Asian Cardiovasc Thorac Ann 1998;6:325-326
© 1998 Asia Publishing EXchange Pte Ltd
Brucella Endocarditis Affecting the Mitral Valve
M Halit Andaç, MD,
Hakan Ceyran, MD,
Alper S Kunt, MD,
Ramazan A
ik, MD,
Hasan Mercan, MD
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Department of Cardiovascular Surgery Erciyes University Medical School Kayseri, Turkey
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For reprint information contact: M Halit Andaç, MD Seyhan Hospital Baraj Yolu 1 Durak Seyhan-Adana, Turkey Tel:90 322 458 6868 Fax:90 322 453 7979
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ABSTRACT
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Brucellosis is still prevalent in Mediterranean and Middle East countries and Brucella endocarditis is a rare and often fatal complication. We describe a case of Brucella endocarditis in a 23-year-old male who required mitral valve replacement after successful antibacterial treatment.
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INTRODUCTION
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Brucellosis is still prevalent in Mediterranean and Middle East countries.1,2 Although the human types, Brucella melitensis and Brucella abortus are common, Brucella suis and Brucella canis are also seen.3 Brucella endocarditis is one of the rare and often fatal complications of brucellosis.4 It is more common in males than females and generally involves the aortic valve. A few cases of Brucella endocarditis have been successfully treated by medication alone but most require surgical intervention.5,6
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CASE REPORT
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A 23-year-old male was admitted to our hospital complaining of rigor, fever, and dyspnea of 10 days duration. Five days earlier after a positive Brucella tube agglutination test (titer 1/640), he was started on streptomycine at a dose of 1 g per day intramuscularly and oral tetracycline at 500 mg 4 times daily. On the 5th day of treatment, he was hospitalized because his symptoms increased. The patient was conscious but in poor general condition with difficulty in breathing. His arterial blood pressure was 110/60 mm Hg, pulse 122 beats per minute, respiratory rate 44 per minute, and temperature 38°C. His conjunctivae were pale and he had slight neck stiffness. His heart rate was regular and a 4/6 systolic souffle was heard over the mitral area extending to the armpit. The liver was enlarged by 8 cm and the spleen was palpable about 7 cm below the costal margin. Other systemic findings were normal.
Laboratory findings included hemoglobin 99 g·L–1, leukocytes 3800 per mm3, and platelets 5900 per mm3. The erythrocyte sedimentation rate was 65 mm·h–1, urine analysis was normal. Serum aspartate aminotransferase was 114 U·L–1, alanine aminotransferase 79 U·L–1, and total creatine kinase 291 U·L–1. Other biochemical parameters were within the normal limits. In the Brucella tube agglutination test, the titer was 1/2560. Echocardiography revealed serious mitral insufficiency. Ceftriaxone treatment was given for 4 weeks. After 5 weeks, the signs of active infection had decreased. Mitral valve replacement was performed using a 27 mm TAD Sorin bileaflet prosthetic valve (Sorin Biomedica, Saluggia, VC, Italy). Histopathologic examination of the valve material removed at surgery showed collagenous connective tissue. Culture of the valve material was negative, however, treatment with doxycycline and rifampicin was continued for 6 months. At a follow-up examination 9 months after the operation, the patient was symptom-free.
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DISCUSSION
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Brucella endocarditis is a rare but serious complication that accounts for 80% of the deaths from brucellosis.7 Brucella endocarditis, despite effective antibiotic treatment, often requires urgent or emergency surgical intervention because of acutely developing valve pathology and congestive heart failure. As reported by Cohen and colleagues,6 very few cases have been treated with medication alone.
Our patient was a dental technician who bred animals and admitted eating non-pasteurized fresh cheese. His brother had contracted brucellosis one year previously. Brucella endocarditis was diagnosed on the basis of a positive blood culture and from echocardiographic findings. With uncomplicated chronic brucellosis, the blood culture is generally negative. For this reason, a positive blood culture can be a good indication of acutely developing Brucella endocarditis.
Although various periods have been suggested, ranging from one week to one year, for antibiotic treatment following surgery for brucella endocarditis, it is generally believed that it should be for at least 3 months. Our patient was treated for 6 months. There is also no consensus on the type of antibiotic therapy during the postoperative period and whether it should be single or multiple. Multiple antibiotic therapy is advisable to avoid development of resistance to a single drug. It is generally accepted that rifampicin and/or co-trimoxazole plus doxycycline is the best choice of treatment.3,7 Other antibiotics, such as tetracycline, streptomycin, gentamycin, and ceftriaxone have been used by other authors.5
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REFERENCES
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ABSTRACT
INTRODUCTION
