Brucellosis overview: Difference between revisions

	Brucellosis Microchapters
Home
Patient Information
Overview
Historical Perspective
Pathophysiology
Causes
Differentiating Brucellosis from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
Principles of diagnosis
History and Symptoms
Physical Examination
Laboratory Findings
X-Ray
CT Scan
MRI
Other Diagnostic Studies
Treatment
Medical Therapy
Primary Prevention
Secondary Prevention
Cost-Effectiveness of Therapy
Future or Investigational Therapies
Case Studies
Case #1
Brucellosis overview On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
American Roentgen Ray Society Images of Brucellosis overview All Images X-rays Echo & Ultrasound CT Images MRI
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Brucellosis overview
CDC on Brucellosis overview
Brucellosis overview in the news
Blogs on Brucellosis overview
Directions to Hospitals Treating Brucellosis
Risk calculators and risk factors for Brucellosis overview

VisualWikitext

Revision as of 23:04, 23 January 2017

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Raviteja Guddeti, M.B.B.S. [2] Danitza Lukac Vishal Devarkonda, M.B.B.S [1]

Overview

Brucellosis is a zoonosis (infectious disease transmitted from animals to humans) caused by bacteria of the genus Brucella. Brucella is usually transmitted via the digestive route to the human host. Following transmission, white blood cells phagocyte the pathogen and transports it via the hematologic or lymphatic route to different organs, specially to those of the reticuloendothelial system.^[1][2] Brucellosis must be differentiated from typhoid fever, malaria, tuberculosis, lymphoma, dengue, leptospirosis and rheumatic diseases.^[3] Brucellosis is not very common in the United States, but brucellosis can be very common within countries that do not have good standardized and effective public health and domestic animal health programs. Areas currently listed as high risk are the Mediterranean Basin (Portugal, Spain, Southern France, Italy, Greece, Turkey, North Africa), South and Central America, Eastern Europe, Asia, Africa, the Caribbean, and the Middle East.^[4] Common risk factors in the development of brucellosis are consuming unpasteurized dairy products, unsafe hunting practices and occupational risks such as slaughther house workers, meat-packing employees, veterinarian and laboratory workers.^[4] If left untreated, patients with brucellosis may progress to develop focal infections, relapses or chronic brucellosis.^[5] Common complications of brucellosis include granulomatous hepatitis, arthritis, sacroiliitis, meningitis, orchitis, epididymitis uveitis, and endocarditis. The prognosis of brucellosis is good with adequate treatment. Relapse may occur, and symptoms may continue for years.^[5][6][7] Symptoms of brucellosis include undulant fever, night sweats (with characteristic smell, likened to wet hay), and joint pain.^[7] Patients with brucellosis are usually well-appearing.^[2] Common physical examination findings include hepatomegaly, splenomegaly, and lymphadenopathy.^[8] The mainstay of therapy for brucellosis is antimicrobial therapy. The preferred regimen for uncomplicated brucellosis is a combination of Doxycycline and Streptomycin. Rifampin is the drug of choice for brucellosis in pregnancy. For children less than 8 years of age, the preferred regimen is either Gentamycin or a combination of Trimethoprim-sulfamethoxazole and Streptomycin.^[7][9] The optimal way to prevent brucellosis is by not consuming unpasteurized dairy or undercooked meat, and having safe occupational practices. There are no available vaccines for humans against brucellosis.^[7][10]

Historial Perspective

In 1887, David Bruce, a Scottish pathologist and microbiologist, was the first to discover the association between Brucella and the development of brucellosis.^[7]

Pathophysiology

Brucella is usually transmitted via the digestive route to the human host. Following transmission, white blood cells phagocyte the pathogen and transport it via the hematologic or lymphatic route to different organs, specially those of the reticuloendothelial system.^[1][2]

Causes

Human brucellosis is caused by four Brucellae species: B. abortus, B. canis, B. melitensis, and B. suis.

