HUMAN BRUCELLOSIS IN REPUBLIC OF MACEDONIA – CLINICAL EXPERIENCE IN ENDEMIC REGION
Mile Bosilkovski
Sveučilišna klinika za infektivne bolesti i febrilna stanja Medicinskog fakulteta, Skopje, Makedonija. Radna skupina za zoonoze, Međunarodno društvo za kemoterapiju. Skopje, Republika Makedonija
E-mail: milebos@yahoo.com
B ruceloza je jedna od najraširenijih zoonoza u svijetu, a ima veliki utjecaj na zdravlje ljudi i životinja, gospodarski razvoj te poljoprivredu i turizam. Evidentirana učestalost u svijetu je 500 000 slučajeva godišnje, što je 25 puta manje od stvarne situacije, jer bolest često ostaje neotkrivena uglavnom zbog netočne dijagnoze i neodgovarajuće zdravstvene zaštite, zatim neprijavljivanja slučajeva, što je uglavnom povezano s lošom suradnjom s osobnom zdravstvenom zaštitom, nedostatkom standardiziranih obrazaca utvrđivanja bruceloze kao i različitim nacionalnim smjernicama koje se odnose na dijagnostiku i liječenje bolesti. Endemska područja s najvećom prevalencijom u svijetu tijekom posljednjih godina su Bliski i Srednji Istok, Mediteran, Indijski potkontinent, Subsaharska Afrika, Mongolija i nekoliko azijskih država bivšeg Sovjetskog Saveza.
Tijekom više od 30 godina Republika Makedonija smatrana je endemskim područjem za brucelozu te jedna od vodećih u svijetu po broju novih slučajeva godišnje (15 – 20 novooboljelih na 100 000 stanovnika).
Cilj ovog retrospektivnog istraživanja bio je prikazati glavna demografska, klinička, laboratorijska obilježja i ishod u bolesnika s brucelozom liječenih u Sveučilišnoj klinici za zarazne bolesti u Skopju, u razdoblju od siječnja 2000. do prosinca 2011. Bruceloza je dijagnosticirana na temelju kliničkih simptoma te potvrđena dokazom specifičnih protutijela u visokom titru. Od 636 bolesnika 71% bili su muškarci u dobi od 1 – 82 godine (prosječno 36 godina).
U izravnom dodiru s bolesnim životinjama bilo je 62% pacijenata. Trajanje bolesti prije terapije iznosilo je 3 – 360 (prosjek 30) dana, a pozitivnu obiteljsku anamnezu imalo je njih 58%.
Kao najčešći simptomi navode se bolovi u zglobovima 81%, groznica 73% i znojenje 70%, dok je hepatomegalija potvrđena u 45% bolesnika. Porast C – reaktivnog proteina (81%) i sedimentacija eritrocita (60%) karakteristični su pokazatelji u laboratorijskoj dijagnostici.
Žarišna bruceloza zabilježena je u 60%, a osteoartikularna u 50% bolesnika. Ostali zahvaćeni organi i/ili organski sustavi su dišni, hematološki i mokraćno spolni (svaki 5%), živčani sustav (3%), a kardiovaskularni i hepatobilijarni u 2% bolesnika. Terapija se sastoji od nekoliko antimikrobnih protokola, a 38% pacijenata liječeno je kombinacijom rifampina, doksiciklina i co-trimoxazola tijekom 45 dana. Ponovna pojava bolesti zabilježena je u 10% pacijenata, a neuspješno liječenje kod njih 5%.
Zaključak je da brucelozu s obzirom na nespecifična klinička obilježja i laboratorijske pokazatelje treba diferencijalno dijagnostički uzeti u obzir u svih bolesnika s povišenom temperaturom, znojenjem, bolovima u zglobovima ili u pacijenata s neobjašnjenom upalom nekog od organa na području na kojemu je bruceloza endemska bolest. Visok postotak bolesnika s ponovnom pojavom bolesti i neuspješnim liječenjem, usprkos uporabi najsuvremenijih načina liječenja, upućuje na ozbiljnost bruceloze i potrebu da se ta bolest drži pod kontrolom.
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HUMAN BRUCELLOSIS IN REPUBLIC OF MACEDONIA – CLINICAL EXPERIENCE IN ENDEMIC REGION
Mile Bosilkovski
University Clinic for Infectious Diseases and Febrile Conditions, Medical Faculty Skopje. Working Group on Zoonoses, International Society of Chemotherapy. Skopje, Macedonia
E-mail: milebos@yahoo.com
Brucellosis is one of the most widespread zoonoses in the world with a high impact on human and animal health, economic development, agricultural trade and tourism. The reported worldwide incidence of 500 000 cases per year might be up to 25 times less than the true incidence, having in mind that this disease quite often remains unrecognized, mainly due to inaccurate diagnosis and inadequate health network systems, or due to its underreporting, mainly associated with poor collaboration from the private health care sector, lack of a standardized case definition for brucellosis, as well as existence of different national policies with regard to diagnosis and treatment of brucellosis cases. Among the most prevalent endemic regions in the world in the recent years are the Near and the Middle East, Mediterranean Basin, Indian Subcontinent, sub-Saharan Africa, Mongolia and several Asian states of the former Soviet Union.
For more than 30 years Republic of Macedonia is considered as an endemic region for brucellosis, and among the leading countries in the World with an annual incidence of 15-25 cases per 100 000 inhabitants.
The aim of this retrospective study was to present the main demographic, clinical, laboratory characteristics and outcome in patients with brucellosis, treated at the University clinic for infectious diseases in Skopje, during the period January 2000 to December 2011. Brucellosis was diagnosed on the basis of clinical signs, and confirmed by the detection of specific antibodies at significant titers. Out of 636 patients, 71% were males. The median age was 36, range 1-82 years. Direct contact with infected animals was present in 62% patients. Illness duration prior to therapy was median 30, range 3-360 days, and positive family history had 58%. Arthralgias, in 81%, fever, in 73%. and sweating, in 70% of the patients were the most frequent complaints, whereas hepatomegaly verified in 45% was the commonest sign. Elevated C-reactive protein in 81% and erythrocyte sedimentation rate found in 60% of the examined patients were the dominant laboratory characteristics. Focal brucellosis was registered in 60%, and 50% of them had osteoarticular form. Other affected organs and/or systems were respiratory, hematological, and urogenital in 5% each, nervous in 3%, and cardiovascular and hepatobiliary in 2% of the patients. Therapy comprised several antimicrobial protocols, and 38% of the patients were treated with a combination of rifampin plus doxycycline plus co-trimoxazole for 45 days. Relapses were found in 10% and therapeutic failure in 5% of the patients.
In conclusion, due to nonspecific clinical manifestation and laboratory parameters, brucellosis should be considered one of the differential diagnoses in any patient with fever, sweating and arthralgias, or suffering from obscure involvement of various systems in a brucellosis-endemic region. The high percentage of relapses and therapeutic failures, in spite of the use of currently recommended therapeutic regimens, indicate the seriousness of this zoonosis and the need to control it.
