccine, current study demonstrates that the RB51-SOD strain does not

When evaluating the Rev. 1, RB51, and RB51-SOD vaccine strains, seroconversion in animals vaccinated with Rev. 1 strain was higher than that shown by the strains RB51 and RB51-SOD by conventional serological tests in infected herds during the evaluated period. Therefore, vaccination with Rev. 1 originates the need to perform confirmatory tests causing an increase in diagnosis costs. According to results of the present study, the RB51-SOD vaccine represents an alternative for controlling one of the most important worldwide zoonosis in goats. However, further studies are required to evaluate the performance of immune response, vaccine

We thank the state committee for the promotion and protection of livestock of Veracruz and the product system goats of Veracruz. This work was supported by SEP-PRODEP research grant project [DSA/I103.5/I5/14220] "Support for the

integration of thematic networks of academic collaboration."

The authors have no conflict of interest to declare.

**14**

Baldomero Molina-Sánchez1 , David I. Martínez-Herrera1 \*, Violeta T. Pardío-Sedas1 , Ricardo Flores-Castro2 , José F. Morales-Álvarez2 and José A. Villagómez-Cortés1

1 Facultad de Medicina Veterinaria y Zootecnia, Universidad Veracruzana, Veracruz, Veracruz, México

2 Centro Nacional de Investigación Disciplinaria Microbiología (CENID-Microbiología), Instituto Nacional de Investigaciones Forestales, Agrícolas y Pecuarias, Santa Fé, Ciudad de México, México

\*Address all correspondence to: dmartinez@uv.mx

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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[29] Fosgate GT, Adesiyun AA, Hird DW, Johnson WO, Hietala SK, Schurig GG, et al. Evaluation of brucellosis RB51 vaccine for domestic water buffalo (*Bubalus bubalis*) in Trinidad. Preventive Veterinary Medicine.

[30] Vemulapalli R, He Y, Cravero S, Sriranganathan N, Boyle SM, Schurig GG. Overexpression of protective antigen as a novel approach to enhance vaccine efficacy of *Brucella abortus* strain RB51. Infection and Immunity.

[31] Oñate AA, Céspedes S, Cabrera A, Rivers R, González A, Muñoz C,

Sons; 2010. pp. 89-93

2015;**9**(05):470-475

2006;**62**(1):33-37

2005;**43**(3):399-404

2003;**58**(3):211-225

2000;**68**(6):3286-3289

of Biology. 2013;**8**(1):60-77

*DOI: http://dx.doi.org/10.5772/intechopen.87065*

[17] Poester FP, Ramos ET, Gomes MJP,

Chiminazzo C, Schurig G. The serological response of adult cattle after vaccination with *Brucella abortus* strain 19 and RB51. Brazilian Journal of Veterinary Research and Animal

[18] Garin-Bastuji B, Blasco JM, Marín C, Albert D. The diagnosis of brucellosis in sheep and goats, old and new tools. Small Ruminant Research.

[19] Rahman S, Baek BK. Diagnostic efficacy of *Brucella abortus* strain RB51 in experimentally inoculated Sprague-Dawley rats using western blot assay. Journal of Infection in Developing

Countries. 2008;**2**(05):384-388

[21] Garin – Bastuji B, Blasco JM, Marín C, Albert D. The diagnosis of brucellosis in sheep and goats, old and new tolos. Small Ruminant Research.

[22] Coelho AM, Díez JG, Coelho AC. Brucelosis en pequeños rumiantes: efecto de la aplicación de un programa especial de vacunación en masa con REV-1. Revista electrónica de Veterinaria. 2013;**14**(12):1-16

[23] Thrusfield M. Veterinary

Science Oxford; 2005

Epidemiology. 3rd ed. UK: Blackwell

2006;**62**:63-70

[20] Mikolon AB, Gardner IA, Hietala SK, de Anda JH, Pestaña EC, Hennager SG, et al. Evaluation of North American antibody detection tests for diagnosis of brucellosis in goats. Journal of Clinical Microbiology. 1998;**36**(6):1716-1722

of *Brucella abortus* strain RB51 and *Brucella melitensis* Rev. 1 live vaccines against experimental infection with *Brucella melitensis* in pregnant ewes. Revue Scientifique et Technique-Office International des Épizooties.

2001;**20**(3):741-744

Science. 2000;**37**(1)

2006;**62**(1):63-70

*Comparative Field Trial Effect of* Brucella *spp. Vaccines on Seroconversion in Goats… DOI: http://dx.doi.org/10.5772/intechopen.87065*

of *Brucella abortus* strain RB51 and *Brucella melitensis* Rev. 1 live vaccines against experimental infection with *Brucella melitensis* in pregnant ewes. Revue Scientifique et Technique-Office International des Épizooties. 2001;**20**(3):741-744

[17] Poester FP, Ramos ET, Gomes MJP, Chiminazzo C, Schurig G. The serological response of adult cattle after vaccination with *Brucella abortus* strain 19 and RB51. Brazilian Journal of Veterinary Research and Animal Science. 2000;**37**(1)

[18] Garin-Bastuji B, Blasco JM, Marín C, Albert D. The diagnosis of brucellosis in sheep and goats, old and new tools. Small Ruminant Research. 2006;**62**(1):63-70

[19] Rahman S, Baek BK. Diagnostic efficacy of *Brucella abortus* strain RB51 in experimentally inoculated Sprague-Dawley rats using western blot assay. Journal of Infection in Developing Countries. 2008;**2**(05):384-388

[20] Mikolon AB, Gardner IA, Hietala SK, de Anda JH, Pestaña EC, Hennager SG, et al. Evaluation of North American antibody detection tests for diagnosis of brucellosis in goats. Journal of Clinical Microbiology. 1998;**36**(6):1716-1722

[21] Garin – Bastuji B, Blasco JM, Marín C, Albert D. The diagnosis of brucellosis in sheep and goats, old and new tolos. Small Ruminant Research. 2006;**62**:63-70

[22] Coelho AM, Díez JG, Coelho AC. Brucelosis en pequeños rumiantes: efecto de la aplicación de un programa especial de vacunación en masa con REV-1. Revista electrónica de Veterinaria. 2013;**14**(12):1-16

[23] Thrusfield M. Veterinary Epidemiology. 3rd ed. UK: Blackwell Science Oxford; 2005

[24] Campbell MJ, Machin D, Walters SJ. Medical Statistics: A Textbook for the Health Sciences. 4th ed. Chichester, West Sussex, England: John Wiley & Sons; 2010. pp. 89-93

[25] Ali S, Akhter S, Neubauer H, Melzer F, Khan I, Ali Q, et al. Serological, cultural, and molecular evidence of Brucella infection in small ruminants in Pakistan. Journal of Infection in Developing Countries. 2015;**9**(05):470-475

[26] Blasco JM. Existing and future vaccines against brucellosis in small ruminants. Small Ruminant Research. 2006;**62**(1):33-37

[27] Martínez Martínez OL, Pérez De la Rosa R, Díaz Aparicio E, Snyderlaar Hardwicke AC, Hernández Andrade L, Suárez Güemes F. Estudio de la eliminación en la leche de la cepa Rev 1 de *Brucella melitensi*s en cabras vacunadas con dosis reducida. Tecnica Pecuaria en Mexico. 2005;**43**(3):399-404

[28] Yang X, Skyberg JA, Cao L, Clapp B, Thornburg T, Pascual DW. Progress in Brucella vaccine development. Frontiers of Biology. 2013;**8**(1):60-77

[29] Fosgate GT, Adesiyun AA, Hird DW, Johnson WO, Hietala SK, Schurig GG, et al. Evaluation of brucellosis RB51 vaccine for domestic water buffalo (*Bubalus bubalis*) in Trinidad. Preventive Veterinary Medicine. 2003;**58**(3):211-225

[30] Vemulapalli R, He Y, Cravero S, Sriranganathan N, Boyle SM, Schurig GG. Overexpression of protective antigen as a novel approach to enhance vaccine efficacy of *Brucella abortus* strain RB51. Infection and Immunity. 2000;**68**(6):3286-3289

[31] Oñate AA, Céspedes S, Cabrera A, Rivers R, González A, Muñoz C,

**16**

*New Insight into* Brucella *Infection and Foodborne Diseases*

[9] Mendez-Lozano M, Rodríguez-Reyes EJ, Sánchez-Zamorano LM. Brucelosis, una zoonosis presente en la población: estudio de series de tiempo en México. Salud Pública México. 2015;**57**:519-527

[10] Tsegay A, Tuli G, Kassa T, Kebede N. Seroprevalence and risk factors of Brucellosis in small ruminants slaughtered at Debre Ziet and Modjo export abattoirs, Ethiopia. Journal of Infection in Developing Countries.

[11] Wareth G, Melzer F, Elschner MC, Neubauer H, Roesler U. Detection of *Brucella melitensis* in bovine milk and milk products from apparently healthy animals in Egypt by real-time PCR. Journal of Infection in Developing

Countries. 2014;**8**(10):1339-1343

México. 2017;**153**(1):26-30

[12] Román-Ramírez DL, Martínez-Herrera DI, Villagómez-Cortés JAJ, Peniche-Cardeña ÁE, Morales-Álvarez JF, Flores-Castro R. Epidemiología de la brucelosis caprina en la Zona Centro del Estado de Veracruz. Gaceta Médica de

[13] Villa R, Perea M, Aparicio ED, Mobarak AS, Andrade LH, Güemes FS. Abortions and stillbirths in goats immunized against brucellosis using RB51, rfbK and Rev 1 vaccines. Tecnica Pecuaria en Mexico. 2008;**46**(3):249-257

[14] Schurig GG, Sriranganathan N, Corbel MJ. Brucellosis vaccines: past, present and future. Veterinary Microbiology. 2002;**90**(1):479-496

[15] Luna-Martı́nez JE, Mejı́a-Terán C. Brucellosis in Mexico: Current status and trends. Veterinary Microbiology.

[16] El Idrissi AH, Benkirane A, El Maadoudi M, Bouslikhane M, Berrada J, Zerouali A. Comparison of the efficacy

2002;**90**(1):19-30

2015;**9**:373-380

[1] Gul ST, Khan A. Epidemiology and epizootology of brucellosis: A review. Pakistan Veterinary Journal.

[2] Arenas-Gamboa AM, Rossetti CA, Chaki SP, Garcia-Gonzalez DG, Adams LG, Ficht TA. Human brucellosis and adverse pregnancy outcomes. Current Tropical Medicine Reports.