Differentiating Brucellosis from other Diseases

Brucellosis must be differentiated from typhoid fever, malaria, tuberculosis, lymphoma, dengue, leptospirosis and rheumatic diseases.^[3]

Epidemiology and Demographics

Brucellosis is not very common in the United States, but brucellosis can be very common within countries that do not have good standardized and effective public health and domestic animal health programs. Areas currently listed as high risk are the Mediterranean Basin (Portugal, Spain, Southern France, Italy, Greece, Turkey, North Africa), South and Central America, Eastern Europe, Asia, Africa, the Caribbean, and the Middle East.^[4]

Risk Factors

Common risk factors in the development of brucellosis are consuming unpasteurized dairy products, unsafe hunting practices and occupational risks such as slaughther house workers, meat-packing employees, veterinarian, and laboratory workers.^[4]

Screening

There are no guidelines for brucellosis screening. Some endemic areas screen family members of patients with brucellosis. ^[12] ^[13]

Natural history, Complications and Prognosis

If left untreated, patients with brucellosis may progress to develop focal infections, relapses or chronic brucellosis.^[5] Common complications of brucellosis include granulomatous hepatitis, arthritis, sacroiliitis, meningitis, orchitis, epididymitis uveitis, and endocarditis. The prognosis of brucellosis is good with adequate treatment. Relapse may occur, and symptoms may continue for years.^[5][6][7]

Diagnosis

Criteria

The diagnosis of brucellosis is based on clinical and laboratory criteria.^[14]

History and Symptoms

Symptoms of brucellosis include undulant fever, night sweats (with characteristic smell, likened to wet hay), and joint pain.^[7]

Physical Examination

Patients with brucellosis are usually well-appearing.^[2] Common physical examination findings include hepatomegaly, splenomegaly, and lymphadenopathy.^[8]

Laboratory Findings

A positive culture or presence of Brucella antibody in serological tests are diagnostic of brucellosis.^[14]

Other Diagnostic Studies

Spine x-ray, CT o MRI may be helpful in the diagnosis of focal brucellosis infection. Findings of Pedro Pons sign can be suggestive of brucellic spondylitis.^[15]

Treatment

Medical Therapy

The mainstay of therapy for brucellosis is antimicrobial therapy. The preferred regimen for uncomplicated brucellosis is a combination of Doxycycline and Streptomycin. Rifampin is the drug of choice for brucellosis in pregnancy. For children less than 8 years of age, the preferred regimen is either Gentamycin or a combination of Trimethoprim-sulfamethoxazole and Streptomycin.^[7][9]

Prevention

Effective measures for the primary prevention of brucellosis include not consuming unpasteurized dairy or undercooked meat, and having safe occupational practices. There are no available vaccines for humans against brucellosis.^[10][7]

