Clinical Infectious Diseases
BRIEF REPORT
First Case of Human Brucella canis
Infection in the Netherlands
Eva Kolwijck,1 Suzanne P. M. Lutgens,1 Vanessa X. N. Visser,2
Marjan J. van Apeldoorn,3 Heather Graham,4 Ad P. Koets,5
Michelle M. W. P. Schrauwen,6 Frans A. G. Reubsaet,7 Els M. Broens,8
and Laetitia M. Kortbeek7
1
Department of Medical Microbiology, Jeroen Bosch Hospital, ‘s Hertogenbosch, The
Netherlands; 2Netherlands Food and Consumer Product Safety Authority, Utrecht, The
Netherlands; 3Department of Internal Medicine, Jeroen Bosch Hospital, ‘s Hertogenbosch, The
Netherlands; 4Department of Diagnostics and Crisis Organisation, Wageningen Bioveterinary
Research, Lelystad, The Netherlands; 5Department of Bacteriology, Host Pathogen Interaction
and Diagnostic Development, Wageningen Bioveterinary Research, Lelystad, The Netherlands;
6
Municipal Health Service GGD Hart voor Brabant, ‘s Hertogenbosch, The Netherlands; 7Centre
for Infectious Disease Control, National Institute for Public Health and the Environment,
Bilthoven, The Netherlands; and 8Utrecht University Faculty of Veterinary Medicine, Utrecht,
The Netherlands
A patient was diagnosed with Brucella canis following exposure
to infected dogs in her breeding facility. Transboundary spread
of B. canis through (illegal) import of infected dogs to non-
endemic countries in Europe suggest that B. canis infection
should be considered in European patients with occupational
exposure to dogs.
Keywords. Brucella canis; human; brucellosis; Europe; canine.
Canine brucellosis is considered endemic to North, Central,
and South America. The prevalence of B. canis in European
dogs is unknown because of lack of surveillance data and man­
datory testing. However, infections might be widespread
among dogs in Eastern European countries [1, 2]. Recently,
transboundary spread of B. canis through import of infected
dogs to non-endemic countries in Europe has been described
[2]. So far, human cases of B. canis have almost exclusively
been reported from the Americas and Asia [3–8].
In May 2021, a Dutch patient was diagnosed with B. canis
following exposure to infected dogs in her breeding facility.
We aimed to raise awareness on the relevance of B. canis as a
zoonotic pathogen and for improving the control of B. canis
in European dogs.
Case Report
A 55-year-old previously healthy female dog breeder visited her
general practitioner (GP) in June 2021 with a four-day history
Received 20 January 2022; editorial decision 20 May 2022; published online 2 June 2022
Correspondence: E. Kolwijck, Henri Dunantstraat 1, 5223 GZ ‘s-Hertogenbosch, The
Netherlands (e.kolwijck@jbz.nl).
Clinical Infectious Diseases® 2022;75(12):2250–2
© The Author(s) 2022. Published by Oxford University Press on behalf of the Infectious Diseases
Society of America. All rights reserved. For permissions, please e-mail: journals.permissions
@oup.com
https://doi.org/10.1093/cid/ciac425
2250 • CID 2022:75 (15 December) • BRIEF REPORT
of fever, malaise and headache. Because of a recent history of
B. canis infections in her dog breeding facility, the patient herself
suspected a zoonotic infection with B. canis. The GP consulted
the medical microbiologist of the local hospital who advised
to draw serum and 2 sets of blood cultures. No antibiotics
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were administered at the time and the patient stayed at home.
After 60 hours of incubation, 2 aerobic vials (BD Plus
Aerobic/F medium) were flagged positive by the BACTEC FX
system (Becton Dickinson, Franklin Lakes, New Jersey, USA).
Gram stains showed gram-negative coccobacilli and cultures
were further processed in a biosafety level 3 laboratory. The pa­
tient was contacted and subsequently examined at the
Emergency Department of the Jeroen Bosch Hospital,
Hertogenbosch, the Netherlands. She presented with fever
(38.3°C), headache and chills. Apart from 2 palpable cervical
lymph nodes, findings on physical examination were unre­
markable. Laboratory tests showed unremarkable blood
count and renal function. Liver tests were elevated: ASAT
86 U/L (0–29 U/L), ALAT 118 U/L (0–34 U/L), LD 296 U/L
(0–249 U/L), AF 217 U/L (40–120 U/L), GGT 296 U/L
(0–54 U/L), and bilirubin 9 µmol/L (0–4 µmol/L). The
C-reactive protein (CRP) was 28 mg/L (0–8 mg/L).