[3] Kaltungo BY, Saidu SNA, Musa IW, Baba AY. Brucellosis: A neglected zoonosis. British Microbiology Research

Journal. 2014;**4**:1551-1574

2007;**82**(3):282-290

1992;**34**(2):230-240

Practice. 2011;**27**(1):95-104

2013;**45**(6):1383-1389

[4] Reviriego FJ, Moreno MA, Domınguez L. Risk factors for brucellosis seroprevalence of sheep and goat flocks in Spain. Preventive Veterinary Medicine. 2000;**44**:167-173

[5] Solorio-Rivera JL, Segura-Correa JC, Sánchez-Gil LG. Seroprevalence of and risk factors for brucellosis of goats in herds of Michoacan, Mexico. Preventive Veterinary Medicine.

[6] Lopez-Merino AH, Migrañas-Ortiz R, Perez-Miravete A, Magos C, Izaba BS, Tapia-Coyner R, et al. Seroepidemiología de la brucelosis en México. Salud Pública de México.

[7] Blasco JM, Molina-Flores B. Control and eradication of *Brucella melitensis* infection in sheep and goats. Veterinary Clinics of North America: Food Animal

[8] Montiel DO, Frankena K, Udo H, Baer NMK, Van der Zijpp A. Prevalence and risk factors for brucellosis in goats in areas of Mexico with and without brucellosis control campaign. Tropical Animal Health and Production.

**References**

2007;**27**:145-151

2016;**3**:164-172

et al. A DNA vaccine encoding Cu, Zn superoxide dismutase of *Brucella abortus* induces protective immunity in BALB/c mice. Infection and Immunity. 2003;**71**(9):4857-4861

[32] Olsen SC, Boyle SM, Schurig GG, Sriranganathan NN. Immune responses and protection against experimental challenge after vaccination of bison with *Brucella abortus* strain RB51 or RB51 overexpressing superoxide dismutase and glycosyltransferase genes. Clinical and Vaccine Immunology. 2009;**16**(4):535-540

[33] Dorneles EM, Sriranganathan N, Lage AP. Recent advances in *Brucella abortus* vaccines. Veterinary Research. 2015;**46**(1):76

[34] Goodwin ZI, Pascual DW. Brucellosis vaccines for livestock. Veterinary Immunology and Immunopathology. 2016;**181**:51-58

**19**

**Chapter 3**

**Abstract**

**1. Introduction**

**2. Glomerular disease in brucellosis**

*Shokoufeh Savaj*

Kidney Disease in Brucellosis

the disease, especially when they practice in the endemic area.

**Keywords:** kidney, brucellosis, glomerular disease, dialysis, kidney transplant

Brucellosis, a prevalent zoonosis disease with a worldwide distribution, can involve the kidney during infection. In 1889, Bruce [1] firstly reported kidney disease in Malt fever. Since then, a wide range of kidney involvements from direct invasion of Brucella with abscess and tubulointerstitial nephritis, immune complex disease, vasculitis, and drug toxicity have been reported. Brucella infection in immunocompromised patient can induce a confusing picture with peritonitis in peritoneal dialysis (PD), spondylodiscitis in hemodialysis, and complicated form of the disease in kidney transplant (TX) patients. Immunosuppressive monitoring, drug side effects, and donor to recipient transmission or recurrence are great challenges in the management of organ recipients with brucellosis. In this chapter, different presentations of brucellosis in kidney including glomeruli, tubulointerstitial, and vasculature involvement are discussed. Secondly, the Brucella infection in PD, HD, and Tx patients are reviewed, and finally, the chance of infection transmission of Brucellosis in the donor and recipients and the challenging point of pretransplant evaluation in donors and recipients are discussed.

Glomerular disease is an uncommon presentation in brucellosis. It can present with hematuria, pyuria, proteinuria, increased blood pressure, edema, and renal

Brucellosis, a prevalent zoonosis disease in different countries, can involve the kidney during infection and also present in the complicated form in hemodialysis (HD), peritoneal dialysis (PD), and kidney transplant (Tx) patient. In spite of few reports of kidney involvements in the literature, this infection can imitate a wide range of glomerular disease from minimal change, membranous glomeropathy, focal and diffuse proliferative glomerular disease to rapidly progressive glomerulonephritis. Cryoglobulinemia, thrombotic microangiopathy, and ANCA-associated glomerular disease are vasculitis form of the disease. Tubulointerstitial involvement, electrolyte disorder, renal abscess, and pyelonephritis can present the same as other Gram-negative infections. Moreover, peritonitis in PD patient, spondyloarthropathy in HD, and severe infection in kidney Tx patients have been reported. Infection recurrence and infection from kidney donors are another dilemma in renal recipients. Brucellosis as a multifaced disease can mimic a wide range of presentations in nephrology. Clinicians should keep in mind the diverse pictures of

## **Chapter 3** Kidney Disease in Brucellosis

*Shokoufeh Savaj*

#### **Abstract**

*New Insight into* Brucella *Infection and Foodborne Diseases*

et al. A DNA vaccine encoding Cu, Zn superoxide dismutase of *Brucella abortus* induces protective immunity in BALB/c mice. Infection and Immunity.

[32] Olsen SC, Boyle SM, Schurig GG, Sriranganathan NN. Immune responses and protection against experimental challenge after vaccination of bison with *Brucella abortus* strain RB51 or RB51 overexpressing superoxide dismutase and glycosyltransferase genes. Clinical and Vaccine Immunology.

[33] Dorneles EM, Sriranganathan N, Lage AP. Recent advances in *Brucella abortus* vaccines. Veterinary Research.

[34] Goodwin ZI, Pascual DW. Brucellosis vaccines for livestock. Veterinary Immunology and Immunopathology. 2016;**181**:51-58

2003;**71**(9):4857-4861

2009;**16**(4):535-540

2015;**46**(1):76

**18**

Brucellosis, a prevalent zoonosis disease in different countries, can involve the kidney during infection and also present in the complicated form in hemodialysis (HD), peritoneal dialysis (PD), and kidney transplant (Tx) patient. In spite of few reports of kidney involvements in the literature, this infection can imitate a wide range of glomerular disease from minimal change, membranous glomeropathy, focal and diffuse proliferative glomerular disease to rapidly progressive glomerulonephritis. Cryoglobulinemia, thrombotic microangiopathy, and ANCA-associated glomerular disease are vasculitis form of the disease. Tubulointerstitial involvement, electrolyte disorder, renal abscess, and pyelonephritis can present the same as other Gram-negative infections. Moreover, peritonitis in PD patient, spondyloarthropathy in HD, and severe infection in kidney Tx patients have been reported. Infection recurrence and infection from kidney donors are another dilemma in renal recipients. Brucellosis as a multifaced disease can mimic a wide range of presentations in nephrology. Clinicians should keep in mind the diverse pictures of the disease, especially when they practice in the endemic area.

**Keywords:** kidney, brucellosis, glomerular disease, dialysis, kidney transplant

#### **1. Introduction**

Brucellosis, a prevalent zoonosis disease with a worldwide distribution, can involve the kidney during infection. In 1889, Bruce [1] firstly reported kidney disease in Malt fever. Since then, a wide range of kidney involvements from direct invasion of Brucella with abscess and tubulointerstitial nephritis, immune complex disease, vasculitis, and drug toxicity have been reported. Brucella infection in immunocompromised patient can induce a confusing picture with peritonitis in peritoneal dialysis (PD), spondylodiscitis in hemodialysis, and complicated form of the disease in kidney transplant (TX) patients. Immunosuppressive monitoring, drug side effects, and donor to recipient transmission or recurrence are great challenges in the management of organ recipients with brucellosis. In this chapter, different presentations of brucellosis in kidney including glomeruli, tubulointerstitial, and vasculature involvement are discussed. Secondly, the Brucella infection in PD, HD, and Tx patients are reviewed, and finally, the chance of infection transmission of Brucellosis in the donor and recipients and the challenging point of pretransplant evaluation in donors and recipients are discussed.

#### **2. Glomerular disease in brucellosis**

Glomerular disease is an uncommon presentation in brucellosis. It can present with hematuria, pyuria, proteinuria, increased blood pressure, edema, and renal

failure. Glomerular involvement from mild proteinuria, microscopic hematuria up to the severe presentations of glomerular disease including rapidly progressive glomerulitis resulted in end-stage kidney disease have been reported. Glomeruli affected by immune complexes or vasculitis during Brucella endocarditis. The usual glomerulopathy in cases with endocarditis is focal and diffuse proliferative glomerulonephritis which are presented in the literature as membranoproliferative [2] and rapidly progressive glomerulonephritis; IgA nephropathy reported in two patients [3, 4] with proteinuria and hematuria. Siegelmann et al. [4] reported a case with nephrotic range proteinuria (6.0–13.0 g/day) and focal and segmental glomerulonephritis with mesangial proliferation and heavy deposit of IgA. Proteinuria persisted 3 months after completion of therapy, which indicates a secondary form of IgA nephropathy. Minimal change disease is a rare presentation of brucellosis reported only in one case without endocarditis. The patient had massive proteinuria who received prednisolone and antimicrobial treatment with complete remission and no recurrence after 1 year [5]. Membranous nephropathy is also diagnosed in one case with proteinuria [6].

#### **3. Vasculitis in brucellosis**

Vasculitis is a lethal picture of brucellosis with systemic organ involvement. Turgay et al. [7] reported 52-year-old male with Brucella infection and ANCAassociated vasculitis that induced rapidly progressive glomerulitis. The patient had endocarditis with vegetation on the aortic valve and leukocytoclastic vasculitis. Serology showed a high titer of serum agglutinin for Brucella and positive P-ANCA test. The patient recovered with combination therapy of plasmapheresis, methylprednisolone pulse, and antibiotic therapy. The other vasculitis form of kidney disease is cryoglobulinemia. This systemic disease can happen in malignancy, autoimmune, and infectious disease. Mixed cryoglobulinemia in brucellosis has been reported in five cases (four from Peru and one from Spain). They had a high polyclonal cryoglobulin level (IgG, IgA, and IgM) with a female preponderance (4:1). Four cases had positive bone marrow culture and one diagnosed based on serology [8]. Thrombotic microangiopathy that presents with microangiopathic hemolytic anemia, thrombocytopenia, and variable signs of organ impairment due to platelet aggregation in the microcirculation has been reported in patients with brucellosis. Erdem et al. [9] reported a 51-year-old man with thrombotic microangiopathy, hematuria, diminished consciousness, and renal failure. The patient received combination therapy with antimicrobials and plasma exchange with a good response and no recurrence in 1.5 years follow-up.