References

↑ ^{Jump up to:1.0} ^1.1
↑ ^{Jump up to:2.0} ^2.1 ^2.2 ^2.3 Brucelosis. Wikipedia. https://es.wikipedia.org/wiki/Brucelosis. Accessed on February 2, 2016 Cite error: Invalid <ref> tag; name "aa" defined multiple times with different content Cite error: Invalid <ref> tag; name "aa" defined multiple times with different content Cite error: Invalid <ref> tag; name "aa" defined multiple times with different content
↑ ^{Jump up to:3.0} ^3.1 Enfermedades infecciosas: Brucelosis -Diagnóstico de Brucelosis,Guia para el Equipo de Salud. Ministerio de Salud-Argentina. http://www.msal.gob.ar/images/stories/bes/graficos/0000000304cnt-guia-medica-brucelosis.pdf. Accessed on February 2, 2016
↑ ^{Jump up to:4.0} ^4.1 ^4.2 ^4.3 Brucellosis. CDC. http://www.cdc.gov/brucellosis/exposure/index.html.html. Accessed on February 3, 2016 Cite error: Invalid <ref> tag; name "c" defined multiple times with different content Cite error: Invalid <ref>tag; name "c" defined multiple times with different contentCite error: Invalid <ref> tag; name "c" defined multiple times with different content
↑ ^{Jump up to:5.0} ^5.1 ^5.2 ^5.3 Brucellosis. CDC. http://wwwnc.cdc.gov/travel/yellowbook/2016/infectious-diseases-related-to-travel/brucellosis. Accessed on February 3, 2016 Cite error: Invalid<ref> tag; name "f" defined multiple times with different content Cite error: Invalid <ref> tag; name "f" defined multiple times with different content Cite error: Invalid <ref>tag; name "f" defined multiple times with different content
↑ ^{Jump up to:6.0} ^6.1 FAO/WHO/OIE Brucellosis in humans and animals. WHO (2006). http://www.who.int/csr/resources/publications/Brucellosis.pdf Accessed on February 3, 2016
↑ ^{Jump up to:7.0} ^7.1 ^7.2 ^7.3 ^7.4 ^7.5 ^7.6 ^7.7 ^7.8 Brucellosis. Wikipedia. https://en.wikipedia.org/wiki/Brucellosis. Accessed on February 1, 2016 Cite error: Invalid <ref> tag; name "a" defined multiple times with different content Cite error: Invalid <ref> tag; name "a" defined multiple times with different content Cite error: Invalid<ref> tag; name "a" defined multiple times with different content Cite error: Invalid <ref> tag; name "a" defined multiple times with different content Cite error: Invalid <ref>tag; name "a" defined multiple times with different contentCite error: Invalid <ref> tag; name "a" defined multiple times with different content Cite error: Invalid <ref> tag; name "a" defined multiple times with different content Cite error: Invalid<ref> tag; name "a" defined multiple times with different content
↑ ^{Jump up to:8.0} ^8.1
↑ ^{Jump up to:9.0} ^9.1 Brucellosis. CDC. http://www.cdc.gov/brucellosis/treatment/index.html. Accessed on February 5, 2016
↑ ^{Jump up to:10.0} ^10.1 Brucellosis. CDC. http://www.cdc.gov/brucellosis/prevention/index.html. Accessed on February 5, 2016
Jump up↑ Brucella. Wikipedia. https://en.wikipedia.org/wiki/Brucella#Characteristics. Accessed on February 2, 2016
Jump up↑
Jump up↑
↑ ^{Jump up to:14.0} ^14.1 Brucellosis 2010 Case Definition. CDC. http://wwwn.cdc.gov/nndss/conditions/brucellosis/case-definition/2010/. Accessed on February 2, 2016
Jump up↑ Pourbagher A, Pourbagher MA, Savas L, Turunc T, Demiroglu YZ, Erol I; et al. (2006). "Epidemiologic, clinical, and imaging findings in brucellosis patients with osteoarticular involvement.". AJR Am J Roentgenol. 187 (4): 873–80. PMID 16985128. doi:10.2214/AJR.05.1088.