Pending results of bacterial identification, oral doxycycline
(100 mg 2×/day) and intravenous gentamicin (5 mg/kg 1×/
day) were administered at the Emergency Department. The pa­
tient went home to receive daily intravenous antibiotics in an
outpatient setting, as she refused admission. After 24 hours of
incubation, culture plates showed faint growth on blood and
chocolate agars, identified as Brucella species by matrix-assisted
laser desorption/ionization-time of flight (MALDI-TOF) mass
spectrometry (MS) security library SR 1.0.0.0. (Bruker
Daltonics, Germany). MALDI-TOF was unable to differentiate
between Brucella canis, B. suis, and B. melitensis.
After 4 days of administration of antibiotics, high fever
(40°C) and malaise resolved. Three weeks after presentation,
magnetic resonance imaging (MRI) of the spine was performed
in outpatient setting, as the patient complained about lower
back pain. MRI findings were unremarkable and showed no
signs of spondylodiscitis. After 3 weeks of antibiotic treatment,
liver tests and CRP had normalized. The patient received oral
doxycycline for 6 weeks and intravenous gentamicin for
14 days. After discontinuation of antibiotic treatment and at
last follow-up at 6 months after presentation, she showed no
symptoms of recurrence.
Identification of Brucella canis
Serum samples and isolated bacteria were sent to the reference
laboratory of the National Institute for Public Health and the
Environment (RIVM), Bilthoven, the Netherlands, for species
identification. RIVM reported the bacterial isolates as
Brucella canis by conventional phenotypical analysis, fatty
acid analysis (Sherlock Microbial Identification Systems, Midi
Labs), and 16S rDNA sequencing (Seqstudio, Applied
Biosystems). Serum agglutination test was negative for smooth
Brucella strains (B. abortus and B. melitensis) (antibody titer
,1:20). In the Netherlands, no serological test is available
for the detection of B. canis antibodies in human serum.
Wageningen Bioveterinary Research (WBVR) performed a B.
canis serum agglutination test validated for canine sera [9].
Three serum samples of our patient (at presentation, 3 days,
and 7 weeks after presentation) were sent to WBVR; all tested
negative (antibody titer ,1:50).
Public Health Investigation
A public health investigation uncovered that the patient owns a
dog breeding facility. In the summer of 2020, our patient
bought a bitch that appeared to be imported from Russia.
This bitch was tested serologically positive for B. canis after
producing a stillborn litter in October 2020. After consultation
with the Netherlands Food and Consumer Product Safety
Authority (NVWA), the dog was euthanized. The sire of the lit­
ter tested negative for B. canis. No other dogs were tested at the
time. In May 2021, another bitch gave birth to a litter of still­
born puppies. During the delivery, our patient had direct con­
tact with the placenta and other secretions. She also performed
(mouth-to-mouth) resuscitation on 2 of the puppies. Several
days later, she reported the incident to the NVWA, and samples
from the stillborn litter were sent to WBVR and tested positive
for B. canis DNA. In May and July 2021, all 30 dogs in the
breeding kennel were serologically tested for B. canis-specific
antibodies by the 2-Mercapto-ethanol serum agglutination
test at the WVBR as described by Alton et al [9]. Six dogs tested
positive (antibody titer ≥1:200). The dogs that tested seropos­
itive, and the dogs they were in close contact with, were eutha­
nized. Dog owners of already sold puppies were informed by
the NVWA. The remaining dogs will be periodically tested
for 6 months, and a breeding ban is imposed ending July
2022. The patient had no coworkers, and her family did not
have contact with the dogs in the kennel.
Ethical Statement
Written consent for the case report was obtained from the
patient.
Discussion
Human brucellosis is mainly caused by Brucella melitensis,
B. abortus, and B. suis and to a much lesser extent by B. canis
[3, 6, 10, 11]. So far, less than 60 cases of human B. canis
infections have been described in literature, almost exclusively
reported from the Americas and Asia [3–7], where B. canis is
considered endemic in dogs [11].