#### **4. Tubulointerstitial and parenchymal involvement in brucellosis**

Direct invasion of parenchyma and abscess formation is a rare manifestation of Brucella, which has been reported in five cases in the literature. Li et al. [10] reported a 45-year-old man with fever and flank pain. CT scan showed a low-density lesion in the right kidney in CT scan and positive culture for Brucella. He received 8 weeks course of treatment and relapse after discontinuation of treatment, which needed another 16 weeks course of rifampin and moxifloxacin for the eradication of bacteria. There are reports of acute interstitial nephritis [11] and pyelonephritis [12] after Brucella infection. A perplexing point is antimicrobial therapy with rifampin, which can induce interstitial nephritis. Salih et al. reported a 52-year-old man with a diagnosis of Brucella. Patient referred with acute renal failure 2 weeks after treatment with rifampin. Renal failure recovered since the drug was discontinued [13].

**21**

and doxycycline.

*Kidney Disease in Brucellosis*

*DOI: http://dx.doi.org/10.5772/intechopen.86432*

**5. Electrolyte abnormality in Brucella infection**

dysfunction is another presentation of Brucella infection.

**6. Brucellosis in hemodialysis patients**

Syndrome of inappropriate secretion of ADH (SIADH), which presented with hyponatremia in a euvolemic patient without other electrolyte abnormality has been reported in patients with brucellosis. Bala et al. [14] in a study of 160 children and adolescent with SIADH reported 21.9% prevalence of SIADH. Urinary sodium (>25 mmol/L) with normal dietary salt intake, low uric acid (<2 mg/dL), the absence of kidney, thyroid or adrenal disease, and history of diuretic use were the criteria for diagnosis. Hyponatremia had a correlation to the severity of disease and managed with fluid restriction. Renal tubular disorder presented in 31 patients with active brucellosis [15]. They had phosphorus, potassium, and sodium handling abnormality in 31 patients. These patients were not malnourished, received fluid therapy, or hospitalized. They proposed that besides glomerular damage, tubular

Musculoskeletal problem is a prevalent feature in hemodialysis (HD) patients, which presents due to renal osteodystrophy and amyloidosis resulted from beta 2 microglobulin deposition in the joints. These symptoms can mislead the clinician to overlook Brucella diagnosis. Inversely, fever as a common presentation of the infectious disease is missing in those ill patients. Most of the reported cases of brucellosis in HD patients presented with musculoskeletal pain, arthralgia, low back pain, and malaise in the acute form of brucellosis. Paravertebral and epidural abscess with spondylodiscitis in thoracic and lumbar vertebra and neurobrucellosis with a headache, diplopia, and cranial nerve involvement were reported as the complicated chronic form brucellosis in HD patients [16]. There is also a report of fatal septicemia and endocarditis [17, 18] in HD patients. Blood cultures should be performed in HD patients when typical symptoms of brucellosis exist even when the patient has no fever. Drug toxicity and dose adjustment are the other obstacles in the treatment of these patients. Rifampin and doxycycline with a hepatic metabolism do not need any dose adjustment; however, aminoglycosides, cephalosporins, and fluoroquinolones should be prescribed based on

patient's eGFR and patient needs a supplement dose after dialysis course.

Peritoneal dialysis patients are at risk of peritonitis. Gram-positive organisms are the common cause of infections in 80% of the episodes. There are few reports of peritonitis due to Brucella infection in the literature. All of the cases presented with a typical peritoneal infection with neutrophil predominance with a positive culture in 5−21 days [19]. Organ involvement is hematogenous in most of the studies; however, Osizik et al. [20] showed a positive peritoneal fluid culture with a negative blood culture and serology. They proposed a direct inoculation of bacteria from the catheter to peritoneum based on the patient's occupation. The other issue in Brucella peritonitis in PD patients is any need for catheter removal after Brucella infection. Taskapan et al. [21] and Alothman et al. [22] reported two cases with a recurrence of infection in 6−8 weeks after treatment that resulted in catheter removal for complete eradication of bacteria. On the other hand, Unal et al. [23] and Solak et al. [19] in two different reports showed the complete cure of infection despite keeping peritoneal catheter. Drug regimen in these studies was 6 weeks course of rifampin

**7. Brucellosis in peritoneal dialysis (PD) patients**

*New Insight into* Brucella *Infection and Foodborne Diseases*

**3. Vasculitis in brucellosis**

response and no recurrence in 1.5 years follow-up.

**4. Tubulointerstitial and parenchymal involvement in brucellosis**

Direct invasion of parenchyma and abscess formation is a rare manifestation of Brucella, which has been reported in five cases in the literature. Li et al. [10] reported a 45-year-old man with fever and flank pain. CT scan showed a low-density lesion in the right kidney in CT scan and positive culture for Brucella. He received 8 weeks course of treatment and relapse after discontinuation of treatment, which needed another 16 weeks course of rifampin and moxifloxacin for the eradication of bacteria. There are reports of acute interstitial nephritis [11] and pyelonephritis [12] after Brucella infection. A perplexing point is antimicrobial therapy with rifampin, which can induce interstitial nephritis. Salih et al. reported a 52-year-old man with a diagnosis of Brucella. Patient referred with acute renal failure 2 weeks after treatment with rifampin. Renal failure recovered since the drug was discontinued [13].

failure. Glomerular involvement from mild proteinuria, microscopic hematuria up to the severe presentations of glomerular disease including rapidly progressive glomerulitis resulted in end-stage kidney disease have been reported. Glomeruli affected by immune complexes or vasculitis during Brucella endocarditis. The usual glomerulopathy in cases with endocarditis is focal and diffuse proliferative glomerulonephritis which are presented in the literature as membranoproliferative [2] and rapidly progressive glomerulonephritis; IgA nephropathy reported in two patients [3, 4] with proteinuria and hematuria. Siegelmann et al. [4] reported a case with nephrotic range proteinuria (6.0–13.0 g/day) and focal and segmental glomerulonephritis with mesangial proliferation and heavy deposit of IgA. Proteinuria persisted 3 months after completion of therapy, which indicates a secondary form of IgA nephropathy. Minimal change disease is a rare presentation of brucellosis reported only in one case without endocarditis. The patient had massive proteinuria who received prednisolone and antimicrobial treatment with complete remission and no recurrence after 1 year [5]. Membranous nephropathy is also diagnosed in one case with proteinuria [6].

Vasculitis is a lethal picture of brucellosis with systemic organ involvement. Turgay et al. [7] reported 52-year-old male with Brucella infection and ANCAassociated vasculitis that induced rapidly progressive glomerulitis. The patient had endocarditis with vegetation on the aortic valve and leukocytoclastic vasculitis. Serology showed a high titer of serum agglutinin for Brucella and positive P-ANCA test. The patient recovered with combination therapy of plasmapheresis, methylprednisolone pulse, and antibiotic therapy. The other vasculitis form of kidney disease is cryoglobulinemia. This systemic disease can happen in malignancy, autoimmune, and infectious disease. Mixed cryoglobulinemia in brucellosis has been reported in five cases (four from Peru and one from Spain). They had a high polyclonal cryoglobulin level (IgG, IgA, and IgM) with a female preponderance (4:1). Four cases had positive bone marrow culture and one diagnosed based on serology [8]. Thrombotic microangiopathy that presents with microangiopathic hemolytic anemia, thrombocytopenia, and variable signs of organ impairment due to platelet aggregation in the microcirculation has been reported in patients with brucellosis. Erdem et al. [9] reported a 51-year-old man with thrombotic microangiopathy, hematuria, diminished consciousness, and renal failure. The patient received combination therapy with antimicrobials and plasma exchange with a good

**20**

### **5. Electrolyte abnormality in Brucella infection**

Syndrome of inappropriate secretion of ADH (SIADH), which presented with hyponatremia in a euvolemic patient without other electrolyte abnormality has been reported in patients with brucellosis. Bala et al. [14] in a study of 160 children and adolescent with SIADH reported 21.9% prevalence of SIADH. Urinary sodium (>25 mmol/L) with normal dietary salt intake, low uric acid (<2 mg/dL), the absence of kidney, thyroid or adrenal disease, and history of diuretic use were the criteria for diagnosis. Hyponatremia had a correlation to the severity of disease and managed with fluid restriction. Renal tubular disorder presented in 31 patients with active brucellosis [15]. They had phosphorus, potassium, and sodium handling abnormality in 31 patients. These patients were not malnourished, received fluid therapy, or hospitalized. They proposed that besides glomerular damage, tubular dysfunction is another presentation of Brucella infection.

#### **6. Brucellosis in hemodialysis patients**

Musculoskeletal problem is a prevalent feature in hemodialysis (HD) patients, which presents due to renal osteodystrophy and amyloidosis resulted from beta 2 microglobulin deposition in the joints. These symptoms can mislead the clinician to overlook Brucella diagnosis. Inversely, fever as a common presentation of the infectious disease is missing in those ill patients. Most of the reported cases of brucellosis in HD patients presented with musculoskeletal pain, arthralgia, low back pain, and malaise in the acute form of brucellosis. Paravertebral and epidural abscess with spondylodiscitis in thoracic and lumbar vertebra and neurobrucellosis with a headache, diplopia, and cranial nerve involvement were reported as the complicated chronic form brucellosis in HD patients [16]. There is also a report of fatal septicemia and endocarditis [17, 18] in HD patients. Blood cultures should be performed in HD patients when typical symptoms of brucellosis exist even when the patient has no fever. Drug toxicity and dose adjustment are the other obstacles in the treatment of these patients. Rifampin and doxycycline with a hepatic metabolism do not need any dose adjustment; however, aminoglycosides, cephalosporins, and fluoroquinolones should be prescribed based on patient's eGFR and patient needs a supplement dose after dialysis course.