@@ Line 1: / Line 1: @@
 __NOTOC__
 {{Brucellosis}}
-{{CMG}}; {{AE}} {{RT}} {{DL}}
-==Overview==
+'''Editor-In-Chief:''' [[User:C Michael Gibson|C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com <nowiki>[1]</nowiki>]; '''Associate Editor(s)-in-Chief:''' [[User:Raviteja Reddy Guddeti|Raviteja Guddeti, M.B.B.S.]] [mailto:ravitheja.g@gmail.com <nowiki>[2]</nowiki>] [[User:Danitza Lukac|Danitza Lukac]] {{VD}}
-[[Brucellosis]] is a Zoonotic disease. According to some studies, there is evidence that [[Brucellosis]] occurred in animals 60 million years ago and 3 million years ago in human beings. In 450 BC, Hippocrates described a disease similar to [[Brucellosis]]. Traditionally [[Brucella]], due to its propensity for [[airborne transmission]], low lethality, minimal [[mortality]], and ease of manufacturing made it to be considered as a biological weapon. [[Centers for Disease Control and Prevention|CDC]] classifies it into [https://autismoevaccini.files.wordpress.com/2016/01/cdc_bioterrorism_agents.pdf category B] pathogen. ''[[Brucella]]'' is usually transmitted via the digestive route to the [[human]][[Host (biology)|host]]. Following transmission, [[white blood cells]] [[phagocyte]] the [[pathogen]] and transports it via the [[hematologic]] or [[Lymphatic system|lymphatic]] route to different organs, specially to those of the [[reticuloendothelial system]]. [[Human]] brucellosis is caused by four [[Brucella|Brucellae]] species: [[Brucella abortus|B. abortus]], [[Brucella canis|B. canis]], [[Brucella melitensis|B. melitensis]], and B. suis. [[Brucellosis]] must be differentiated from [[Typhoid fever]], [[Malaria]], [[Tuberculosis]], [[Lymphoma]], [[Dengue fever|Dengue]], [[Leptospirosis]], [[Rheumatology|Rheumatic disease]], [[Epstein-barr virus]], [[Toxoplasmosis]], [[Cytomegalovirus]], and [[Human Immunodeficiency Virus|HIV]]. Worldwide, the [[incidence]] of [[Brucellosis]] ranges from a low of 0.01 per 100,000 to high of 200 per 100,000 individuals. [[Case fatality rate]] is less than 2% when untreated. [[Brucellosis]] most commonly affects men in age group between 20 to 45 years old. Areas currently listed as high risk are the Mediterranean Basin (Portugal, Spain, Southern France, Italy, Greece, Turkey, North Africa), South and Central America, Eastern Europe, Asia, Africa, the Caribbean, and the Middle East. Common risk factors in the development of brucellosis are: 1) consuming unpasteurized dairy products or raw meat products, 2) unsafe hunting practices, and 3) occupational risks. There are no guidelines for [[brucellosis]] [[screening]]. However, some [[endemic]] areas screen family members of patients with [[brucellosis]]. If left untreated, patients with brucellosis may progress to develop focal infections, relapses or chronic brucellosis. Common complications of brucellosis include: [[Hepatitis|granulomatous hepatitis]], [[arthritis]], [[sacroiliitis]], [[meningitis]], [[orchitis]], [[epididymitis]] [[uveitis]], and [[endocarditis]]. The prognosis of brucellosis is good with adequate treatment.There is no specific diagnostic criteria for Brucellosis, Diagnosis is based on history of potential exposure, presentation consistent with the disease, and supporting laboratory findings. Brucellosis can present with diverse clinical presentation, which include systemic flu-like symptoms and symptoms due to focal involvement of organs. Patients with brucellosis are usually well-appearing. Physical examination usually reveal combination of several non-specific findings. The diagnosis of brucellosis can be confirmed by either a positive bacterial culture or a positive titre of anti-[[Brucella|''Brucella'']] antibodies on serological testing. There is no specific X-ray, CT or MRI finding associated with [[Brucellosis]].  The mainstay of [[therapy]] for brucellosis is antimicrobial therapy. The preferred regimen for uncomplicated brucellosis is a combination of [[Doxycycline]] and [[Streptomycin]]. [[Rifampin|Rifampicin]] is the [[drug]] of choice for brucellosis in [[pregnancy]]. For children less than 8 years of age, the preferred regimen is either [[Gentamycin]] or a combination of [[Trimethoprim-sulfamethoxazole]] and [[Streptomycin]]. Effective measures for the primary prevention of brucellosis include not consuming unpasteurized dairy or undercooked meat, and having safe occupational practices. There are no available vaccines for humans against brucellosis. Secondary prevention strategies of Brucellosis include following the patient upto 2 years following the diagnosis of Brucellosis to monitor for relapse.
