Brucellosis
http://www.100md.com
《新英格兰医药杂志》
To the Editor: We were surprised by two omissions in the otherwise commendable review of brucellosis by Pappas and colleagues (June 2 issue).1 Without acknowledging the long-standing opinion of expert clinicians and investigators2 that Brucella melitensis causes more severe infections than does B. abortus, the authors cite a recent direct comparison3 and state that clinical severity is similar between the two strains. In contrast, our more recent analysis of brucellosis in San Diego, California,4 supports the traditional position. B. melitensis infections presented more acutely as fever of unknown origin with substantially higher rates of abdominal tenderness, hepatomegaly, splenomegaly, thrombocytopenia, pancytopenia, and hepatic dysfunction. Possible explanations for the differences between patients in San Diego and those in reports from Turkey include "widespread use of antibiotics inappropriately before the diagnosis"3 and variations in the virulence of B. melitensis biotypes.1
Pappas et al. also did not note the extensive conflicting data5 concerning whether childhood brucellosis is relatively benign. We would suggest that both sides of important, unresolved issues should have been included in this review.
Charles E. Davis, M.D.
University of California, San Diego, Medical Center
San Diego, CA 92103
chdavis@ucsd.edu
Stephanie B. Troy, M.D.
University of Illinois Medical Center
Chicago, IL 60612
References
Pappas G, Akritidis N, Bosilkovski M, Tsianos E. Brucellosis. N Engl J Med 2005;352:2325-2336.
Young EJ. An overview of human brucellosis. Clin Infect Dis 1995;21:283-290.
Dokuzoguz B, Ergonul O, Baykam N, et al. Characteristics of B. melitensis versus B. abortus bacteraemias. J Infect 2005;50:41-45.
Troy SB, Rickman LS, Davis CE. Brucellosis in San Diego: epidemiology and species-related differences in acute clinical presentations. Medicine (Baltimore) 2005;84:174-187.
Mantur BG, Akki AS, Mangalgi SS, Patil SV, Gobbur RH, Peerapur BV. Childhood brucellosis -- a microbiological, epidemiological and clinical study. J Trop Pediatr 2004;50:153-157.
To the Editor: We would like to add a historical perspective on brucellosis. B. melitensis was first isolated in 1887 by David Bruce.1 It was the cause of Malta fever, a hitherto mysterious illness affecting a number of English soldiers serving on the Maltese islands.2 In 1904, Bruce was instrumental in the setting up of a Mediterranean Fever Commission to investigate this disease and its mode of transmission.3 One of the team was a Maltese bacteriologist, Sir Themistocles Zammit. He worked on Maltese goats, since these were common in Malta, being bred in every village to provide the locals with a supply of fresh milk. In 1905, Zammit discovered brucella in goat blood, and Major William Horrocks, also on the Mediterranean Fever Commission, found the organism in milk.3 This important discovery led to the total ban on consumption of goat's milk by the military. Pasteurization was introduced as a legal requirement in Malta in 1938.4 The last documented outbreak of brucella on the island occurred in 1995.5
Ivan Tonna, M.R.C.P.
Antonella Tonna, M.R.Pharm.S.
Oxford Radcliffe Hospitals
Oxford OX3 9DZ, United Kingdom
References
Young EJ. Brucella species. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett's principles and practice of infectious diseases. 6th ed. Vol. 2. New York: Elsevier/Churchill Livingstone, 2005.
Vassallo DJ. The corps disease: brucellosis and its historical association with the Royal Army Medical Corps. J R Army Med Corps 1992;138:140-150.
Vassallo DJ. The saga of brucellosis: controversy over credit for linking Malta fever with goats' milk. Lancet 1996;348:804-808.
History of medical practice and pharmacy. In: Savona-Ventura C. Outlines of Maltese medical history. Valletta, Malta: Midsea Books, 1997:41-58.
Brucellosis associated with unpasteurised milk products abroad. Commun Dis Rep CDR Wkly 1995;5:151-151.
The authors reply: In response to the comments made by Dr. Davis and Dr. Troy regarding the difference in clinical severity between B. melitensis and B. abortus, we should state that Table 2 in our review of medical progress on brucellosis acknowledges this difference. We do not state that the severity is similar but acknowledge that the findings of a Turkish study1 merit consideration. The very interesting study of brucellosis in San Diego2 was published just as our review went to press.
Regarding the comments on childhood brucellosis, results from the majority of reviews of the outcome of childhood brucellosis, including reviews from Greece,3 allow for the characterization of a generally more benign course in children, especially if one considers that childhood brucellosis is generally not treated with regimens endorsed by the World Health Organization. Moreover, spondylitis, an often grave complication, is rarely present in childhood.4 We describe the course of brucellosis in childhood as generally benign (and not universally benign) to account for the majority of available data, without ignoring isolated reports of severe complications. Clarification of the severity of childhood disease would necessitate the development of an extended multinational database, comparing the outcome of childhood brucellosis with that of adult brucellosis in similar geographic areas. Such a database is currently being developed and may allow for clarification of this and other unresolved issues regarding brucellosis.
Georgios Pappas, M.D.
Nikolaos Akritidis, M.D.
Epameinondas V. Tsianos, M.D.
University Hospital of Ioannina
45110 Ioannina, Greece
gpele@otenet.gr
References
Dokuzoguz B, Ergonul O, Baykam N, et al. Characteristics of B. melitensis versus B. abortus bacteraemias. J Infect 2005;50:41-45.
Troy SB, Rickman LS, Davis CE. Brucellosis in San Diego: epidemiology and species-related differences in acute clinical presentations. Medicine (Baltimore) 2005;84:174-187.