#### **7. Brucellosis in peritoneal dialysis (PD) patients**

Peritoneal dialysis patients are at risk of peritonitis. Gram-positive organisms are the common cause of infections in 80% of the episodes. There are few reports of peritonitis due to Brucella infection in the literature. All of the cases presented with a typical peritoneal infection with neutrophil predominance with a positive culture in 5−21 days [19]. Organ involvement is hematogenous in most of the studies; however, Osizik et al. [20] showed a positive peritoneal fluid culture with a negative blood culture and serology. They proposed a direct inoculation of bacteria from the catheter to peritoneum based on the patient's occupation. The other issue in Brucella peritonitis in PD patients is any need for catheter removal after Brucella infection. Taskapan et al. [21] and Alothman et al. [22] reported two cases with a recurrence of infection in 6−8 weeks after treatment that resulted in catheter removal for complete eradication of bacteria. On the other hand, Unal et al. [23] and Solak et al. [19] in two different reports showed the complete cure of infection despite keeping peritoneal catheter. Drug regimen in these studies was 6 weeks course of rifampin and doxycycline.

#### **8. Brucellosis in renal transplant recipients**

However, the prevalence of brucellosis is around 1 in 500,000 population, and there are few reports in renal transplant recipients. In another view, these patients are at risk of different opportunistic infections. Most of the time, diagnosis of brucellosis was lately with the complicated form of the disease. There were two reports of neurobrucellosis in renal Tx patients in the literature, one with loss of consciousness and encephalitis [24] and the other one with a seizure and headache [25]. Endocarditis [26], pulmonary involvement [27], hepatobiliary and hematologic [28], pyelonephritis and dysuria [29], and arthritis [30] were other presentations of the disease. They were diagnosed based on serology or fluid culture that finally guided to the diagnosis of brucellosis. In addition to the complicated form of the disease and late diagnosis, drug interferences, especially calcineurin inhibitors, are another challenging point in the treatment of disease. Rifampin decreases drug level and inversely clarithromycin increases drug level that induces calcineurin toxicity. Hence, streptomycin with nephrotoxic nature cannot be the first choice in renal Tx patient. Ting et al. suggested tigecycline as an alternative drug in renal Tx patient. Triple antibacterial treatment has experienced in these immunocompromised patients with a complicated form of the disease [26, 30]. In these six reports, all of the patients completed the 6−12 weeks course of treatment with a good outcome and no recurrence; however, they experienced a serum creatinine rise.

#### **9. Kidney donor evaluation before transplant**

Evaluation for Brucella infection is suggested before organ transplantation in donors and recipients, especially in endemic areas. There are some reports of Brucella transmission and recurrence after liver [31], bone marrow transplantation [32, 33]. Serologic tests including serum agglutination and ELISA should be performed before organ transplant. Positive titers consisted of 1:80 in the non-endemic area and 1:160 in the endemic area are suspicious and needs further evaluation. Serologic tests are not enough to distinguish active and past infection, which needs more evaluation by infectious disease specialist.

#### **10. Conclusion**

In this chapter, a wide range of Brucella presentations was discussed. Brucellosis as a multifaced disease can imitate a large group of non-infectious causes of kidney disease. Hence, the misdiagnosis could be hazardous and end to the patient's morbidity and mortality. Clinicians should keep in mind the diverse pictures of the disease, especially when they practice in the endemic area.

**23**

**Author details**

Shokoufeh Savaj

Sciences, Firoozgar Hospital, Tehran, Iran

provided the original work is properly cited.

\*Address all correspondence to: savaj.sh@iums.ac.ir

Internal Medicine Department, Branch of Nephrology, Iran University of Medical

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

*Kidney Disease in Brucellosis*

*DOI: http://dx.doi.org/10.5772/intechopen.86432*

*Kidney Disease in Brucellosis DOI: http://dx.doi.org/10.5772/intechopen.86432*

*New Insight into* Brucella *Infection and Foodborne Diseases*

**8. Brucellosis in renal transplant recipients**

experienced a serum creatinine rise.

**9. Kidney donor evaluation before transplant**

more evaluation by infectious disease specialist.

**10. Conclusion**

Evaluation for Brucella infection is suggested before organ transplantation in donors and recipients, especially in endemic areas. There are some reports of Brucella transmission and recurrence after liver [31], bone marrow transplantation [32, 33]. Serologic tests including serum agglutination and ELISA should be performed before organ transplant. Positive titers consisted of 1:80 in the non-endemic area and 1:160 in the endemic area are suspicious and needs further evaluation. Serologic tests are not enough to distinguish active and past infection, which needs

In this chapter, a wide range of Brucella presentations was discussed. Brucellosis as a multifaced disease can imitate a large group of non-infectious causes of kidney disease. Hence, the misdiagnosis could be hazardous and end to the patient's morbidity and mortality. Clinicians should keep in mind the diverse

pictures of the disease, especially when they practice in the endemic area.

However, the prevalence of brucellosis is around 1 in 500,000 population, and there are few reports in renal transplant recipients. In another view, these patients are at risk of different opportunistic infections. Most of the time, diagnosis of brucellosis was lately with the complicated form of the disease. There were two reports of neurobrucellosis in renal Tx patients in the literature, one with loss of consciousness and encephalitis [24] and the other one with a seizure and headache [25]. Endocarditis [26], pulmonary involvement [27], hepatobiliary and hematologic [28], pyelonephritis and dysuria [29], and arthritis [30] were other presentations of the disease. They were diagnosed based on serology or fluid culture that finally guided to the diagnosis of brucellosis. In addition to the complicated form of the disease and late diagnosis, drug interferences, especially calcineurin inhibitors, are another challenging point in the treatment of disease. Rifampin decreases drug level and inversely clarithromycin increases drug level that induces calcineurin toxicity. Hence, streptomycin with nephrotoxic nature cannot be the first choice in renal Tx patient. Ting et al. suggested tigecycline as an alternative drug in renal Tx patient. Triple antibacterial treatment has experienced in these immunocompromised patients with a complicated form of the disease [26, 30]. In these six reports, all of the patients completed the 6−12 weeks course of treatment with a good outcome and no recurrence; however, they

**22**

### **Author details**

Shokoufeh Savaj Internal Medicine Department, Branch of Nephrology, Iran University of Medical Sciences, Firoozgar Hospital, Tehran, Iran

\*Address all correspondence to: savaj.sh@iums.ac.ir

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **References**

[1] Bruce DJ. Observations on Malta fever. BMJ. 1101;**1**(1481):1889

[2] Provatopoulou S, Papasotiriou M, Papachristou E, Gakiopoulou H, Marangos M, Goumenos DS, et al. Membranoproliferative glomerulonephritis in a patient with chronic brucellosis. Kidney Research and Clinical Practice. 2018;**37**(3):298

[3] Ardalan MR, Shoja MM. Rapidly progressive glomerulonephritis in a patient with brucellosis. Nephrology Dialysis Transplantation. 2006;**21**(6):1743-1744

[4] Siegelmann N, Abraham A, Rudensky B, Shemesh OJ. Brucellosis with nephrotic syndrome, nephritis, and IgA nephropathy. Postgraduate Medical Journal. 1992;**68**(804):834-836

[5] Sabanis N, Gavriilaki E, Paschou E, Tsotsiou E, Kalaitzoglou A, Kavlakoudis C, et al. Renal manifestations of human brucellosis: First report of minimal change disease. Saudi Journal of Kidney Disease and Transplantation. 2016;**27**(3):590

[6] Eugene M, Gauvain J, Roux C, Barthez J. A case of acute brucellosis with membranous glomerulopathy. Clinical Nephrology. 1987;**28**(3):158

[7] Turgay M, Ertuğrul E, Küçükşahin O, Şahin A. Brucellosis with p-ANCAassociated renal failure, leukocytoclastic vasculitis and endocarditis: Case report. Journal of Microbiology and Infectious Diseases. 2011;**1**(01):31-34

[8] Delgado S, Bravo F, Gotuzzo E. Mixed cryoglobulinemia due to brucellosis. Clinical Infectious Diseases. 2008;**47**(3):435-436

[9] Erdem F, Kiki İ, Gündoğdu M, Kaya H. Thrombotic thrombocytopenic purpura in a patient with Brucella infection is highly responsive

to combined plasma infusion and antimicrobial therapy. Medical Principles and Practice. 2007;**16**(4):324-326

[10] Li J, Li Y, Wang Y, Huo N, Wan H, Lin X, et al. Renal abscess caused by Brucella. International Journal of Infectious Diseases. 2014;**28**:26-28

[11] Patino R, Blanco J, Yubero B. Interstitial nephritis caused by Brucella. Revista Clínica Española. 1973;**129**(1):93-96

[12] Honey RM, Gelfand M, Myers NH. Chronic brucella pyelonephritis with calcification: Short review of the literature and report of a case. Central African Journal of Medicine. 1957

[13] Salih SB, Kharal M, Qahtani M, Dahneem L, Nohair S. Acute interstitial nephritis induced by intermittent use of rifampicin in patient with brucellosis. Saudi Journal of Kidney Diseases and Transplantation. 2008;**19**(3):450-452

[14] Bala KA, Doğan M, Kaba S, Akbayram S, Aslan O, Kocaman S, et al. The syndrome of inappropriate secretion of anti-diuretic hormone (SIADH) and brucellosis. Medical Science Monitor. 2016;**22**:3129

[15] Conkar S, Kosker M, Cevik S, Ay M. Association of brucellosis with renal tubular and glomerular damage in children in Turkey. Saudi Journal of Kidney Diseases and Transplantation. 2018;**29**(2):284

[16] Turunç T, Demiroğlu YZ, Alişkan H, Çolakoğlu Ş, Timurkaynak F, Özdemir N, et al. Brucellosis in cases of end-stage renal disease. Nephrology Dialysis Transplantation. 2008;**23**(7):2344-2349

[17] Sungur C, Sungur A, Gedikoglu G, Usubutun A, Yasavul U, Turgan C, et al. Fatal *Brucella melitensis* endocarditis

**25**

2017;**23**(6):978

*Kidney Disease in Brucellosis*

1994;**67**(2):234-235

*DOI: http://dx.doi.org/10.5772/intechopen.86432*

[26] Bishara J, Robenshtok E, Weinberger M, Yeshurun M, Sagie A, Pitlik S. Infective endocarditis in renal transplant recipients. Transplant Infectious Disease. 1999;**1**(2):138-143

[27] Ay N, Kaya S, Anil M, Alp V, Beyazit

U, Yuksel E, Danis R. Pulmonary Involvement in Brucellosis, a Rare Complication of Renal Transplant: Case

Report and Brief Review. 2016

2013;**15**(5):E191-E1E5

bcr-2018-225865

2003;**18**(7):836-840

2017;**22**(5):539-546

[28] Ting IW, Ho MW, Sung YJ, Tien N, Chi CY, Ho HC, et al. Brucellosis in a renal transplant recipient.