-==References==
+== Overview ==
-{{Reflist|2}}
+'''Brucellosis''' is a [[zoonosis]] (infectious disease transmitted from animals to humans) caused by bacteria of the genus ''[[Brucella]]''. ''[[Brucella]]'' is usually transmitted via the digestive route to the human host. Following transmission, [[white blood cells]] [[phagocyte]] the pathogen and transports it via the [[hematologic]] or [[lymphatic]] route to different organs, specially to those of the [[reticuloendothelial system]].<sup>[1][2]</sup> Brucellosis must be differentiated from [[typhoid fever]], [[malaria]], [[tuberculosis]], [[lymphoma]], [[dengue]], [[leptospirosis]] and [[Rheumatic disease|rheumatic diseases]].<sup>[3]</sup> Brucellosis is not very common in the United States, but brucellosis can be very common within countries that do not have good standardized and effective public health and domestic animal health programs. Areas currently listed as high risk are the Mediterranean Basin (Portugal, Spain, Southern France, Italy, Greece, Turkey, North Africa), South and Central America, Eastern Europe, Asia, Africa, the Caribbean, and the Middle East.<sup>[4]</sup> Common risk factors in the development of brucellosis are consuming unpasteurized dairy products, unsafe hunting practices and occupational risks such as slaughther house workers, meat-packing employees, veterinarian and laboratory workers.<sup>[4]</sup> If left untreated, patients with brucellosis may progress to develop focal infections, relapses or chronic brucellosis.<sup>[5]</sup> Common complications of brucellosis include [[Hepatitis|granulomatous hepatitis]], [[arthritis]], [[sacroiliitis]], [[meningitis]], [[orchitis]], [[epididymitis]] [[uveitis]], and [[endocarditis]]. The prognosis of brucellosis is good with adequate treatment. Relapse may occur, and symptoms may continue for years.<sup>[5][6][7]</sup> Symptoms of brucellosis include [[undulant fever]], [[night sweats]] (with characteristic smell, likened to wet hay), and [[joint pain]].<sup>[7]</sup> Patients with brucellosis are usually well-appearing.<sup>[2]</sup> Common physical examination findings include hepatomegaly, splenomegaly, and lymphadenopathy.<sup>[8]</sup> The mainstay of therapy for brucellosis is [[Antimicrobial drug|antimicrobial therapy]]. The preferred regimen for uncomplicated brucellosis is a combination of [[Doxycycline]] and [[Streptomycin]]. [[Rifampin]] is the drug of choice for brucellosis in pregnancy. For children less than 8 years of age, the preferred regimen is either [[Gentamycin]] or a combination of [[Trimethoprim-sulfamethoxazole]] and [[Streptomycin]].<sup>[7][9]</sup> The optimal way to prevent brucellosis is by not consuming unpasteurized dairy or undercooked meat, and having safe occupational practices. There are no available vaccines for humans against brucellosis.<sup>[7][10]</sup>
+== Historial Perspective ==
+In 1887, [[David Bruce (microbiologist)|David Bruce]], a Scottish pathologist and microbiologist, was the first to discover the association between [[Brucella|''Brucella'']] and the development of brucellosis.<sup>[7]</sup>
+== Pathophysiology ==
+''[[Brucella]]'' is usually transmitted via the digestive route to the human host. Following transmission, [[white blood cells]] [[phagocyte]] the pathogen and transport it via the [[hematologic]] or [[lymphatic]] route to different organs, specially those of the [[reticuloendothelial system]].<sup>[1][2]</sup>
+== Causes ==
