Brucellosis (also known as brucellosis, or brucellosis) is a zoonotic disease caused by Brucella infection. Infected animals such as sheep and cattle are the main source of infection for brucellosis. Brucella can be transmitted through broken skin mucous membranes, the digestive tract and the respiratory tract. Acute cases are characterized by fever, malaise, excessive sweating, muscle and joint pain, and enlarged liver, spleen and lymph nodes. Chronic cases mostly show joint damage, etc.
The disease is a Class B infectious disease under the Prevention and Control of Infectious Diseases Law of China.
I. Clinical manifestations and stages
The incubation period is generally 1-3 weeks, with an average of 2 weeks. Some cases have a longer incubation period.
(A) Clinical manifestations
1. Fever: Typical cases show wavy fever, often accompanied by chills, headache and other symptoms, which can be seen in all stages of patients. Some cases may show hypothermia and irregular fever type, and mostly occur in the late afternoon or at night.
2. Excessive sweating: Sweating is especially heavy in acute cases and can soak through clothes and bedding.
3.Muscle and joint pain: The pain is generalized muscle and multiple, wandering large joints. Some chronic cases may also have spinal (mainly lumbar) involvement, manifesting as pain, deformity and functional impairment.
4. Weakness: almost all cases have this manifestation.
5.Liver, spleen and lymph nodes enlargement: Most of the cases are in the acute stage.
6, Other: male cases may be accompanied by testicular inflammation, female cases may be seen ovarian inflammation; a few cases may have cardiac, renal and neurological involvement.
(B) Clinical stages
1, acute stage: with the above clinical manifestations, the duration of the disease within 6 months.
2. Chronic stage: the disease has not been cured for more than 6 months.
II. Laboratory tests
(A) General laboratory tests
1.Blood picture: white blood cell count is normal or low, lymphocytes are relatively increased, sometimes abnormal lymphocytes may appear, and red blood cells and platelets are reduced in a few cases.
2.Blood sedimentation: The blood sedimentation may be accelerated in the acute stage, but is mostly normal in the chronic stage.
(B) Immunological examination
1.Plate agglutination test: Tiger red plate (RBPT) or plate agglutination test (PAT) result is positive, used for primary screening.
2, Test tube agglutination test (SAT): titer of 1:l00 ++ and above or titer of 1:50 ++ and above for more than one year of disease; or history of Brucella vaccination within six months and titer of 1:100 ++ and above.
3, Complement binding test (CFT): titer 1:10 ++ and above.
4.Brucellosis anti-human immunoglobulin test (Coomb’s): titer of 1:400 ++ and above.
(C) Pathogenetic examination
Brucella can be isolated from blood, bone marrow, joint fluid, cerebrospinal fluid, urine, lymphatic tissue, and other cultures. The positive rate of blood, bone marrow and joint fluid is higher in the acute stage, but lower in the chronic stage.
Diagnosis and differential diagnosis
(A) Diagnosis
Diagnosis should be made by combining epidemiological history, clinical manifestations and laboratory tests.
1.Suspected cases
Suspected cases are those who meet the following criteria.
1.1, epidemiological history: history of close contact with livestock or livestock products, brucella cultures, etc. before the onset of the disease, or residents living in areas where brucellosis is endemic, etc.
1.2. Clinical manifestations: fever, malaise, excessive sweating, muscle and joint pain, or accompanied by enlargement of liver, spleen, lymph nodes and testicles, etc.
2.Clinical diagnosis cases
Suspected cases with positive immunological examination item 1 (primary screening test).
3.Confirmed cases
Suspected or clinically diagnosed cases with one or more positive immunological examination items 2, 3 and 4 and/or isolation of Brucella.
4.Covert infection cases
Epidemiological history, meeting the criteria of immunological and pathogenic examination of confirmed cases, but without clinical manifestations.
(II) Differential diagnosis
1.Typhoid fever and paratyphoid fever
Patients with typhoid fever and paratyphoid fever have persistent high fever, indifferent expression, slow relative pulse, skin rose rash, hepatosplenomegaly as the main manifestations, but no muscle, joint pain, excessive sweating and other manifestations of brucellosis. Laboratory tests are positive for serum fertilizer reaction, positive culture for S. typhi, and negative for specific tests for brucellosis.
2.Rheumatic fever
Both brucellosis and rheumatic fever can show fever and wandering arthralgia, but rheumatic fever can be seen as rheumatic nodules and erythema, mostly combined with heart damage, while hepatosplenomegaly, orchitis and neurological damage are extremely rare. Laboratory tests are positive for anti-streptococcal hemolysin “O” and negative for specific tests for brucellosis.
3.Rheumatoid arthritis
Chronic brucellosis and rheumatoid arthritis both have severe joint pain, with recurrent attacks and intensification on cloudy days. Rheumatoid arthritis mostly has a history of rheumatic fever, lesions are mostly seen in large joints, joint cavity effusion is rare, joint deformity usually does not occur, often combined with heart damage, serum anti-streptococcal hemolysin “O” titer is increased, negative laboratory tests specific for brucellosis can help to differentiate.
4.Other
The acute phase of brucellosis should be distinguished from tuberculosis and sepsis, and the chronic phase should be distinguished from other joint damage diseases and neurological disorders.
IV. Treatment
(A) General treatment
Pay attention to rest, supplement nutrition, high-calorie, multivitamin, easy-to-digest diet, and maintain water and electrolyte balance. If the fever is high, use physical methods to lower the temperature. If the fever does not subside, use symptomatic treatment such as antipyretics.