Galanakis E, Bourantas KL, Leveidiotou S, Lapatsanis PD. Childhood brucellosis in north-western Greece: a retrospective analysis. Eur J Pediatr 1996;155:1-6.
Benjamin B, Annobil SH, Khan MR. Osteoarticular complications of childhood brucellosis: a study of 57 cases in Saudi Arabia. J Pediatr Orthop 1992;12:801-805.
Pappas et al. also did not note the extensive conflicting data5 concerning whether childhood brucellosis is relatively benign. We would suggest that both sides of important, unresolved issues should have been included in this review.
Charles E. Davis, M.D.
University of California, San Diego, Medical Center
San Diego, CA 92103
chdavis@ucsd.edu
Stephanie B. Troy, M.D.
University of Illinois Medical Center
Chicago, IL 60612
References
Pappas G, Akritidis N, Bosilkovski M, Tsianos E. Brucellosis. N Engl J Med 2005;352:2325-2336.
Young EJ. An overview of human brucellosis. Clin Infect Dis 1995;21:283-290.
Dokuzoguz B, Ergonul O, Baykam N, et al. Characteristics of B. melitensis versus B. abortus bacteraemias. J Infect 2005;50:41-45.
Troy SB, Rickman LS, Davis CE. Brucellosis in San Diego: epidemiology and species-related differences in acute clinical presentations. Medicine (Baltimore) 2005;84:174-187.
Mantur BG, Akki AS, Mangalgi SS, Patil SV, Gobbur RH, Peerapur BV. Childhood brucellosis -- a microbiological, epidemiological and clinical study. J Trop Pediatr 2004;50:153-157.
To the Editor: We would like to add a historical perspective on brucellosis. B. melitensis was first isolated in 1887 by David Bruce.1 It was the cause of Malta fever, a hitherto mysterious illness affecting a number of English soldiers serving on the Maltese islands.2 In 1904, Bruce was instrumental in the setting up of a Mediterranean Fever Commission to investigate this disease and its mode of transmission.3 One of the team was a Maltese bacteriologist, Sir Themistocles Zammit. He worked on Maltese goats, since these were common in Malta, being bred in every village to provide the locals with a supply of fresh milk. In 1905, Zammit discovered brucella in goat blood, and Major William Horrocks, also on the Mediterranean Fever Commission, found the organism in milk.3 This important discovery led to the total ban on consumption of goat's milk by the military. Pasteurization was introduced as a legal requirement in Malta in 1938.4 The last documented outbreak of brucella on the island occurred in 1995.5
Ivan Tonna, M.R.C.P.
Antonella Tonna, M.R.Pharm.S.
Oxford Radcliffe Hospitals
Oxford OX3 9DZ, United Kingdom
References
Young EJ. Brucella species. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett's principles and practice of infectious diseases. 6th ed. Vol. 2. New York: Elsevier/Churchill Livingstone, 2005.
Vassallo DJ. The corps disease: brucellosis and its historical association with the Royal Army Medical Corps. J R Army Med Corps 1992;138:140-150.
Vassallo DJ. The saga of brucellosis: controversy over credit for linking Malta fever with goats' milk. Lancet 1996;348:804-808.
History of medical practice and pharmacy. In: Savona-Ventura C. Outlines of Maltese medical history. Valletta, Malta: Midsea Books, 1997:41-58.
Brucellosis associated with unpasteurised milk products abroad. Commun Dis Rep CDR Wkly 1995;5:151-151.
The authors reply: In response to the comments made by Dr. Davis and Dr. Troy regarding the difference in clinical severity between B. melitensis and B. abortus, we should state that Table 2 in our review of medical progress on brucellosis acknowledges this difference. We do not state that the severity is similar but acknowledge that the findings of a Turkish study1 merit consideration. The very interesting study of brucellosis in San Diego2 was published just as our review went to press.
Regarding the comments on childhood brucellosis, results from the majority of reviews of the outcome of childhood brucellosis, including reviews from Greece,3 allow for the characterization of a generally more benign course in children, especially if one considers that childhood brucellosis is generally not treated with regimens endorsed by the World Health Organization. Moreover, spondylitis, an often grave complication, is rarely present in childhood.4 We describe the course of brucellosis in childhood as generally benign (and not universally benign) to account for the majority of available data, without ignoring isolated reports of severe complications. Clarification of the severity of childhood disease would necessitate the development of an extended multinational database, comparing the outcome of childhood brucellosis with that of adult brucellosis in similar geographic areas. Such a database is currently being developed and may allow for clarification of this and other unresolved issues regarding brucellosis.
Georgios Pappas, M.D.
Nikolaos Akritidis, M.D.
Epameinondas V. Tsianos, M.D.
University Hospital of Ioannina
45110 Ioannina, Greece
gpele@otenet.gr
References
Dokuzoguz B, Ergonul O, Baykam N, et al. Characteristics of B. melitensis versus B. abortus bacteraemias. J Infect 2005;50:41-45.
Troy SB, Rickman LS, Davis CE. Brucellosis in San Diego: epidemiology and species-related differences in acute clinical presentations. Medicine (Baltimore) 2005;84:174-187.
Galanakis E, Bourantas KL, Leveidiotou S, Lapatsanis PD. Childhood brucellosis in north-western Greece: a retrospective analysis. Eur J Pediatr 1996;155:1-6.
Benjamin B, Annobil SH, Khan MR. Osteoarticular complications of childhood brucellosis: a study of 57 cases in Saudi Arabia. J Pediatr Orthop 1992;12:801-805.