Asian Cardiovasc Thorac Ann 2000;8:266-267
© 2000 Asia Publishing EXchange Pte Ltd
Brucella Endocarditis Treated by Surgical and Medical Combination
Bülent Kaya, MD,
Mustafa Sirlak, MD,
Mehmet Özkan, MD,
Sadik Eryilmaz, MD,
Hakki Akalin, MD
Department of Cardiovascular Surgery
University of Ankara Medical School
Ankara, Turkey
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For reprint information contact: Bülent Kaya, MD Tel: 90 312 362 3030 Fax: 90 312 362 4825 Department of Cardiovascular Surgery, University of Ankara Medical School, Dikimevi, Ankara 06100, Turkey.
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Abstract
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A 40-year-old man developed brucella endocarditis. Brucella melitensis was isolated from blood cultures. Echocardiography revealed flail mitral valve with ruptured chordae. Mitral valve replacement was performed and the infection was cured with tetracycline and rifampin given for 3 months after surgery.
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Introduction
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Brucella continues to be a serious health problem in some hyperendemic areas in the Middle East.
1 Brucellosis is transmitted to humans through consumption of un-pasteurized milk or milk products and contact with infected animal products. Brucella endocarditis is a rare com-plication of brucella infection encountered in less than 2% of patients but it is nevertheless responsible for the majority of deaths related to this disease.
2
Brucella melitensis and Brucella abortus are the species most frequently isolated. Valve replacement is indicated when signs of heart failure appear despite appropriate anti-microbial therapy.
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Case Report
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A 40-year-old man was admitted with a 3-month history of high fever, sweating, and malaise. He complained of exertional dyspnea, fatigue, and pretibial edema. Hepato-megaly was noted. A pansystolic mitral murmur radiating to the left axilla was detected. His erythrocyte sedi-mentation rate was 64 mm•h
–1
, hemoglobin 12 g•L
–1
, hematocrit 36%, white blood cell count 5.0 x 10
9
/L, platelets 243 x 10
9
/L. Urine analysis, liver and kidney function were normal. Mild cardiomegaly was seen on chest radiography. His electrocardiogram showed sinus rhythm and right bundle brunch block. Transthoracic echocardiography revealed rupture of the mitral chordae (flail mitral valve), vegetations on the anterior mitral leaflet, third-degree mitral regurgitation, and minimal aortic regurgitation. Blood culture at admission was positive for Brucella melitensis. The brucella agglutination titer was 1/1600. Antibiotic treatment was initiated with streptomycin 1 g daily, tetracycline 200 mg daily, and third-generation cephalosporin 1 g daily. After 3 weeks, rifampicin 600 mg daily and tetracycline 100 daily were added to the treatment combination. The patient was also given diuretic and inotropic medication. The symptoms remained unchanged in spite of this medical treatment.
On the 40th day after admission, the patient underwent mitral valve replacement. At surgery, a destroyed mitral valve, ruptured chordae, and vegetations on the anterior leaflet of the mitral valve were observed. There was no abscess formation around the commissures. A Sorin no. 27 bileaflet mitral valve (Sorin Biomedica Cardio s.p.a., Saluggia, Italy) was inserted. The postoperative period was uneventful and the patient was discharged after 2 weeks. Cultures of the vegetations grew Brucella melitensis. After surgery, treatment with tetracycline and rifampicin at the same dosage was continued for 3 months. Blood cultures at the time of discharge and at follow-up 3 months later were negative.
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Discussion
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In a review of 3 large series totalling 2016 patients with brucellosis, only 8 cases of endocarditis (0.4%) were noted.
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Although the mortality rate for brucellosis is less than 1%, endocarditis is the major cause of death from this infection. Since 1900, 108 cases of brucella endo-carditis have been reported in the English and French literature.
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The aortic valve is the most frequently affected cardiac valve.
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Gross abscesses of the myocardium or their consequent aneurysms are more frequent in brucella endocarditis than in endocarditis caused by other bacteria, the abscesses are apparently more frequent in endocarditis involving the semilunar valves than the atrioventricular valves.
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The most frequent complication is congestive heart failure, which was observed in 86% of patients and was directly responsible for the majority of the deaths. Chan and Hardiman
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studied autopsy findings in 44 cases of fatal brucellosis and found endocarditis in 80% with cardiac abscesses and aneurysm in 43%. A more chronic evolution and a greater tendency toward fibrosis, hyalinization, and calcification characterize this type of endocarditis in contrast to endocarditis caused by other bacteria. Moreover, the predominant involvement of the aortic valve makes myocardial abscesses and aneurysms more common (43%).
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This observation might explain the higher death rate from brucella endocarditis (due mainly to valve lesions and congestive heart failure rather than to sepsis or emboli) and might also account for the poor results with antibiotic treatment alone. Thus, cure with antibiotics alone is apparently rare and has in fact been reported in only 11 cases. The combination of antibiotic administration with valve replacement appears to be the most effective therapy for brucella endocarditis.
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Three findings may help raise the suspicion of brucella endocarditis: the presence of vegetation; positive serologi-cal results; and positive blood cultures of the organism. It is possible for blood cultures to be positive with negative serological results. Positive blood cultures are most helpful because they are uncommon in brucellosis.
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The main indication for surgery is hemodynamic compromise. Septic and embolic complications are less frequently seen. Reported cases were treated with various combinations of rifampicin, trimethoprim-sulfameth-oxazole, tetracycline and streptomycin. Current recom-mendations are for a combination of at least 2 drugs. The duration of follow-up is important in evaluating claims of cure with antibiotics alone, as relapses have been documented even after prolonged administration of anti-microbial drugs.
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Medical therapy alone does not seem to be sufficient to eradicate an organism with such a destructive character and with a tendency toward abscess formation. Early surgical intervention combined with triple-antibiotic therapy with an aminoglycoside and tetracycline together with either rifampicin or sulfameth-oxazole, provides the best chance of preventing abscess formation and reduces the risk of mortality. The duration of medical therapy after early surgical intervention is still controversial, but continuation for 3 months may be advisable in patients with aortic root abscess formation.
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References
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Abstract
Introduction
