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• W1520771189 abstract "Brucellosis is a zoonosis with a worldwide distribution, especially in the Mediterranean basin, the Arabian peninsula, the Indian subcontinent, Mexico and Central and South America [1Young E An overview of human brucellosis.Clin Infect Dis. 1995; 21: 283-289Crossref PubMed Scopus (614) Google Scholar]. It is a systemic disease, and almost every organ can be affected. The infection usually manifests itself as a febrile syndrome with no apparent focus, chills, sweating, arthralgia, and myalgia. About 30% of patients suffer from some localization, most commonly bone and joint involvement [2Ariza J Brucellosis.Curr Opin Infect Dis. 1996; 9: 126-131Crossref Scopus (27) Google Scholar]. Cardiovascular complications are rare, occurring in less than 2% of patients with brucellosis; they include endocarditis, myocarditis, and pericarditis [3Colmenero JD Reguera JM Martos F et al.Complications associated with Brucella melitensis infection: a study of 530 cases.Medicine (Baltimore). 1996; 75: 195-211Crossref PubMed Scopus (480) Google Scholar]. Brucella endocarditis accounts for the majority of deaths related to brucellosis [4Peery TM Belter LF Brucellosis and heart disease: II. Fatal brucellosis.Am J Pathol. 1960; 36: 673-697PubMed Google Scholar]. The treatment for brucella endocarditis has not been well established, basically because of the low number of reported cases. We herein report our experience with four cases of brucella endocarditis, discuss treatment options, and review the pertinent literature. Between 1987 and 1999, four patients were diagnosed as having brucella endocarditis at Hamad Medical Corporation. Diagnosis was based on the presence of vegetations on echocardiography, and further supported by positive blood culture, culture of infected tissue growing Brucella organisms, or a high brucella serologic titer of over 1 : 320 dilution. The following data were collected: age, sex, nationality, occupation, raw milk ingestion, symptoms, physical findings at presentation, total white blood cell count, erythrocyte sedimentation rate, serology, echocardiography, blood culture, culture of infected tissue, treatment, complications, and outcome. The age of the patients ranged between 29 and 40 years. All patients complained of fever. Other symptoms included anorexia, cough, and night sweats. One patient had hemiparesis. The duration of symptoms ranged between 2 weeks and 9 months. All patients had a history of raw milk ingestion. Three patients had a history of valvular heart disease, and had mechanical valvular prostheses. Physical findings on admission included fever in all patients, and splenomegaly and right-sided hemiparesis in one patient each. None of the patients had evidence of heart failure on presentation or during follow-up. All patients had normal white blood cell counts. The erythrocyte sedimentation rate was elevated in all patients (range 33–96 mm/h). Blood culture grew Brucella organisms in three patients. The brucella antibody titer was elevated in three patients (range 1280–5120). In one patient, brucella serology was negative in spite of repeated testing; however, the blood culture was positive in this patient. Transesophageal echocardiography showed vegetations in all patients. It also showed paravalvular leak in two patients and an abscess in one patient. One patient with native valve brucella endocarditis was treated with antibiotics alone. The other three with prosthetic valve brucella endocarditis were treated with antibiotics and valve replacement. Details of antibiotic therapy are shown in Table 1. The indications for valve replacement were failure of medical treatment in one patient (number 3; vegetations developed while he was receiving antibiotics), and brucella prosthetic valve endocarditis in the other two. The duration of antibiotic treatment was between 10 weeks and 20 weeks. Surgery on the three patients was carried out 4 days, 10 days, and 11 weeks, respectively, after starting antibiotic treatment.Table 1Clinical findings, treatment and outcome of patients with brucella endocarditisPatient no.1234Age (years)/Sex40/M29/M39/M35/MRisk factorRaw milk ingestionRaw milk ingestionRaw milk ingestionRaw milk ingestionDuration of fever2 months9 months2 weeks3 monthsClinical featuresFever, palpitationFever, anorexia, right hemiparesisFever, night sweats, coughFever, coughKnown heart diseaseNoYesYesYesValve involvedNative aortic valveAortic valve prosthesisAortic valve prosthesisMitral valve prosthesisBlood cultureBrucella melitensisBrucella melitensisBrucella speciesNegativeCulture of valveNDPositiveNegativeNegativeBrucella titer1:25601:5120Negative1:1280Treatment