[29] Inayat F, Mahboob M, Ali NS, Bokhari SRA, Ashraf A. Brucellosis in renal transplant recipients: A comparative review of 5 cases. BMJ Case Reports. 2018;**2018**. DOI: 10.1136/

[30] Einollahi B, Hajarizadeh B,

[31] Islek A, Sayar E, Yilmaz A, Günseren F, Artan R. Relapsing brucellosis after liver transplantation in a child: What is the appropriate regimen and duration of therapy? Transplantation. 2013;**96**(2):e6-e7

[32] Ertem M, Kürekçi A, Aysev D, Ünal E, Ikincioğulları A. Brucellosis transmitted by bone marrow transplantation. Bone Marrow Transplantation. 2000;**26**(2):225

[33] Tuon FF, Gondolfo RB, Cerchiari N. Human-to-human transmission of Brucella—A systematic review. Tropical Medicine & International Health.

Bakhtiari S, Lesanpezeshki M, Khatami MR, Nourbala MH, et al. Pretransplant hepatitis C virus infection and its effect on the post-transplant course of living renal allograft recipients. Journal of Gastroenterology and Hepatology.

[18] Stich-Kreitner V, Piper C, Schassan H. A rare cause of infection in chronic dialysis patients: Malta fever (febris undulans melitensis). Klinische Wochenschrift. 1988;**66**(16):743-746

[19] Solak Y, Biyik Z, Demircioglu S, Polat I, Genc N, Turkmen K, et al. *Brucella peritonitis* in peritoneal dialysis: A case report and review of the literature. Peritoneal Dialysis International. 2012;**32**(2):126-130

[20] Ozisik L, Akman B, Huddam B, Azap OK, Bilgic A, Sezer S, et al. Isolated *Brucella peritonitis* in a CAPD patient. American Journal of Kidney Diseases. 2006;**47**(5):e65-ee6. DOI:

[21] Taskapan H, Oymak O, Sümerkan

[22] Alothman A, Al Khurmi A, Al Sadoon S, Alhejaili F. *Brucella peritonitis* in a patient on peritoneal dialysis. Saudi Journal of Kidney Diseases and Transplantation. 2008;**19**(3):428

[23] Taskapan H, Oymak O, Sümerkan B, Tokgoz B, Utas C. *Brucella peritonitis* in a patient on continuous ambulatory peritoneal dialysis with acute brucellosis. Nephron. May 2002;**91**(1):156-158

Neurobrucellosis—A rare complication of renal transplantation. American Journal of Nephrology. 2001;**21**(1):66-68

[25] Alqwaifly M, Al-Ajlan FS, Al-Hindi H, Al Semari A. Central nervous system brucellosis granuloma and white matter disease in immunocompromised patient. Emerging Infectious Diseases.

10.1136/bcr-2018-225865

2002;**91**(1):156-158

[24] Yousif B, Nelson J.

B, Tokgoz B, Utas C. *Brucella peritonitis* in a patient on continuous ambulatory peritoneal dialysis with acute brucellosis. Nephron.

in a hemodialysis patient. Nephron.

*Kidney Disease in Brucellosis DOI: http://dx.doi.org/10.5772/intechopen.86432*

in a hemodialysis patient. Nephron. 1994;**67**(2):234-235

[18] Stich-Kreitner V, Piper C, Schassan H. A rare cause of infection in chronic dialysis patients: Malta fever (febris undulans melitensis). Klinische Wochenschrift. 1988;**66**(16):743-746

[19] Solak Y, Biyik Z, Demircioglu S, Polat I, Genc N, Turkmen K, et al. *Brucella peritonitis* in peritoneal dialysis: A case report and review of the literature. Peritoneal Dialysis International. 2012;**32**(2):126-130

[20] Ozisik L, Akman B, Huddam B, Azap OK, Bilgic A, Sezer S, et al. Isolated *Brucella peritonitis* in a CAPD patient. American Journal of Kidney Diseases. 2006;**47**(5):e65-ee6. DOI: 10.1136/bcr-2018-225865

[21] Taskapan H, Oymak O, Sümerkan B, Tokgoz B, Utas C. *Brucella peritonitis* in a patient on continuous ambulatory peritoneal dialysis with acute brucellosis. Nephron. 2002;**91**(1):156-158

[22] Alothman A, Al Khurmi A, Al Sadoon S, Alhejaili F. *Brucella peritonitis* in a patient on peritoneal dialysis. Saudi Journal of Kidney Diseases and Transplantation. 2008;**19**(3):428

[23] Taskapan H, Oymak O, Sümerkan B, Tokgoz B, Utas C. *Brucella peritonitis* in a patient on continuous ambulatory peritoneal dialysis with acute brucellosis. Nephron. May 2002;**91**(1):156-158

[24] Yousif B, Nelson J. Neurobrucellosis—A rare complication of renal transplantation. American Journal of Nephrology. 2001;**21**(1):66-68

[25] Alqwaifly M, Al-Ajlan FS, Al-Hindi H, Al Semari A. Central nervous system brucellosis granuloma and white matter disease in immunocompromised patient. Emerging Infectious Diseases. 2017;**23**(6):978

[26] Bishara J, Robenshtok E, Weinberger M, Yeshurun M, Sagie A, Pitlik S. Infective endocarditis in renal transplant recipients. Transplant Infectious Disease. 1999;**1**(2):138-143

[27] Ay N, Kaya S, Anil M, Alp V, Beyazit U, Yuksel E, Danis R. Pulmonary Involvement in Brucellosis, a Rare Complication of Renal Transplant: Case Report and Brief Review. 2016

[28] Ting IW, Ho MW, Sung YJ, Tien N, Chi CY, Ho HC, et al. Brucellosis in a renal transplant recipient. 2013;**15**(5):E191-E1E5

[29] Inayat F, Mahboob M, Ali NS, Bokhari SRA, Ashraf A. Brucellosis in renal transplant recipients: A comparative review of 5 cases. BMJ Case Reports. 2018;**2018**. DOI: 10.1136/ bcr-2018-225865

[30] Einollahi B, Hajarizadeh B, Bakhtiari S, Lesanpezeshki M, Khatami MR, Nourbala MH, et al. Pretransplant hepatitis C virus infection and its effect on the post-transplant course of living renal allograft recipients. Journal of Gastroenterology and Hepatology. 2003;**18**(7):836-840

[31] Islek A, Sayar E, Yilmaz A, Günseren F, Artan R. Relapsing brucellosis after liver transplantation in a child: What is the appropriate regimen and duration of therapy? Transplantation. 2013;**96**(2):e6-e7

[32] Ertem M, Kürekçi A, Aysev D, Ünal E, Ikincioğulları A. Brucellosis transmitted by bone marrow transplantation. Bone Marrow Transplantation. 2000;**26**(2):225

[33] Tuon FF, Gondolfo RB, Cerchiari N. Human-to-human transmission of Brucella—A systematic review. Tropical Medicine & International Health. 2017;**22**(5):539-546

**24**

*New Insight into* Brucella *Infection and Foodborne Diseases*

to combined plasma infusion and antimicrobial therapy. Medical Principles and Practice.

[10] Li J, Li Y, Wang Y, Huo N, Wan H, Lin X, et al. Renal abscess caused by Brucella. International Journal of Infectious Diseases. 2014;**28**:26-28

[11] Patino R, Blanco J, Yubero B. Interstitial nephritis caused by Brucella. Revista Clínica Española.

[12] Honey RM, Gelfand M, Myers NH. Chronic brucella pyelonephritis with calcification: Short review of the literature and report of a case. Central African Journal of Medicine. 1957

[13] Salih SB, Kharal M, Qahtani M, Dahneem L, Nohair S. Acute interstitial nephritis induced by intermittent use of rifampicin in patient with brucellosis. Saudi Journal of Kidney Diseases and Transplantation. 2008;**19**(3):450-452

[14] Bala KA, Doğan M, Kaba S, Akbayram S, Aslan O, Kocaman S, et al. The syndrome of inappropriate secretion of anti-diuretic hormone (SIADH) and brucellosis. Medical Science Monitor. 2016;**22**:3129

[15] Conkar S, Kosker M, Cevik S, Ay M. Association of brucellosis with renal tubular and glomerular damage in children in Turkey. Saudi Journal of Kidney Diseases and Transplantation.

[16] Turunç T, Demiroğlu YZ, Alişkan H, Çolakoğlu Ş, Timurkaynak F, Özdemir N, et al. Brucellosis in cases of end-stage renal disease. Nephrology Dialysis Transplantation. 2008;**23**(7):2344-2349

[17] Sungur C, Sungur A, Gedikoglu G, Usubutun A, Yasavul U, Turgan C, et al. Fatal *Brucella melitensis* endocarditis

2018;**29**(2):284

2007;**16**(4):324-326

1973;**129**(1):93-96

[1] Bruce DJ. Observations on Malta fever. BMJ. 1101;**1**(1481):1889

**References**

[2] Provatopoulou S, Papasotiriou M, Papachristou E, Gakiopoulou H, Marangos M, Goumenos DS, et al. Membranoproliferative glomerulonephritis in a patient with chronic brucellosis. Kidney Research and Clinical Practice. 2018;**37**(3):298

[3] Ardalan MR, Shoja MM. Rapidly progressive glomerulonephritis in a patient with brucellosis.

Nephrology Dialysis Transplantation.

[5] Sabanis N, Gavriilaki E, Paschou E, Tsotsiou E, Kalaitzoglou A, Kavlakoudis C, et al. Renal manifestations of human brucellosis: First report of minimal change disease. Saudi Journal of Kidney Disease and Transplantation. 2016;**27**(3):590

[6] Eugene M, Gauvain J, Roux C, Barthez J. A case of acute brucellosis with membranous glomerulopathy. Clinical Nephrology. 1987;**28**(3):158

[7] Turgay M, Ertuğrul E, Küçükşahin O, Şahin A. Brucellosis with p-ANCAassociated renal failure, leukocytoclastic vasculitis and endocarditis: Case report. Journal of Microbiology and Infectious

Diseases. 2011;**1**(01):31-34

2008;**47**(3):435-436

[8] Delgado S, Bravo F, Gotuzzo E. Mixed cryoglobulinemia due to

brucellosis. Clinical Infectious Diseases.

