Successful management of Brucella mellitensis endocarditis with combined medical and surgical approach

Neurobrucellosis

PURPOSE OF REVIEW

Brucellosis is one of the most common zoonosis worldwide, affecting 500 000 people, annually. Neurobrucellosis incidence is approximately 4%, and it is almost always heterogeneous. As there are no typical clinical features, its diagnosis is frequently misdiagnosing by other infections.

RECENT FINDINGS

Neurobrucellosis picture includes meningitis, meningoencephalitis, encephalitis, cranial neuropathies, intracranial hypertension, sinus thrombosis, hemorrhages radiculitis, peripheral neuropathy, myelitis, and psychiatric manifestations. The diagnosis should be based on symptoms and signs suggestive of neurobrucellosis, not explained by other neurological disease, cerebrospinal fluid analysis, a positive Brucella serology or culture, and a response to specific antibiotics, with a significant improvement of cerebrospinal fluid parameters.

SUMMARY

Neurobrucellosis can be insidious, and despite its global distribution, it is still unrecognized and frequently goes unreported. The understanding of the current epidemiology is necessary for eradication of the disease in humans, as well as the disease control in animals and prevention based on occupational hygiene and food hygiene.

A Case Report of Brucellosis-Associated Infective Endocarditis

Brucellosis is a prevalent zoonotic infection that can be relatively well managed and tolerated if appropriate treatment is initiated. Unfortunately, likely secondary to decreased awareness and vague symptoms, the diagnosis can be easily missed leading to worsening complications that severely increase the mortality rate. We present a case of a 25-year-old female who presented from a rural setting with a diagnosis of brucellosis, which was delayed. She ultimately developed infective endocarditis with cardiac vegetations on imaging. Despite improvement on antibiotics and reduction in size of cardiac vegetation, she suffered a fatal cardiac arrest before undergoing surgical intervention. Better awareness regarding hygiene and sanitary food handling should be encouraged, especially in underdeveloped rural areas, to help prevent infection. More studies need to be performed to help better identify symptoms coupled with maintaining a high index of suspicion so as to expedite diagnosis, treatment, management and hopefully prevent the progression of disease and worsening complications.

Pseudoaneurysm of Ascending Aorta induced by Brucella Endocarditis In bicuspid Aortic Valve

Brucellosis is endemic in the Mediterranean region, South American countries, and Asia. In China, it is frequently diagnosed in herdsmen who often have contact with livestock. Brucella endocarditis (BE) is a rare complication, but it is the leading reason for mortality. We report a rare case of BE of bicuspid aortic valve with consequent pseudoaneurysm of ascending aorta, which has never been reported before. The major educational value lies in acknowledging a novel presentation of BE which happened in a patient in remission of BE and appreciation of the role of echocardiography in early diagnosis and definitive surgical therapy.

Brucella Endocarditis of the Native Mitral Valve Treated With Antibiotics

Brucellosis is a rare zoonotic infection with a low annual incidence in the United States. Infective endocarditis secondary to brucellosis involving native or prosthetic valves is contemplated to be an extremely rare entity. As Brucella can present with non-specific sign and symptoms, clinicians need to have a higher degree of suspicion of Brucella endocarditis in culture-negative endocarditis patients, particularly those who have a history of exposure to farm animals. Timely diagnosis with appropriate management using antibiotics can prevent valvular damage and restore the valve's structural integrity. In this case report, we present a case of culture-negative, serology-proven Brucella endocarditis of native mitral valve, with an initial presentation of stroke that was successfully treated with combination antibiotic therapy.

An Uncommon Presentation of Brucella Endocarditis Masquerading as Neurobrucellosis

Brucella endocarditis is a rare but a severe complication of brucellosis, observed in less than 2% of cases. It is the main cause responsible for up to 80% of deaths in brucellosis. Herein, we present a case of brucella endocarditis that developed on a native aortic valve, but presented to us with fever for several months and acute neurological symptoms. This case report signifies the importance of considering brucella endocarditis as one of the differentials in patients presenting with Pyrexia of Unknown Origin (PUO) and Central Nervous System (CNS) manifestations.

Brucella endocarditis - a series of five case reports

Endocarditis due to brucellosis is considered a rare occurrence involving native, congenital and prosthetic valves. The diagnosis needs high degree of suspicion in culture negative endocarditis especially in those with history of exposure to farm animals. A positive culture in a susceptible patient confirms the diagnosis with 91% sensitivity. An early diagnosis and prompt treatment with appropriate antibiotics can restore the valve structural integrity with minimal damage. Here we present a series of five cases of culture proven Brucella endocarditis (four native valves, one prosthetic valve) and this report discusses the diagnostic and management issues involved.