+[[Human]] brucellosis is caused by four [[Brucella|Brucellae]] species: [[Brucella abortus|''B. abortus'']], [[Brucella canis|''B. canis'']], [[Brucella melitensis|''B. melitensis'']], and ''B. suis''.
+== Differentiating Brucellosis from other Diseases ==
+Brucellosis must be differentiated from [[typhoid fever]], [[malaria]], [[tuberculosis]], [[lymphoma]], [[dengue]], [[leptospirosis]] and [[Rheumatic disease|rheumatic diseases]].<sup>[3]</sup>
+== Epidemiology and Demographics ==
+Brucellosis is not very common in the United States, but brucellosis can be very common within countries that do not have good standardized and effective public health and domestic animal health programs. Areas currently listed as high risk are the Mediterranean Basin (Portugal, Spain, Southern France, Italy, Greece, Turkey, North Africa), South and Central America, Eastern Europe, Asia, Africa, the Caribbean, and the Middle East.<sup>[4]</sup>
+== Risk Factors ==
+Common risk factors in the development of brucellosis are consuming unpasteurized dairy products, unsafe hunting practices and occupational risks such as slaughther house workers, meat-packing employees, veterinarian, and laboratory workers.<sup>[4]</sup>
+== Screening ==
+There are no guidelines for brucellosis screening. Some [[Endemic (epidemiology)|endemic]] areas screen family members of patients with brucellosis. <sup>[12]</sup> <sup>[13]</sup>
+== Natural history, Complications and Prognosis ==
+If left untreated, patients with brucellosis may progress to develop focal infections, relapses or chronic brucellosis.<sup>[5]</sup> Common [[Complication (medicine)|complications]] of brucellosis include [[Hepatitis|granulomatous hepatitis]], [[arthritis]], [[sacroiliitis]], [[meningitis]], [[orchitis]], [[epididymitis]] [[uveitis]], and [[endocarditis]]. The [[prognosis]] of brucellosis is good with adequate treatment. Relapse may occur, and symptoms may continue for years.<sup>[5][6][7]</sup>
+== Diagnosis ==
+=== Criteria ===
+The diagnosis of brucellosis is based on clinical and laboratory criteria.<sup>[14]</sup>
+=== History and Symptoms ===
+Symptoms of brucellosis include [[undulant fever]], [[night sweats]] (with characteristic smell, likened to wet hay), and [[joint pain]].<sup>[7]</sup>
+=== Physical Examination ===
+Patients with brucellosis are usually well-appearing.<sup>[2]</sup> Common physical examination findings include hepatomegaly, splenomegaly, and lymphadenopathy.<sup>[8]</sup>
+=== Laboratory Findings ===
+A positive culture or presence of [[Brucella|''Brucella'']] antibody in [[Serological testing|serological tests]] are diagnostic of brucellosis.<sup>[14]</sup>
+=== Other Diagnostic Studies ===
+Spine x-ray, CT o MRI may be helpful in the diagnosis of focal brucellosis infection. Findings of Pedro Pons sign can be suggestive of brucellic [[spondylitis]].<sup>[15]</sup>
+== Treatment ==
+=== Medical Therapy ===
+The mainstay of therapy for brucellosis is [[Antimicrobial drug|antimicrobial therapy]]. The preferred regimen for uncomplicated brucellosis is a combination of [[Doxycycline]] and [[Streptomycin]]. [[Rifampin]] is the drug of choice for brucellosis in pregnancy. For children less than 8 years of age, the preferred regimen is either [[Gentamycin]] or a combination of [[Trimethoprim-sulfamethoxazole]] and [[Streptomycin]].<sup>[7][9]</sup>
+=== Prevention ===
+Effective measures for the [[primary prevention]] of brucellosis include not consuming unpasteurized dairy or undercooked meat, and having safe occupational practices. There are no available vaccines for humans against brucellosis.<sup>[10][7]</sup>
+== References ==
+# ↑ <sup>Jump up to:1.0</sup> <sup>1.1</sup>
+# ↑ <sup>Jump up to:2.0</sup> <sup>2.1</sup> <sup>2.2</sup> <sup>2.3</sup> Brucelosis. Wikipedia. https://es.wikipedia.org/wiki/Brucelosis. Accessed on February 2, 2016 Cite error: Invalid <code><nowiki><ref></nowiki></code> tag; name "aa" defined multiple times with different content Cite error: Invalid <code><nowiki><ref></nowiki></code> tag; name "aa" defined multiple times with different content Cite error: Invalid <code><nowiki><ref></nowiki></code> tag; name "aa" defined multiple times with different content