[9] Erdem F, Kiki İ, Gündoğdu M, Kaya H. Thrombotic thrombocytopenic purpura in a patient with Brucella infection is highly responsive

[4] Siegelmann N, Abraham A, Rudensky B, Shemesh OJ. Brucellosis with nephrotic syndrome, nephritis, and IgA nephropathy. Postgraduate Medical Journal. 1992;**68**(804):834-836

2006;**21**(6):1743-1744

**27**

**Chapter 4**

**Abstract**

*Fatemeh Eghbalian*

Neonatal Brucellosis

must monitor by a *Brucella* titer of <1:40.

**Keywords:** neonate, brucellosis, congenital

**1. Introduction**

Brucellosis is a zoonotic infectious disease caused by the *Brucella* bacteria. Neonatal brucellosis is very rare and preventable and is an example of intrauterine infection, but clinical manifestations as well as transmission route are not well defined but presumed transplacental transmission. The neonate can be either infected transplacentally, or by ingestion of mother's secretions and blood during delivery, or by ingestion of breast milk. Presentation of the neonatal brucellosis including fever, arthralgia, weakness, malaise, respiratory distress, pneumonia, enlargement of liver and spleen, fever, thrombocytopenia, late neonatal hyperbilirubinemia, and septicoemia. The diagnosis of brucellosis was based on a positive blood culture (isolation *Brucella* of blood culture from both the mother and the neonate or only neonate) and on a high or rising titer of antibodies to the *Brucella* organism (positive serology only in the mother or both). The neonates with negative *Brucella* serology may also have *Brucella* infection. The mortality rate is very high, and infected neonates need early detection and timely treatment. Early detection and treatment reduce the incidence of complications. The treatment of rifampicin and trimethoprim/sulfamethoxazole is useful for neonatal brucellosis. More patients with neonatal brucellosis well respond to antibiotic therapy and

Brucellosis is one of the most widespread zoonoses world [1, 2]. It is an acute or chronic zoonotic infection usually transmitted to humans through direct contact with infected animals or by eating contaminated food from infected animals (cattle, sheep, goats, pigs, or another animals) or food products such as unpasteurized milk, cheese or inhalation of contaminated air or dust particles and exposure is frequently occupational [1–4]. The prevalence of brucellosis has been increasing due to growing international tourism and migration of peoples [5, 6]. It is an important cause of economic loss and public health problems and is one of the important human infections in many developing countries or parts of the world. Brucellosis affects humans in all age groups and both genders with variable incidence according to the geographic location and the strain [1–43]. Although this disease is now uncommon in the United States and Britain but common in the Latin America, Africa, Mediterranean and Persian Gulf regions and parts of Asia specially in Iran [1–8, 32, 39]. Brucellosis has high morbidity both for animals or humans and one of the causes of abortion in animals but in humans it causes multisystem disease [1–8, 44]. Brucellosis is not uncommon in many parts of the world but human-to-human transmission, for example, through sexual intercourse, mother to newborn is rare,

## **Chapter 4** Neonatal Brucellosis

*Fatemeh Eghbalian*

### **Abstract**

Brucellosis is a zoonotic infectious disease caused by the *Brucella* bacteria. Neonatal brucellosis is very rare and preventable and is an example of intrauterine infection, but clinical manifestations as well as transmission route are not well defined but presumed transplacental transmission. The neonate can be either infected transplacentally, or by ingestion of mother's secretions and blood during delivery, or by ingestion of breast milk. Presentation of the neonatal brucellosis including fever, arthralgia, weakness, malaise, respiratory distress, pneumonia, enlargement of liver and spleen, fever, thrombocytopenia, late neonatal hyperbilirubinemia, and septicoemia. The diagnosis of brucellosis was based on a positive blood culture (isolation *Brucella* of blood culture from both the mother and the neonate or only neonate) and on a high or rising titer of antibodies to the *Brucella* organism (positive serology only in the mother or both). The neonates with negative *Brucella* serology may also have *Brucella* infection. The mortality rate is very high, and infected neonates need early detection and timely treatment. Early detection and treatment reduce the incidence of complications. The treatment of rifampicin and trimethoprim/sulfamethoxazole is useful for neonatal brucellosis. More patients with neonatal brucellosis well respond to antibiotic therapy and must monitor by a *Brucella* titer of <1:40.

**Keywords:** neonate, brucellosis, congenital

#### **1. Introduction**

Brucellosis is one of the most widespread zoonoses world [1, 2]. It is an acute or chronic zoonotic infection usually transmitted to humans through direct contact with infected animals or by eating contaminated food from infected animals (cattle, sheep, goats, pigs, or another animals) or food products such as unpasteurized milk, cheese or inhalation of contaminated air or dust particles and exposure is frequently occupational [1–4]. The prevalence of brucellosis has been increasing due to growing international tourism and migration of peoples [5, 6]. It is an important cause of economic loss and public health problems and is one of the important human infections in many developing countries or parts of the world. Brucellosis affects humans in all age groups and both genders with variable incidence according to the geographic location and the strain [1–43]. Although this disease is now uncommon in the United States and Britain but common in the Latin America, Africa, Mediterranean and Persian Gulf regions and parts of Asia specially in Iran [1–8, 32, 39]. Brucellosis has high morbidity both for animals or humans and one of the causes of abortion in animals but in humans it causes multisystem disease [1–8, 44]. Brucellosis is not uncommon in many parts of the world but human-to-human transmission, for example, through sexual intercourse, mother to newborn is rare,

but possible and has been reported [9–11]. Vertical transmission from mother to fetus during pregnancy (transplacental) or perinatal exposure has been reported [7, 8, 12, 13, 16–18, 25, 44]. Other modes of human-to-human transmission of brucellosis include blood transfusion, bone marrow transplantation and breastfeeding [20–25]. Although few cases of perinatal brucellosis have been reported but the mode of transmission of *Brucella* from the mother to the baby remains uncertain.

#### **2. Neonatal brucellosis**

Brucellosis is a primarily zoonotic infection, public health problem and serious threat for people living in endemic areas of world which is caused by Gramnegative, intracellular, non-spore-forming, non-capsulated, aerobic, nonmotile *Coccobacilli* [1, 26–41]. *Brucella melitensis* is the most important species for human brucellosis, but other species, including *B. abortus*, *B. suis*, *B. canis*, and *B. novel* marine have also been associated with human cases [1–3, 26, 29, 32, 43]. Brucellosis can be transmitted to humans from direct contact by infected animals, products of conception, or animal discharge, and by consumption of infected milk, milk products or meat [2, 3, 5, 26, 32, 43]. Human-to-human transmission is rare, but has been reported in association with blood transfusions, bone marrow transplantation, trans placental or perinatal exposure and possibly postnatally by consumption breast feeding [7, 8, 12, 13, 16–18, 20–25, 44].

Neonatal brucellosis is rare and there are only a few reports of congenital brucellosis [7, 8, 12–14, 17, 43, 44]. There are few data supporting transmission from mother to fetus or transmission via breast milk [7, 8, 12, 13, 16–18, 23, 25]. It seems that in most cases *Brucella* passes through the placenta. Transplacental and consumption breast milk are the main routes of *Brucella* transmission in mammalian reservoirs [7, 8, 12, 13, 23–25]. Ingestion of maternal blood, urine or feces during delivery might be another rout of *Brucella* transmission [10, 14, 19].

Although infected pregnant animals transfer *Brucella* to their offspring transplacentally with resultant massive wastage of conception, this mode of transmission and resultant interference with the normal course of pregnancy has been disputed in humans [2, 32, 43].

Neonatal brucellosis is a very rare cause of early onset neonatal sepsis but should be considered in neonates born from mothers at risk for brucellosis [7–10]. Physicians dealing with mothers who lived in endemic areas during pregnancy should maintain a large index of suspicion when these mothers present with unexplained symptoms, especially for those with social and occupational risk for brucellosis because as soon as diagnosis and therapy can lead to good and better outcome. Education for pregnant women living in endemic areas for avoidance of exposure to sheep, goat, camels and do not consumption of unpasteurized products is most important and highly recommended. Family history of brucellosis or exposure must be obtained during prenatal care in endemic areas [1, 38, 39]. Sometimes maternal brucellosis lead to preterm delivery and with adverse long-term outcomes [16]. Transplacental transmissions from an infected mother, exposure to maternal blood, urine, or genital secretions during delivery are the main routes of transmission of neonatal brucellosis [10, 14, 19].

Pregnancy caused to impaired immunological status, and infection with *Brucella* can deformation obstetric outcomes, including congenital infection [44, 45]. At one point it was believed that adverse pregnancy outcomes associated with human brucellosis should be uncommon due to the absence of erythritol in the human placenta [46, 47]. Another theory was that amniotic fluid contains anti-*Brucella* activity [48]. However, many reports describe apparent increased rates of

**29**

*Neonatal Brucellosis*

[1, 3, 45–47].

**3. Clinical manifestations**

megaly in endemic regions [53].

**4. Diagnosis**

*DOI: http://dx.doi.org/10.5772/intechopen.86703*

spontaneous abortion, intrauterine fetal death, and preterm birth in mothers with brucellosis during pregnancy [49]. Recognition and suitable treatment of infection in early course of pregnancy lead to decrease of incidence of spontaneous abortion, intrauterine fetal death, and congenital infection [44, 46–49]. The clinical manifestations of brucellosis in pregnancy are similar to other infected people and include arthralgia, arthritis, fever, chills, sweating, headache, malaise, nausea, vomiting, lymphadenopathy, hepatosplenomegaly, anorexia and weight loss [1–3, 45–47]. Positive blood or bone marrow culture are definite diagnosis but serologic tests (Wright and 2-mercapto ethanol, 2ME) are the commonest diagnostic methods

The choice treatment for brucellosis in infected mother during pregnancy is a combination of rifampin and trimethoprim-sulfamethoxazole but trimethoprimsulfamethoxazole is contraindicated in first trimester and the last 2–4 weeks of pregnancy. During the third generation and first trimester of pregnancy, cephalosporins have been used and in the last month of pregnancy, combination of aminoglycosides (gentamycin) with rifampin is an alternative regimen [33, 39, 45–49].