(B) Antibacterial treatment
The principle of treatment is early, combined, adequate amount and full course of medication, and if necessary, extend the course of treatment to prevent recurrence and chronicity. Tetracyclines and rifamycins are commonly used, but quinolones, sulfonamides, aminoglycosides and third-generation cephalosporins are also used (see the table for dosage). Pay attention to the monitoring of blood routine, liver and kidney function during the treatment.
1.Acute treatment
1.1.First-line drugs
Doxycycline combined with rifampin or streptomycin.
1.2.Second-line drugs
If the first-line drugs cannot be used or the effect is not good, the following options can be used: doxycycline combined with cotrimoxazole or tobramycin; rifampin combined with fluoroquinolones.
1.3, refractory cases can be added with fluoroquinolones or third-generation cephalosporins.
1.4. There is no evidence-based medical evidence on the need for treatment in cases of occult infection, and it is recommended that treatment be given.
2.Chronic phase treatment
Antimicrobial therapy: treatment of acute exacerbation cases in the chronic phase mostly uses tetracyclines and rifamycins, the usage is the same as in the acute phase, and some cases need 2-3 courses of treatment.
3.Treatment of complications
3.1, combined with orchitis cases antimicrobial treatment as above, can add a small dose of glucocorticoids for a short time.
3.2. Combined meningitis cases should be treated with cephalosporins of the third generation on top of the above antibacterial treatment, and symptomatic treatment such as dehydration should be given.
3.3 In cases of combined endocarditis, vasculitis, spondylitis, abscesses of other organs or tissues, add cephalosporins of the third generation on top of the above antibacterial drugs; if necessary, give surgical treatment.
4.Special population treatment
4.1 Children: Rifampin combined with cotrimoxazole can be used for treatment, and the choice of drugs for children over 8 years old is the same as that for adults.
4.2 Pregnant women: can be treated with rifampin combined with cotrimoxazole. Within 12 weeks of gestation, use cephalosporins of three generations combined with cotrimoxazole.
(iii) Chinese medicine treatment
Brucellosis belongs to damp-heat paralysis in Chinese medicine, and can be included in the category of damp-heat epidemic because of its infectious nature. The disease is caused by damp-heat and epidemic evil, with the initial manifestation of fever or wave-like fever, profuse sweating but the fever does not subside, vicious cold, irritable and thirsty, accompanied by generalized muscle and joint pain, swollen and painful testicles, etc. Subsequently, the manifestation of the disease is atrophy, weakness, low fever, spontaneous sweating and night sweating, palpitation, soreness of the back and legs, and unfavorable joint flexion and extension. The basic pathogenesis is damp-heat paralysis of the tendons, muscles and joints, and depletion of the liver and kidneys and other internal organs.
1.Acute phase.
1.1, damp-heat invasion
Clinical manifestations: fever or wave-like fever, late afternoon fever, cold, sweating and fever does not subside, irritable and thirsty, or with chest and epigastric stuffiness, head and body joint swelling and pain, testicular swelling and pain, red tongue, yellow or yellowish greasy coating, slippery pulse.
Treatment: Clearing heat and removing evil, relieving dampness and promoting circulation.
Reference formula: Sheng Shi Fa, Zhi Mu, Cang Zhu, Hou Pu
Raw barley, Artemisia annua, Scutellaria baicalensis, Lonicera japonica
Han Fangji, Almond, Guang Di Long, Liu Yi San
Add and subtract: add patchouli and pelargonium in case of severe body pain from vicious cold; add neem and yuan hu in case of testicular swelling and pain.
1.2.Dampness and paralysis
Clinical manifestations: fever, sweating, fever in the afternoon, heavy body and limbs, pain in muscles and joints, enlarged liver and spleen, swollen and painful testicles, white or yellowish fur on the tongue, smooth or moist pulse.
Treatment: Relieving dampness and resolving turbidity, promoting the circulation of the ligaments and clearing paralysis.
Reference formula: Doklamia, raw barley, Han Fangji
Radix Gentiana Macrophyllae, Radix Morindae Sinensis, Atractylodes Macrocephala, Radix et Rhizoma Macrocephala
Red peony, Salvia miltiorrhiza, Scutellaria baicalensis, Glycyrrhiza glabra
Add and subtract: add Gardenia and Zhi Mu if the heat is severe; add Acanthopanax and Papaya if the joint pain is severe.
2. Chronic phase
Qi deficiency and ligament obstruction
Clinical manifestations: prolonged illness, lack of color, shortness of breath, lazy speech, sweating, muscle and joint distension, pale tongue, white fur, sunken and feeble pulse.
Treatment: Benefiting Qi, resolving dampness, nourishing blood and promoting circulation.
Reference formula: Radix Astragali, Radix Codonopsis, Atractylodes Macrocephala, Poria
Radix et Rhizoma Dioscoreae, Radix Angelicae Sinensis, Radix et Rhizoma Paeoniae Alba, Radix et Rhizoma Vittatae
Radix Rehmanniae Praeparata, Rhizoma Atractylodes Macrocephala, Glycyrrhiza glabra
Add and subtract: add Eucommia, Chuanjian, Boneset; add Ocimum sanctum, Pinellia, Zeligia for swollen and painful joints of the limbs; add Shengdi for night sweats and five heartburn; add Baji Tian for heavy cold fear.
External treatment: In the local painful area, acupuncture, fumigation, hot amulet and collapsing can be used for treatment.
V. Prognosis
Acute cases can be cured by the above standardized treatment, some cases can become chronic if the treatment is not timely or not standardized.
The serological test results of brucellosis are not used as criteria for determining the efficacy.