Medical versus medical and surgical treatment for brucella endocarditis

This review was undertaken to determine the role of surgery in the treatment of brucella endocarditis. All English and French articles reporting brucella endocarditis (1966 to 2011) in PubMed, Google, and Scopus were reviewed. In all, 308 cases were identified, and linear and logistic regression was performed. Surgery improved outcomes by decreasing mortality from 32.7% in the medical treatment only group to 6.7% in the combined surgical and medical treatment group (p<0.001). This association was still significant while controlling for other contributing factors. In the absence of a controlled trial, we recommend the utmost vigilance and consideration of surgical management in treating such patients.

Native valve Brucella endocarditis

OBJECTIVE

Brucellosis is frequently seen in Mediterranean and Middle East countries, including Turkey. We report the medical and surgical management of 31 cases of native endocarditis.

MATERIAL AND METHOD

Thirty-one patients were admitted to our clinic with suspected Brucella Endocarditis. The diagnosis was established by either isolation of Brucella species, or the presence of antibodies. Following preoperative antibiotic therapy patients underwent valve replacement with excessive tissue debridement. Patients were followed up with Brucella titers, blood cultures, and echocardiography.

RESULTS

On admission all patients were febrile and mostly dyspneic (NYHA Class 3 or 4). The blood tests were normal except for elevated ESR, CRP and serological tests. The aortic valve was involved in 19 patients, mitral valve in 7 patients, and both valves in 5. After serological confirmation of BE, antibiotic therapy was maintained. Twenty-five of the patients received rifampicine, doxycycline, and cotrimaxozole; 2 of them received a combination of rifampicine, streptomycin, and doxycycline; and 4 of them received rifampicine, tetracycline, and cotrimaxozole. Tissue loss in most of the affected leaflets and vegetations were presenting all patients. Valve replacements were performed with mechanical and biologic prostheses. All the patients were afebrile at discharge but received the antibiotics for 101, 2+/-16, 9 days. The follow-up was 37, 1+/-9, 2 months.

DISCUSSION

In our retrospective study, combination of adequate medical and surgical therapy resulted in declined morbidity and mortality rate. The valve replacement with aggressive debridement is the most important part of the treatment, which should be supported with efficient preoperative and long term postoperative medical treatment.

Brucella endocarditis: a report from Iran

Endocarditis is a rare focal complication of brucellosis but the most common cause of mortality. The diagnosis of the complications of endemic diseases is therefore important. We evaluated Brucella endocarditis cases in a teaching hospital in Iran between April 1998 and March 2006. Nine patients with a median age of 38.11 years were recorded, of whom seven (77.7%) were male. Underlying cardiopathy was present in three patients (33.3%). The median duration of the symptoms prior to diagnosis was 5.33 months. Endocarditis involved the aortic valve in six cases (66.6%), the mitral valve in two cases (22.2%) and the aortic valve plus the mitral valve in one case (11.1%). Serologic tests were positive in eight (88.8%) and blood culture was positive in two (22.2%). Aortic valve replacement surgery was undertaken for five patients (55.5%). One patient died due to arrhythmia. A high degree of suspicion is therefore necessary in order to ameliorate the course of Brucella endocarditis.

Atrial septal defect presenting with Brucella endocarditis

Brucellosis is a zoonosis that behaves as a systemic infection with various clinical signs and symptoms. Brucella endocarditis, although a rare complication of Brucella infection, is nevertheless responsible for the majority of deaths related to this illness. Brucella endocarditis was associated with an atrial septal defect (ASD) in a 45-year-old woman. Echocardiography showed a secundum ASD with vegetations of 0.5 x 0.8 cm arising from the border of the defect, and serologic analysis was positive for Brucella agglutinin, thus confirming the diagnosis. She was initially treated with a 1-month preoperative course of antibiotics. At surgery, the vegetations were excised and the defect was closed with polypropylene. Postoperative recovery was uneventful and she was discharged on the 10th postoperative day.

Myocardial noncompaction presenting with Brucella endocarditis

Noncompaction of ventricular myocardium is a unique congenital cardiomyopathy with its own clinical presentation and course. It is more frequently associated with complications of congestive heart failure, thromboembolism and malignant ventricular arrhythmias; however, concomitance of valvular pathologies or infective endocarditis with noncompaction of ventricular myocardium has seldom been reported. We describe herein the first case of left ventricular myocardial noncompaction presenting with Brucella endocarditis with aortic and mitral valve involvements, whom subsequently underwent successful medical and surgical treatment.

Valve replacement for Brucella endocarditis: two case reports

We report two cases of successful treatment of Brucella endocarditis. Both of them were treated with antibiotics and aortic valve replacement after Brucellosis was diagnosed. In one of these cases emergency operation was required. Our observations suggest that a combined surgical and medical treatment is the best option for the management of this disease. B. endocarditis should be operated after improvement of clinical status but emergency cardiac surgery may be required if heart failure develops.