Newborns with symptom onset in the first week of life have presumably congenital brucellosis, although the incubation period of *Brucella* in newborn period can vary from less 1 week to 1 months (typically 2–4 weeks) [50]. Delayed diagnosis of congenital brucellosis in preterm infants can overlap with other diseases of prematurity. Term infants with onset of symptoms beyond 1 week of age may have acquired *Brucella* through breastfeeding or ingestion of nonhuman milk but congenital infection can also have a delayed presentation [9]. The neonatal immune system is immature, the response to well-characterized infective processes varies from that described in older children and hence clinical manifestations may differ. Differential diagnosis between other bacterial infections in the newborn and brucellosis is difficult and presentations of brucellosis in the neonate are nonspecific and it is very difficult to distinguish brucellosis clinically from other bacterial infections. Fever, arthralgia, night sweating, anemia, bone marrow failure, jaundice, respiratory distress, vomiting, irritability, seizure, hepatosplenomegaly, dearie, skin rash, nausea, vomiting, malaise, poor feeding, failure to thrive (FTT) and distended abdomen are probable signs and symptoms in neonatal brucellosis [48]. The role of *Brucella* in myocarditis and hydrocephalus is difficult to determine both reported from neonates who acquired *Brucella* from breast milk [51, 52]. In summary, brucellosis should be considered as a possible cause of early or late onset sepsis in newborns presenting with fever, respiratory distress and hepatospleno-

Hematological and biochemical tests used in neonatal sepsis are of limited value for the diagnosis of brucellosis [17, 18]. In brucellosis, the white blood cell count is often normal or low. In neonates suspect to brucellosis, the diagnosis was made by the unexpected isolation of *Brucella* from blood culture obtained from a sick neonate with suspected sepsis. Serologic tests are also important methods for clinical diagnosis but should be interpreted judiciously because of transplacental passage of maternal IgG antibodies [54]. A negative serologic test should never exclude the diagnosis, particularly in preterm neonates who may not have mounted their own

#### *Neonatal Brucellosis DOI: http://dx.doi.org/10.5772/intechopen.86703*

*New Insight into* Brucella *Infection and Foodborne Diseases*

breast feeding [7, 8, 12, 13, 16–18, 20–25, 44].

**2. Neonatal brucellosis**

in humans [2, 32, 43].

neonatal brucellosis [10, 14, 19].

but possible and has been reported [9–11]. Vertical transmission from mother to fetus during pregnancy (transplacental) or perinatal exposure has been reported [7, 8, 12, 13, 16–18, 25, 44]. Other modes of human-to-human transmission of brucellosis include blood transfusion, bone marrow transplantation and breastfeeding [20–25]. Although few cases of perinatal brucellosis have been reported but the mode of transmission of *Brucella* from the mother to the baby remains uncertain.

Brucellosis is a primarily zoonotic infection, public health problem and serious threat for people living in endemic areas of world which is caused by Gramnegative, intracellular, non-spore-forming, non-capsulated, aerobic, nonmotile *Coccobacilli* [1, 26–41]. *Brucella melitensis* is the most important species for human brucellosis, but other species, including *B. abortus*, *B. suis*, *B. canis*, and *B. novel* marine have also been associated with human cases [1–3, 26, 29, 32, 43]. Brucellosis can be transmitted to humans from direct contact by infected animals, products of conception, or animal discharge, and by consumption of infected milk, milk products or meat [2, 3, 5, 26, 32, 43]. Human-to-human transmission is rare, but has been reported in association with blood transfusions, bone marrow transplantation, trans placental or perinatal exposure and possibly postnatally by consumption

Neonatal brucellosis is rare and there are only a few reports of congenital brucellosis [7, 8, 12–14, 17, 43, 44]. There are few data supporting transmission from mother to fetus or transmission via breast milk [7, 8, 12, 13, 16–18, 23, 25]. It seems that in most cases *Brucella* passes through the placenta. Transplacental and consumption breast milk are the main routes of *Brucella* transmission in mammalian reservoirs [7, 8, 12, 13, 23–25]. Ingestion of maternal blood, urine or feces during

Although infected pregnant animals transfer *Brucella* to their offspring transplacentally with resultant massive wastage of conception, this mode of transmission and resultant interference with the normal course of pregnancy has been disputed

Neonatal brucellosis is a very rare cause of early onset neonatal sepsis but should be considered in neonates born from mothers at risk for brucellosis [7–10]. Physicians dealing with mothers who lived in endemic areas during pregnancy should maintain a large index of suspicion when these mothers present with unexplained symptoms, especially for those with social and occupational risk for brucellosis because as soon as diagnosis and therapy can lead to good and better outcome. Education for pregnant women living in endemic areas for avoidance of exposure to sheep, goat, camels and do not consumption of unpasteurized products is most important and highly recommended. Family history of brucellosis or exposure must be obtained during prenatal care in endemic areas [1, 38, 39]. Sometimes maternal brucellosis lead to preterm delivery and with adverse long-term outcomes [16]. Transplacental transmissions from an infected mother, exposure to maternal blood, urine, or genital secretions during delivery are the main routes of transmission of

Pregnancy caused to impaired immunological status, and infection with *Brucella* can deformation obstetric outcomes, including congenital infection [44, 45]. At one point it was believed that adverse pregnancy outcomes associated with human brucellosis should be uncommon due to the absence of erythritol in the human placenta [46, 47]. Another theory was that amniotic fluid contains anti-*Brucella* activity [48]. However, many reports describe apparent increased rates of

delivery might be another rout of *Brucella* transmission [10, 14, 19].

**28**

spontaneous abortion, intrauterine fetal death, and preterm birth in mothers with brucellosis during pregnancy [49]. Recognition and suitable treatment of infection in early course of pregnancy lead to decrease of incidence of spontaneous abortion, intrauterine fetal death, and congenital infection [44, 46–49]. The clinical manifestations of brucellosis in pregnancy are similar to other infected people and include arthralgia, arthritis, fever, chills, sweating, headache, malaise, nausea, vomiting, lymphadenopathy, hepatosplenomegaly, anorexia and weight loss [1–3, 45–47]. Positive blood or bone marrow culture are definite diagnosis but serologic tests (Wright and 2-mercapto ethanol, 2ME) are the commonest diagnostic methods [1, 3, 45–47].

The choice treatment for brucellosis in infected mother during pregnancy is a combination of rifampin and trimethoprim-sulfamethoxazole but trimethoprimsulfamethoxazole is contraindicated in first trimester and the last 2–4 weeks of pregnancy. During the third generation and first trimester of pregnancy, cephalosporins have been used and in the last month of pregnancy, combination of aminoglycosides (gentamycin) with rifampin is an alternative regimen [33, 39, 45–49].

#### **3. Clinical manifestations**

Newborns with symptom onset in the first week of life have presumably congenital brucellosis, although the incubation period of *Brucella* in newborn period can vary from less 1 week to 1 months (typically 2–4 weeks) [50]. Delayed diagnosis of congenital brucellosis in preterm infants can overlap with other diseases of prematurity. Term infants with onset of symptoms beyond 1 week of age may have acquired *Brucella* through breastfeeding or ingestion of nonhuman milk but congenital infection can also have a delayed presentation [9]. The neonatal immune system is immature, the response to well-characterized infective processes varies from that described in older children and hence clinical manifestations may differ. Differential diagnosis between other bacterial infections in the newborn and brucellosis is difficult and presentations of brucellosis in the neonate are nonspecific and it is very difficult to distinguish brucellosis clinically from other bacterial infections. Fever, arthralgia, night sweating, anemia, bone marrow failure, jaundice, respiratory distress, vomiting, irritability, seizure, hepatosplenomegaly, dearie, skin rash, nausea, vomiting, malaise, poor feeding, failure to thrive (FTT) and distended abdomen are probable signs and symptoms in neonatal brucellosis [48]. The role of *Brucella* in myocarditis and hydrocephalus is difficult to determine both reported from neonates who acquired *Brucella* from breast milk [51, 52]. In summary, brucellosis should be considered as a possible cause of early or late onset sepsis in newborns presenting with fever, respiratory distress and hepatosplenomegaly in endemic regions [53].

#### **4. Diagnosis**

Hematological and biochemical tests used in neonatal sepsis are of limited value for the diagnosis of brucellosis [17, 18]. In brucellosis, the white blood cell count is often normal or low. In neonates suspect to brucellosis, the diagnosis was made by the unexpected isolation of *Brucella* from blood culture obtained from a sick neonate with suspected sepsis. Serologic tests are also important methods for clinical diagnosis but should be interpreted judiciously because of transplacental passage of maternal IgG antibodies [54]. A negative serologic test should never exclude the diagnosis, particularly in preterm neonates who may not have mounted their own

antibody response nor received transplacental antibodies. For further evaluation, blood should be sent for nested PCR and DNA sequencing. Definite diagnosis in neonates could be verified based on separating etiologic agent since maternal IgG exists in infant serum till 6 months after delivery [7–9, 17, 18, 54].

#### **5. Treatment**

Tetracycline or doxycycline with streptomycin or gentamicin are recommended therapies in older children or adults [39, 55]. Quinolones and doxycycline are sometimes used for treatment of brucellosis in adolescents but their safety in infants and newborns has not been established [32, 33]. Because of the side effects of tetracycline and doxycycline in children younger than 10 years of age, a variety of drugs can be used safely, for example a combination of rifampin and trimethoprimsulfamethoxazole [32, 33, 43, 55].

The combination of intravenous aminoglycosides for 5–7 days plus with rifampicin and trimethoprim-sulfamethoxazole orally 6–8 weeks is a commonly regimen and has been suggested as the treatment of choice for neonatal brucellosis [7, 8, 12, 13, 56].

#### **Author details**

Fatemeh Eghbalian Department of Pediatrics, Hamadan University of Medical Sciences, Hamedan, Iran

\*Address all correspondence to: eghbalian\_fa@yahoo.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**31**

*Neonatal Brucellosis*

Croatica. 2009;**48**:41

Company; 2000. p. 416

2007;**45**:e135-e140

2005;**36**:313

[4] Mesner O, Riesenberg K, Biliar N, et al. The many faces of human-to-human transmission of brucellosis: Congenital infection and outbreak of nosocomial disease related to an unrecognized clinical case. Clinical Infectious Diseases.

**References**

*DOI: http://dx.doi.org/10.5772/intechopen.86703*

[9] Carbajo-Ferreira AJ, Ochoa-

[10] Singer R, Amitai Y, Geist M, et al. Neonatal brucellosis possibly transmitted during delivery. Lancet.