+# ↑ <sup>Jump up to:3.0</sup> <sup>3.1</sup> Enfermedades infecciosas: Brucelosis -Diagnóstico de Brucelosis,Guia para el Equipo de Salud. Ministerio de Salud-Argentina. http://www.msal.gob.ar/images/stories/bes/graficos/0000000304cnt-guia-medica-brucelosis.pdf. Accessed on February 2, 2016
+# ↑ <sup>Jump up to:4.0</sup> <sup>4.1</sup> <sup>4.2</sup> <sup>4.3</sup> Brucellosis. CDC. http://www.cdc.gov/brucellosis/exposure/index.html.html. Accessed on February 3, 2016 Cite error: Invalid <code><nowiki><ref></nowiki></code> tag; name "c" defined multiple times with different content Cite error: Invalid <code><nowiki><ref></nowiki></code>tag; name "c" defined multiple times with different contentCite error: Invalid <code><nowiki><ref></nowiki></code> tag; name "c" defined multiple times with different content
+# ↑ <sup>Jump up to:5.0</sup> <sup>5.1</sup> <sup>5.2</sup> <sup>5.3</sup> Brucellosis. CDC. http://wwwnc.cdc.gov/travel/yellowbook/2016/infectious-diseases-related-to-travel/brucellosis. Accessed on February 3, 2016 Cite error: Invalid<code><nowiki><ref></nowiki></code> tag; name "f" defined multiple times with different content Cite error: Invalid <code><nowiki><ref></nowiki></code> tag; name "f" defined multiple times with different content Cite error: Invalid <code><nowiki><ref></nowiki></code>tag; name "f" defined multiple times with different content
+# ↑ <sup>Jump up to:6.0</sup> <sup>6.1</sup> FAO/WHO/OIE Brucellosis in humans and animals. WHO (2006). http://www.who.int/csr/resources/publications/Brucellosis.pdf Accessed on February 3, 2016
+# ↑ <sup>Jump up to:7.0</sup> <sup>7.1</sup> <sup>7.2</sup> <sup>7.3</sup> <sup>7.4</sup> <sup>7.5</sup> <sup>7.6</sup> <sup>7.7</sup> <sup>7.8</sup> Brucellosis. Wikipedia. https://en.wikipedia.org/wiki/Brucellosis. Accessed on February 1, 2016 Cite error: Invalid <code><nowiki><ref></nowiki></code> tag; name "a" defined multiple times with different content Cite error: Invalid <code><nowiki><ref></nowiki></code> tag; name "a" defined multiple times with different content Cite error: Invalid<code><nowiki><ref></nowiki></code> tag; name "a" defined multiple times with different content Cite error: Invalid <code><nowiki><ref></nowiki></code> tag; name "a" defined multiple times with different content Cite error: Invalid <code><nowiki><ref></nowiki></code>tag; name "a" defined multiple times with different contentCite error: Invalid <code><nowiki><ref></nowiki></code> tag; name "a" defined multiple times with different content Cite error: Invalid <code><nowiki><ref></nowiki></code> tag; name "a" defined multiple times with different content Cite error: Invalid<code><nowiki><ref></nowiki></code> tag; name "a" defined multiple times with different content
+# ↑ <sup>Jump up to:8.0</sup> <sup>8.1</sup>
+# ↑ <sup>Jump up to:9.0</sup> <sup>9.1</sup> Brucellosis. CDC. http://www.cdc.gov/brucellosis/treatment/index.html. Accessed on February 5, 2016
+# ↑ <sup>Jump up to:10.0</sup> <sup>10.1</sup> Brucellosis. CDC. http://www.cdc.gov/brucellosis/prevention/index.html. Accessed on February 5, 2016
+# Jump up↑ Brucella. Wikipedia. https://en.wikipedia.org/wiki/Brucella#Characteristics. Accessed on February 2, 2016
+# Jump up↑
+# Jump up↑
+# ↑ <sup>Jump up to:14.0</sup> <sup>14.1</sup> Brucellosis 2010 Case Definition. CDC. http://wwwn.cdc.gov/nndss/conditions/brucellosis/case-definition/2010/. Accessed on February 2, 2016
+# Jump up↑ Pourbagher A, Pourbagher MA, Savas L, Turunc T, Demiroglu YZ, Erol I; et al. (2006). [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16985128 "Epidemiologic, clinical, and imaging findings in brucellosis patients with osteoarticular involvement."]. ''AJR Am J Roentgenol''. '''187''' (4): 873–80. PMID [http://www.ncbi.nlm.nih.gov/pubmed/16985128 16985128]. [[Digital object identifier|doi]]:[http://dx.doi.org/10.2214%2FAJR.05.1088 10.2214/AJR.05.1088].
 [[Category:Bacterial diseases]]
 [[Category:Occupational diseases]]