A 70-year-old stock-breeder with tricuspid valve and defibrillator lead brucella endocarditis

Brucella endocarditis is a rare and life threatening complication of brucellosis. It usually involves the aortic valve and successful management requires a combination of medical treatment and valve replacement. We describe a case of tricuspid valve and defibrillator lead brucella endocarditis induced by the implantation of the defibrillator itself. Our patient was admitted to hospital with a 2-week history of fever, back pain and night sweats. One month prior to admission, due to episodes of syncope, he was hospitalized at the Cardiology Department and because of a low grade fever he underwent complete investigation with no result. His original symptoms relapsed 2 days after dischargement. Although serological tests were not indicative, blood cultures grew Brucella melitensis and transesophageal echocardiography showed a vegetation on tricuspid valve, which was mildly regurgitant. Fever subsided 2 days following start of triple antibiotic therapy and 2 weeks later the defibrillator and the pacemaker were surgically explanted.

Brucella endocarditis in prosthetic valves

Human brucellosis is a multiple organ disease that presents with fever and is most often transmitted via contaminated, unpasteurized goat milk and cheese. In chronic cases, focal complications (eg, spondylitis, neurobrucellosis and endocarditis) are frequently seen. Although the disease may be severely debilitating, the mortality rate is low. Fatal cases are often due to endocarditis. Because Brucella endocarditis is a rare complication (2% to 5%), therapeutic considerations are based on single-case experiences only. Therapy includes long-term antibiotic treatment using combinations of various antimicrobial drugs and surgical valve replacement when required. A case of Brucella endocarditis complicated by the infection of two valvular prostheses implanted after involvement of the mitral and aortic valve due to rheumatic fever is described. The patient was successfully treated by a medical and surgical approach. Therapeutic strategies in Brucella endocarditis are discussed in light of the current literature.

[Brucella endocardititis: clinical particularities and therapeutic modalities]

Brucella infective endocarditis is an uncommon, but serious complication of brucellosis. The aortic valve is the most commonly affected cardiac valve. Due to characteristics of the infection, medical therapy alone is not sufficient in treating the disease and best results are obtained with surgery combination. We describe a case of Brucella endocarditis involving the aortic valve suspected in front of the clinical data and the results of serology, confirmed by the culture of the native valves. In association with the medical treatment, management valve replacement lead to a favorable medium-term evolution.

Infective endocarditis

Despite improvements in health care, the incidence of infective endocarditis has not decreased over the past decades. This apparent paradox is explained by a progressive evolution in risk factors; while classic predisposing conditions such as rheumatic heart disease have been all but eradicated, new risk factors for infective endocarditis have emerged. These include intravenous drug use, sclerotic valve disease in elderly patients, use of prosthetic valves, and nosocomial disease. Newly identified pathogens, which are difficult to cultivate--eg, Bartonella spp and Tropheryma whipplei--are present in selected individuals, and resistant organisms are challenging conventional antimicrobial therapy. Keeping up with these changes depends on a comprehensive approach, allying understanding of the pathogenesis of disease with the development of new drugs for infective endocarditis. Infection by staphylococci and streptococci is being dissected at the molecular level. New ideas for antimicrobial agents are being developed. These novel insights should help redefine preventive and therapeutic strategies against infective endocarditis.

A Case of Mitral Stenosis Complicated With Seronegative Brucella Endocarditis

Brucellosis is a multisystemic disease. The most common cause of death from the disease is endocarditis. The aortic valve is most commonly affected. The disease rarely involves the mitral valve. A 30 year-old woman presented with complaints of chills and fever up to 38 degrees C at night, fatigue, palpitations, and dyspnea for the previous 3 weeks. Cardiac auscultation revealed a diastolic murmur in the mitral area. Her temperature was 38.3 degrees C. On echocardiographic examination, the mitral valve area was 0.62 cm (2) and an isoechoic mass thought to be a vegetation was detected on the anterior mitral leaflet. A diagnosis of infective endocarditis was made and vancomycin administration was commenced. Brucella melitensis was isolated in all three blood samples, however, the patient remained seronegative with Brucella agglutination titers of up to 1/160. The antibiotic therapy was then shifted to doxycycline (200 mg/day), rifampicin (600 mg/day), and ciprofloxacin (1000 mg/day). After 30 days of treatment, surgery was performed for the severely stenotic mitral valve and to remove the vegetation. The operation was successful. The postoperative period was uneventful. On the follow-up she had no complaints. In cases with Brucella endocarditis, after diagnosis, antibiotic therapy must be started immediately and when the clinical condition improves, surgical intervention should be performed when indicated.

Deliberate release of biological agents

Deliberate release of biological agents is a growing threat, but clinical recognition of the resulting diseases is hampered by their rarity and similar presentation to more common illnesses. Despite substantial publicity, access to information may be difficult. Further, the available data are fragmented and not always relevant to critical care settings. We describe the clinical presentations of some important infections, highlighting the features that are relevant to critically ill patients. We provide an integrated set of guidelines for diagnosis, patient care and infection control and have attempted to list important print- and web-based resources for further information.