[11] Whatmore AM, Davison N, Cloeckaert A, et al. *Brucella papionis* sp. nov., isolated from baboons (*Papio* spp.). International Journal of Systematic and Evolutionary Microbiology. 2014;**64**:4120

[12] Chheda S, Lopez SM, Sanderson EP. Congenital brucellosis in a premature infant. The Pediatric Infectious Disease Journal.

[13] Shamo'on H, Izzat M. Congenital brucellosis. The Pediatric Infectious Disease Journal. 1999;**18**:1110-1111

[14] Giannacopoulos I, Eliopoulou MI, Ziambaras T, Papanastasiou DA. Transplacentally transmitted congenital brucellosis due to *Brucella abortus*. The Journal of Infection.

[15] Ruben B, Band JD, Wong P, Colville

[17] Sarafidis K, Agakidis C, Diamanti E, Karantaglis N, Roilides E. Congenital brucellosis: A rare cause of respiratory

J. Person to person transmission of *Brucella melitensis*. Lancet.

[16] Koklu E, Buyukkayhan D, Akcakus M, Kurtoglu S, Koklu S, Gunes T. Brucellosis with pulmonary involvement in a premature infant. Annals of Tropical Paediatrics.

1995;**14**:406-407

1991;**338**:127-128

1997;**16**:81-83

2002;**45**:209-210

1991;**337**:14-15

2006;**26**:367-370

Sangrador C, Canut-Blasco A, Castano-Garcia MT. Neonatal brucellosis. The Pediatric Infectious Disease Journal.

[1] Bosilkovski M, Dimzova M, Grozdanovski K. Natural history of brucellosis in an endemic region in different time periods. Acta Clinica

[2] Young EJ. *Brucella* species. In: Mandelle G, Bennet J, Dolin R, editors. Principles and Practices of Infections Diseases, 6th edition, Strickland GT (Ed), Churchill Livingstone, Philadelphia; 2005. pp. 2669-2674

[3] Wright SG. Brucellosis. In: Strickland GT, editor. Hunter's Tropical Medicine and Emerging Infectious Diseases. 8th ed. Philadelphia: W.B. Saunders

[5] Godfroid J, Cloeckaert A, Liautard JP, et al. From the discovery of the Malta fever's agent to the discovery of a marine mammal reservoir, brucellosis has continuously been a re-emerging zoonosis. Veterinary Research.

[6] Bricker BJ, Ewalt DR, MacMillan AP, et al. Molecular characterization of *Brucella* strains isolated from marine mammals. Journal of Clinical

Microbiology. 2000;**38**:1258

Pediatrics. 2005;**42**:599-601

Diseases. 2007;**2**(1):29-31

[7] Mosayebi Z, Movahedian AH, Ghayomi A, Kazemi B. Congenital brucellosis in a preterm neonate. Indian

[8] Imani R, Shamsipoor E, Khadivi R. Congenital brucellosis in an infant. Iranian Journal of Clinical Infectious

### **References**

*New Insight into* Brucella *Infection and Foodborne Diseases*

**5. Treatment**

sulfamethoxazole [32, 33, 43, 55].

antibody response nor received transplacental antibodies. For further evaluation, blood should be sent for nested PCR and DNA sequencing. Definite diagnosis in neonates could be verified based on separating etiologic agent since maternal IgG

Tetracycline or doxycycline with streptomycin or gentamicin are recommended therapies in older children or adults [39, 55]. Quinolones and doxycycline are sometimes used for treatment of brucellosis in adolescents but their safety in infants and newborns has not been established [32, 33]. Because of the side effects of tetracycline and doxycycline in children younger than 10 years of age, a variety of drugs can be used safely, for example a combination of rifampin and trimethoprim-

The combination of intravenous aminoglycosides for 5–7 days plus with rifampicin and trimethoprim-sulfamethoxazole orally 6–8 weeks is a commonly regimen and has been suggested as the treatment of choice for neonatal brucellosis [7, 8, 12, 13, 56].

Department of Pediatrics, Hamadan University of Medical Sciences, Hamedan, Iran

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

\*Address all correspondence to: eghbalian\_fa@yahoo.com

provided the original work is properly cited.

exists in infant serum till 6 months after delivery [7–9, 17, 18, 54].

**30**

**Author details**

Fatemeh Eghbalian

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[3] Wright SG. Brucellosis. In: Strickland GT, editor. Hunter's Tropical Medicine and Emerging Infectious Diseases. 8th ed. Philadelphia: W.B. Saunders Company; 2000. p. 416

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[5] Godfroid J, Cloeckaert A, Liautard JP, et al. From the discovery of the Malta fever's agent to the discovery of a marine mammal reservoir, brucellosis has continuously been a re-emerging zoonosis. Veterinary Research. 2005;**36**:313

[6] Bricker BJ, Ewalt DR, MacMillan AP, et al. Molecular characterization of *Brucella* strains isolated from marine mammals. Journal of Clinical Microbiology. 2000;**38**:1258

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[16] Koklu E, Buyukkayhan D, Akcakus M, Kurtoglu S, Koklu S, Gunes T. Brucellosis with pulmonary involvement in a premature infant. Annals of Tropical Paediatrics. 2006;**26**:367-370

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*Neonatal Brucellosis DOI: http://dx.doi.org/10.5772/intechopen.86703*

genomes of *Brucella melitensis* and *Brucella suis*. Journal of Bacteriology. 2005;**187**:2715

*New Insight into* Brucella *Infection and Foodborne Diseases*

Murray PR, Baron EJO, Jorgensen JH, et al., editors. Manual of Clinical Microbiology. 9th ed. Washington, DC:

[27] Celli J. The changing nature of the *Brucella*-containing vacuole. Cellular Microbiology. 2015;**17**(7):951-958. DOI:

[28] Jahans KL, Foster G, Broughton ES. The characterisation of *Brucella* strains isolated from marine mammals. Veterinary Microbiology. 1997;**57**:373

[30] Alton GG, Jones LM, Angus RD, Verger JM. Techniques for the Brucellosis Laboratory. Paris: Institute National de la

[31] Muleme M, Mugabi R. "Brucellosis Outbreak Investigations". Sakran et al;

[32] Pappas G, Akritidis N, Bosilkovski

Implications of laboratory diagnosis on brucellosis therapy. Expert Review of Anti-Infective Therapy. 2011;**9**:833

[34] Brown PJB, De Pedro MA, Kysela DT, Van Der Henst C, Kim J, De Bolle X, et al. Polar growth in the alphaproteobacterial order *Rhizobiales*. Proceedings of the National Academy of

[35] Halling SM, Peterson-Burch BD, Bricker BJ, et al. Completion of the genome sequence of *Brucella abortus* and comparison to the highly similar

recherche Agronomique; 1988

M, Tsianos E. Brucellosis. The New England Journal of Medicine.

[33] Al Dahouk S, Nöckler K.

Sciences. 2012;**109**(5):697-701

ASM Press; 2007. p. 824

[29] Bricker BJ, Halling SM. Differentiation of *Brucella abortus* bv 1,2, and 4, *Brucella melitensis*, *Brucella ovis* and *Brucella suis* bv. 1 by PCR. Journal of Clinical Microbiology.

10.1111/cmi.12452

1994;**32**:2660

2006

2005;**352**:2325

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**35**

[1, 2, 4].

**Chapter 5**

**Abstract**

**1. Introduction**

**2. Antibiotic treatment**

Brucellosis

Update of Antibiotic Therapy of

*Sara Consuelo Arias Villate and Julio Cesar García Casallas*

Currently, the only option for treating brucellosis is antibiotics especially to prevent complications. In this chapter, we want to talk about the drug therapy in brucellosis and the update of these therapies in the last years. Also, we will expose the principal antibiotics in brucellosis such as doxycycline, rifampin, streptomycin, cotrimoxazole (TMP/SMX), and gentamicin by talking about each one of their mechanism of action, pharmacokinetics, administration, risk assessment, adverse effects, and principal drug interactions. Furthermore, we will add the evidence of efficacy therapy in monotherapy or combinate therapy based on the evidence.

**Keywords:** brucellosis, aminoglycoside, doxycycline, rifampin, treatment

Brucellosis is a zoonotic disease that can affect humans around the world, and it can affect any organ system. About the treatment, it is characterized to be prolonged therapy with a concomitant use of at least two or three antibiotics at different administration routes. The antibiotics have some special indications for administration, interactions, and risk assessment to prevent adverse reactions. That is why we will expose the principal antibiotics in brucellosis treatment based on the last evidence.

The principal objective of the treatment in brucellosis is to control the disease, prevent complications, relapse, and unfavorable outcomes. In the context of a zoonotic infection, the goal of its management is an appropriate antibiotic therapy with a prolonged duration of treatment, nevertheless the most effective antibiotic and treatment durations are unclear. Also, there are some limitations to choose the best treatment because of the need to choose antibiotics that act intracellularly and to prevent relapses with a prolonged therapy that can lead to increase the adverse effects of the drugs [1]. Furthermore, the monotherapy for brucellosis has been considered inadequate due to unacceptably high relapse rates, now we present possible treatment schemes [2, 3]. Uncomplicated brucellosis: (defined by not having focal disease like spondylitis,

• Doxycycline 100 mg orally twice daily for 6 weeks, plus streptomycin 1 g intramuscularly one daily for the first 14–21 days (or gentamicin 5 mg/kg for 5–14 days)

neurobrucellosis or endocarditis, and adults or > 30 kg):

#### **Chapter 5**

*New Insight into* Brucella *Infection and Foodborne Diseases*

[52] Drutz JE. Brucellosis of the central nervous system. A case report of an infected infant. La Clinica Pediatrica.

[53] Dogan DG, Aslan M, Menekse E, Yakinci C. Congenital brucellosis: Case report. Annals of Tropical Paediatrics.

[54] Yagupsky P. Neonatal brucellosis: Rare and preventable. Annals of Tropical Paediatrics. 2010;**30**:177-179

[55] Tsolia M, Drakonaki S, Messaritaki A, Farmakakis T, Kostaki M, Tsapra H, et al. Clinical features, complications and treatment outcome of childhood brucellosis in central Greece. The Journal of Infection. 2002;**44**:257-262

[56] Khuri-Bulos NA, Daoud AH, Azab SM. Treatment of childhood brucellosis: Results of prospective trial on 113 children. The Pediatric Infectious Disease Journal. 1993;**12**:377-383

1989;**28**:476-478

2010;**30**:229-231

**34**