Acute phaseStreptomycin/doxycyclineRifampin/doxycycline/co-trimoxazoleDoxycycline/streptomycin, rifampin/doxycyclineCo-trimoxazole/doxycycline/rifampin PostoperativeRifampin/doxycyclineRifampin/doxycycline/co-trimoxazoleRifampin/doxycycline/co-trimoxazoleDoxycycline/rifampinDuration of treatment12 weeks20 weeks13 weeks10 weeksDuration of follow-up15 months10 months12 months10 monthsOutcomeCuredCuredCuredCuredM, male; ND, not done. Open table in a new tab M, male; ND, not done. All patients were followed up in the clinic. The duration of follow-up ranged between 10 months and 15 months. During follow-up, no recurrences were observed. Endocarditis is a rare complication of brucellosis, occurring in less than 2% of cases [3Colmenero JD Reguera JM Martos F et al.Complications associated with Brucella melitensis infection: a study of 530 cases.Medicine (Baltimore). 1996; 75: 195-211Crossref PubMed Scopus (480) Google Scholar]. In a recent review of the English and French language literature since 1900, only 108 cases were reported [5Jacob F Abramowicz D Vereerstraeten P Le Clerc JL Zech F Thys JP Brucella endocarditis. The role of combined medical and surgical treatment.Rev Infect Dis. 1990; 12: 740-744Crossref PubMed Scopus (81) Google Scholar]. Brucellosis is endemic in Qatar; however, despite this, only four cases of brucella endocarditis have been diagnosed during the last 15 years. Brucella melitensis and B. abortus are the most frequently isolated species. Brucella endocarditis produces highly destructive lesions of the valve structure [3Colmenero JD Reguera JM Martos F et al.Complications associated with Brucella melitensis infection: a study of 530 cases.Medicine (Baltimore). 1996; 75: 195-211Crossref PubMed Scopus (480) Google Scholar]; this might explain the high fatality rate for brucella endocarditis. Although the mortality rate for brucellosis is less than 1%, endocarditis accounts for 80% of these deaths [4Peery TM Belter LF Brucellosis and heart disease: II. Fatal brucellosis.Am J Pathol. 1960; 36: 673-697PubMed Google Scholar]. The complication that is responsible for the majority of deaths is heart failure [6Romero‐Vivas J Garcia‐Fernandez F Munoz‐Sanz A Buzon LM Nunez L Bouza E Successful treatment of Brucella endocarditis [abstract 875].in: Program and Abstracts of the 23rd Interscience Conference on Antimicrobial Agents and Chemotherapy. American Society for Microbiology, Washington, DC1983Google Scholar]. Although published reports indicate that brucella endocarditis usually involves normal native valves, and predominantly the aortic valve in 75% of cases [3Colmenero JD Reguera JM Martos F et al.Complications associated with Brucella melitensis infection: a study of 530 cases.Medicine (Baltimore). 1996; 75: 195-211Crossref PubMed Scopus (480) Google Scholar], it is interesting that three of our patients had prosthetic valve brucella endocarditis, and only one had native valve endocarditis. Brucella prosthetic valve endocarditis is a very rare disease, with only 11 cases being reported in the English literature [7Al‐Kassab S Al‐Fagih MR Al‐Yousef S et al.Brucella infective endocarditis. successful combined medical and surgical therapy.J Thorac Cardiovasc Surg. 1988; 95: 862-867PubMed Google Scholar, 8Fernandez‐Guerrero ML Martinell J Aguado JM Del Carmen Ponte M Fraile J De Rabago G Prosthetic valve endocarditis caused by Brucella melitensis: a report of four successfully treated with tetracycline, streptomycin, and sulfamethoxazole and trimethoprim plus valve replacement.Arch Intern Med. 1987; 147: 1141-1143Crossref PubMed Scopus (22) Google Scholar, 9O'Meara JB Eykyn S Jenkins BS Braimbridge MV Phillips I Brucella melitensis endocarditis: successful treatment of an infected prosthetic mitral valve.Thorax. 1974; 29: 377-381Crossref PubMed Scopus (25) Google Scholar, 10Saadeh AM Abu‐Farsakh NA Omari HZ Infective endocarditis and occult splenic abscess caused by Brucella melitensis infection: a case report and review of the literature.Acta Cardiol. 1996; 3: 279-285Google Scholar, 11Iglesias A Nunez L Brucella melitensis endocarditis on a porcine heterograft bioprosthesis.Chest. 1981; 80: 747-749Crossref PubMed Scopus (9) Google Scholar, 12Lezuan R Teruel J Maitre MJ Artaza M Brucella endocarditis on double valvular prosthesis.Post Grad Med. 1980; 56: 119-120Crossref PubMed Scopus (16) Google Scholar, 13Cakalagaoglu C Keser N Alhan C Brucella mediated prosthetic valve endocarditis with brachial artery mycotic aneurysm.J Heart Valve Dis. 1999; 8: 586-590PubMed Google Scholar, 14Arslan H Korkaz ME Kart H Gul C Management of brucella endocarditis of a prosthetic valve.J Infect. 