Nikolaos Akritidis

The new global map of human brucellosis

The epidemiology of human brucellosis, the commonest zoonotic infection worldwide, has drastically changed over the past decade because of various sanitary, socioeconomic, and political reasons, together with the evolution of international travel. Several areas traditionally considered to be endemic--eg, France, Israel, and most of Latin America--have achieved control of the disease. On the other hand, new foci of human brucellosis have emerged, particularly in central Asia, while the situation in certain countries of the Near East (eg, Syria) is rapidly worsening. Furthermore, the disease is still present, in varying trends, both in European countries and in the USA. Awareness of this new global map of human brucellosis will allow for proper interventions from international public-health organisations.

Brucella as a biological weapon.

Abstract.Brucella has traditionally been considered a biological weapon. It was the subject of extensive offensive research in the past, and still belongs to category B pathogens on most lists. Its propensity for airborne transmission and induction of chronic debilitating disease requiring combined antibiotic regimens for treatment, its abundance around the world and its vague clinical characteristics defying rapid clinical diagnosis are some of the characteristics that apply to the pathogen’s weapons potential. Yet minimal mortality, availability of treatment options, protracted inoculation period and the emergence of new, more virulent potential weapons means that its inclusion among agents of bioterrorism is nowadays mainly of historical significance. Nevertheless, in the interest of literacy and of avoiding panic, physicians and the public both should be aware of the most common zoonosis worldwide.

Brucellosis and the Respiratory System

Brucellosis is a zoonotic disease that remains endemic worldwide. Its clinical manifestations and focal complications are often troublesome in making a diagnosis. Involvement of the respiratory system in brucellosis is an acknowledged but rare event that is only occasionally described in literature. We describe 37 cases of respiratory involvement during the course of brucellosis that presented as pneumonia, bronchopneumonia, pleural effusion with a predominance of monocytic or lymphocytic infiltrates, and paroxysmal dry cough. We also discuss aspects of the respiratory pathology, radiological characteristics, coexisting complications, and aspects of treatment of respiratory brucellosis.

Future trends in human brucellosis treatment

The global burden of human brucellosis remains enormous. Existing treatment options, largely based on experience gained > 30 years ago, are adequate but not optimal. The evolving understanding of the pathophysiology of the disease may augment in designing and evaluating alternative approaches that may prove to be superior. Current alternative approaches such as co-trimoxazole-containg regimens, should be widely evaluated as being more cost-effective. New methods of delivery such as gentamicin-loaded microparticles, neutralisation of the environment where Brucella resides and use of novel antibiotics such as tigecycline may be of importance in the future. The role of immunomodulation, widely but inconsistently applied in ‘chronic’ brucellosis, should be further evaluated in all disease stages to define if it is of any use. The development of a subcellular vaccine would be an important step forward although one has to take into account the multiple interactions between Brucella and the immune system, various technical problems and the lack of funds. Reviewing existing attempts at the development of such a vaccine, the authors conclude that a trivalent subcellular vaccine may be needed for adequate efficacy.

Effective treatments in the management of brucellosis

Treatment of uncomplicated brucellosis in humans utilises a variety of anti-biotic combinations, applied to a series of important pathogenetic and clinical parameters. The currently recommended treatment regimens have not been surpassed by newer compounds, and various therapeutic strategies utilising these compounds cannot be adequately evaluated due to the absence of large, multi-centre, multinational trials. The review focuses on the basic principles of brucellosis treatment, the properties of the various regimens used, the results of trials involving them, and the questions raised about the efficacy of these regimens in certain clinical situations.

Unusual causes of reactive arthritis: Leptospira and Coxiella burnetii.

Reactive arthritis is a well-defined clinical syndrome occurring after various infections, although most cases are usually associated with Chlamydiae and gastrointestinal pathogens. Its immunologic background has been extensively studied, as has its relationship with HLA-B27. We describe two cases of reactive arthritis arising after infections with two pathogens not so far related to the occurrence of reactive arthritis: one patient exhibited migratory oligoarthritis shortly after the course of acute Q fever, and another patient developed monoarthritis during recovery from leptospirosis. Arthritis was transient and did not exhibit a chronic course in either patient. We further discuss the context of pathophysiology of the arthritis in these patients, with an emphasis on the immunomodulatory properties of these two pathogens.

