1. Brucella endocarditis fatal but underdiagnosed
Guruprasad.Rai.D, Vasudev B. Pai,Ganesh.S Kamath ,Dept. of Cardiovascular-Thoracic Surgery,
Kasturba Medical College, Manipal University, Manipal.
Introduction
Brucella endocarditis is an underdiagnosed, fatal complication of human brucellosis. We describe two cases of Brucella endocarditis involving the aortic valve and mitral valve suspected in view of the clinical data and the results of serology, confirmed by the culture of the native valves. Medical treatment did not cure the patients and both needed surgical management
Case
Discussion
Case 1: A 23yr old gentleman presented with on and off high grade fever since 2mths and dyspnoea on exertion since 1mth. On admission patient was haemodynamically stable and all routine investigation were normal
Echocardiography revealed RHD: Large(15x9)mm vegetation on aortic valve, Severe AR, Multiple vegetations on mitral valve, severe MR and a diagnosis of infective endocarditis was made after blood cultures grew Brucella.
Patient was started on appropriate antibiotics and planned for DVR. During the course of antibiotic therapy patient had CVA - Rt hemiplegia and aphasia. In v/o embolic stroke surgery was planned after 2weeks. Patient was taken for emergency surgery as patient deteriorated inspite of antifailure therapy.
Patient underwent Mitral valve replacement (SJM 29 sized) with PML preservation and Aortic- valve replacement (SJM 21 sized). Valve was sent for Cultures which grew Brucella. Antibiotics continued for 6 months.
Case 2: A 35 year old male patient presented with on and off fever since 9 months and altered sensorium since 2 days. He was diagnosed to have CVA-right facio brachial monoparesis with Broca's aphasia. Brucella serology was significantly positive though the blood cultures were sterile.
Echo showed large vegetation in aortic valve, severe AR, severe MR. Patient was started on appropriate antibiotic. He was planned for surgery after 3 weeks course of antibiotics.
Mitral SJM 31 with PML preservation and Aortic valve SJM 21 replacement was performed electively. The valve which was sent for Cultures was Brucella negative. Antibiotics were continued for three months after operation. There was no early or late mortality and no recurrence after a follow up of 15 months.
Cardiovascular involvement is rare, only occurring in 1–2% of patients with brucellosis and includes endocarditis, myocarditis and pericarditis. Although in developed countries brucellosis is almost always an occupational disease, in endemic areas the main route of infection is the intake of nonpasteurized dairy products. Both our patients had given history of consuming nonpasteurized dairy products.
Among previous studies there has been a wide range of incidence of heart failure reported between 0% and more than 80%.
Brucella endocarditis is often associated with negative blood cultures. The most usual cause of negative cultures is previous consumption of antibiotics. Other problems are the slow growth rate of Brucella spp
The conventional treatment of Brucella endocarditis involves a combination of clinical and surgical methods. However, there have been reports of Brucella endocarditis being cured with medical treatment alone. In some studies the absence of left ventricular failure and a short duration of symptoms have been reported as two important factors associated with the success of medical treatment 2. Both our patients received a combination of rifampicin and doxycycline plus one or two other antibiotics.
The diagnosis of Brucella endocarditis was based on Duke’s criteria, and was established according to the following criteria:
1. Echocardiographic characteristics. 2.The isolation of Brucella spp in the blood, bone marrow or tissue samples. 3. High Brucella serologic titre (Wright’s seroagglutination 1/160 or Coombs’ antibrucella test 1/320 þ 2 mercaptoethanol 1/80).
Even with a high clinical suspicion, the diagnosis of brucellosis is not easy. Isolation of the organism is difficult and serologic tests have low specificity which may be difficult to interpret in endemic area 1.
Surgical treatment is recommended in patients with left ventricular failure
Conclusion
Currently, there is still ambiguity in the management of Brucella endocarditis. Our observations suggest that a combined surgical and medical treatment is the best option for the management of this disease. Brucella endocarditis should be operated according to the clinical status but emergency cardiac surgery may be required as per clinical guidelines.
References
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Alsoub H. Brucella infective endocarditis: a report of four successfully treated patients. Clinical Microbiology & Infection2001;7:382–5