Transmission of B. canis to humans may occur through di­
rect contact with aborted fetuses or placenta, vaginal secretions,
semen, or blood from infected dogs. The bacteria can enter the
human body through mucous membranes or broken skin
[3, 11]. Most dogs infected with B. canis are asymptomatic
and can shed the organism for months or years in reproductive
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fluids [11].
Human brucellosis caused by B. canis is considered an occu­
pational disease, with a higher risk for veterinarians, breeders,
kennel employees, dog trainers, and laboratory technicians
[6–8, 12]. It resembles the clinical manifestations associated
with other Brucella species such as intermittent fever, chills,
fatigue, headaches, splenomegaly, spondylodiscitis, and/or
arthritis, but infection may often follow a subclinical course
[3, 11, 12]. In the United States, Krueger et al performed
B. canis serology in persons with occupational exposure to
dogs and found a seroprevalence of 3.6%, but only 2 of the
306 seropositive persons reported any clinical signs of symp­
toms associated with brucellosis [8]. This might suggest that
healthy humans are less prone to clinical illness from B. canis
than dogs. Although B. canis is considered less pathogenic to
humans than other Brucella species, severe complications
such as neurobrucellosis, endocarditis, arthritis, osteomyelitis,
epidural abscesses, and therapeutic failure and relapses have
been described [3]. In Europe, human infection with B. canis
is probably underdiagnosed due to low awareness, nonspecific
clinical signs, the lack of accurate serological tests for B. canis
antibodies in humans and the potential misidentification
by MALDI-TOF if used without a security library [7]. We
report the first human case of B. canis infection in the
Netherlands, and to our knowledge, first human case in
Europe in 35 years [13].
In Europe, canine brucellosis is mainly reported from
Eastern European countries [1, 2]. These countries harbor
large-scale (illegal) dog breeding facilities and have large stray
and shelter dog populations, both of which are risk factors
for canine brucellosis [11, 14]. Occasionally, single cases of
B. canis infection have been reported in dogs from
North-Western European countries [1, 2, 15, 16], but these cas­
es could generally be linked to the import of infected dogs from
Eastern Europe [2, 15, 16]. True prevalence of B. canis infection
among (Eastern) European dogs is unknown as brucellosis in
dogs is not a notifiable disease according to the World
Organization for Animal Health or the European Union. In ad­
dition, routine serological surveillance of canine brucellosis is
not performed in European countries. Most diagnostic tests
are performed in preselected groups of dogs from kennels
with reproductive problems or single incidents of discospondy­
litis [1].
BRIEF REPORT • CID 2022:75 (15 December) • 2251
 The public health relevance of B. canis infection in humans is
unclear as much of the knowledge comes from case reports. In
Northwestern Europe, there is an increasing incidence of adop­
tions of stray dogs from Southern and Eastern European coun­
tries and illegal import of puppies from large-scale breeding
kennels in Eastern Europe. The Netherlands imports an esti­
mated 21 000 dogs legally per year [2], but at least 50 000 pup­
pies are thought to yearly enter the Netherlands illegally [2].
Testing for B. canis is not a mandatory control measure before
import of dogs, and no active surveillance is performed.
Accordingly, the size of the current zoonotic risk is unknown.
Until 2016, canine brucellosis had not been isolated in The
Netherlands. Currently, over 50 cases of canine brucellosis
have been reported [2], and we report the first Dutch human
case of B. canis. This case proves that transboundary trafficking
of dogs might lead to introduction of B. canis in countries to
which it is not endemic and lead to spill over into the human
population [2].
Notes
Author contributions. E. K., S. P. M. L., and E. M. B. directed and eval­
uated the laboratory diagnosis, and drafted the manuscript. M. J. A. clini­
cally managed the patient and provided detailed case information. V. X.
N. V. and M. M. W. P. S. performed the epidemiological
investigation. H. G. and A. P. K. directed and evaluated serological analysis
of both the patient and her dogs. F. A. G. R. and L. M. K. performed the
definitive identification of the cultured B. canis strain of the patient. All au­
thors reviewed and approved the final version of the manuscript.
Potential conflicts of interest. All authors: No reported conflicts.
All authors have submitted the ICMJE Form for Disclosure of Potential
Conflicts of Interest.
2252 • CID 2022:75 (15 December) • BRIEF REPORT
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