Infectious Diseases in Cinema: Virus Hunters and Killer Microbes

The world of infectious diseases has been rarely presented in the cinema with accuracy. Apart from random biographies of scientists and retellings of stories about great epidemics from the past, most films focus on the dangers presented by outbreaks of unknown agents that originate from acts of bioterrorism, from laboratory accidents, or even from space. We review these films and underline the possible effect that they have on the publics perception of infection--a perception that, when misguided, could prove to be problematic in times of epidemics.

Chilaiditi's sign.

A 79-year-old man presented with symptoms and signs of upper respiratory tract infection; he had a history of permanent pacemaker implantation. An upright posteroanterior chest radiograph showed a raised right hemidiaphragm delineated by subdiaphragmatic air. Unlike free air, which forms an uninterrupted crescent-shaped subdiaphragmatic radiolucency, this radiograph showed a haustral pattern of subdiaphragmatic lucency (fi gure), overlapping the upper border of the liver shadow. On examination, clinical fi ndings suggesting acute abdomen from rupture of a hollow viscus were absent and there was no recent history of abdominal surgery to account for the presence of subdiaphragmatic air. The visualisation of a gas fi lled transverse colon lumen interpositioned between the right hemidiaphragm and the liver on a chest fi lm is called Chilaiditi’s sign. A CT scan may confi rm these anatomical relations. In our patient’s radiograph, the haustral pattern of air was indicative of colonic origin, and the continuity of the subdiaphragmatic air was broken up by the shadow of the vertical plicae semilunares of the colon. Chilaiditi’s sign was fi rst described in 1910 by Demetrious Chilaiditi and it is an incidental radiographic fi nding. This sign can be mistaken for pneumoperitoneum and can lead to needless surgical intervention. Our patient was treated only for his upper respiratory tract infection. Lancet 2009; 373: 836

Reclassifying bioterrorism risk: Are we preparing for the proper pathogens?

Existing classifications of potential biological weapons, acknowledge only limited important parameters of biological weapon potential. Certain pathogen factors would further influence the outcome of a potential attack in context with social and political aspects of the time and space of the attack. The importance of these factors was investigated through various attack scenarios that have been developed by the authors, and an individual score for each of these factors was calculated, based on the overall effect their variation had in the scenario outcome. A new classification score for potential biological weapons was subsequently developed, one, which drastically alters the perception of risk for certain pathogens, such as filoviruses and anthrax. This frame further allows for more accurate evaluation of the bioweapon potential of agents such as avian flu. Recognition of intervening factors and proper assessment of the actual risk might augment in proper distribution of interest and funds on relevant medical research.

Subacute thyroiditis in the course of novel H1N1 influenza infection

To describe the first documented case of subacute (De Quervain) thyroiditis in the course of novel H1N1 influenza infection. This is a case report of a patient diagnosed at the General Hospital “G. Hatzikosta” of Ioannina, Greece. A 55-year-old previously healthy male developed an influenza-like syndrome that was accompanied by severe neck pain, palpitations, weight loss, and disproportionately increased erythrocyte sedimentation rate. Polymerase chain reaction assay of pharyngeal swabs confirmed the diagnosis of novel H1N1 influenza infection. Serum thyroid-stimulating hormone was suppressed to zero and levels of free thyroxine and particularly triiodothyronine were increased. Technetium-99m-pertechnetate scintigraphy showed diffuse and inhomogeneous very low technetium trapping. The patient was treated with non-steroidal anti-inflammatory drugs and thyroid function gradually normalized without evolving to a hypothyroid phase. This is the first case of subacute thyroiditis associated with novel H1N1 influenza infection. Furthermore, this is the first case to definitely demonstrate active influenza infection of any type concurrent with thyroiditis, and one of the very rare similar cases for any active viral disease etiologically implicated in the pathogenesis of subacute thyroiditis.