1998; 37: 70-71Abstract Full Text PDF PubMed Scopus (18) Google Scholar]. Three of our patients were males, in keeping with other reports [5Jacob F Abramowicz D Vereerstraeten P Le Clerc JL Zech F Thys JP Brucella endocarditis. The role of combined medical and surgical treatment.Rev Infect Dis. 1990; 12: 740-744Crossref PubMed Scopus (81) Google Scholar]. The clinical features in our patients were similar in many respects to those reported by others [5Jacob F Abramowicz D Vereerstraeten P Le Clerc JL Zech F Thys JP Brucella endocarditis. The role of combined medical and surgical treatment.Rev Infect Dis. 1990; 12: 740-744Crossref PubMed Scopus (81) Google Scholar, 15Fernandez‐Guerrero ML Zoonotic endocarditis.Infect Dis Clin North Am. 1993; 7: 135-141PubMed Google Scholar]. Although heart failure is reported to be common in these patients, being either present initially or developing later on during the course of illness [5Jacob F Abramowicz D Vereerstraeten P Le Clerc JL Zech F Thys JP Brucella endocarditis. The role of combined medical and surgical treatment.Rev Infect Dis. 1990; 12: 740-744Crossref PubMed Scopus (81) Google Scholar, 7Al‐Kassab S Al‐Fagih MR Al‐Yousef S et al.Brucella infective endocarditis. successful combined medical and surgical therapy.J Thorac Cardiovasc Surg. 1988; 95: 862-867PubMed Google Scholar, 15Fernandez‐Guerrero ML Zoonotic endocarditis.Infect Dis Clin North Am. 1993; 7: 135-141PubMed Google Scholar, 16Jeroudi M Halim MA Harder JE Al‐Sibai MB Ziady G Mercer EN Brucella endocarditis.Br Heart J. 1987; 58: 279-283Crossref PubMed Scopus (41) Google Scholar], none of our patients had this complication. One of our patients had hemiparesis, most probably secondary to an embolus originating from valve vegetation. Diagnosis of brucella endocarditis may be difficult. Routine laboratory tests are not helpful. Diagnosis depends on isolation of Brucella from blood culture or cardiac tissue [15Fernandez‐Guerrero ML Zoonotic endocarditis.Infect Dis Clin North Am. 1993; 7: 135-141PubMed Google Scholar]. Blood cultures were positive in three of our patients; B. melitensis grew in two, and in the third the species was not specified. Culture of cardiac tissue taken during surgery may be positive, despite prior antibiotic therapy for up to 6 weeks [8Fernandez‐Guerrero ML Martinell J Aguado JM Del Carmen Ponte M Fraile J De Rabago G Prosthetic valve endocarditis caused by Brucella melitensis: a report of four successfully treated with tetracycline, streptomycin, and sulfamethoxazole and trimethoprim plus valve replacement.Arch Intern Med. 1987; 147: 1141-1143Crossref PubMed Scopus (22) Google Scholar]. In our series, cultures of cardiac tissue were done in three patients. Brucella grew in the culture from one patient who had only had 5 days of antibiotic treatment before surgery. The two patients whose cultures were negative had received 10 days and 11 weeks of antibiotic treatment before surgery. The use of serologic tests to measure antibodies against Brucella is helpful in the diagnosis of brucellosis. The standard tube agglutination test (STA) is sensitive and specific. A titer of 1 : 160 or more is presumptive evidence of brucella infection [15Fernandez‐Guerrero ML Zoonotic endocarditis.Infect Dis Clin North Am. 1993; 7: 135-141PubMed Google Scholar]. Three patients in this series had a positive STA test of 1 : 1280 or more. The fourth patient had repeatedly negative serology. This patient's blood grew Brucella species. A false-negative STA test in patients with brucellosis can occur if serum is not diluted beyond 1 : 320 owing to a prozone, or if the infection is caused by B. canis, which does not react to the antigen routinely used in the STA test [17Salata RA Ravdin JI Brucella species (brucellosis).in: Mandell GL Douglas RD Bennet JE Principles and Practice of Infectious Diseases. John Wiley, New York1985: 1283-1290Google Scholar]. It is unlikely that the negative test in our patient is related to a prozone, since serum is routinely tested to dilution beyond 1 : 320 in our laboratory. Echocardiography, especially transesophageal echocardiography, was very helpful in establishing the diagnosis of brucella endocarditis in our patients by showing vegetations in all patients, paravalvular leak in two patients, and an abscess in one patient. Uncertainty exists regarding many aspects of the treatment of brucella endocarditis, including the appropriate antibiotic combination and its duration, and the indications for surgery and its timing [5Jacob F Abramowicz D Vereerstraeten P Le Clerc JL Zech F Thys JP Brucella endocarditis. The role of combined medical and surgical treatment.Rev Infect Dis. 1990; 12: 740-744Crossref PubMed Scopus (81) Google Scholar, 15Fernandez‐Guerrero ML Zoonotic endocarditis.Infect Dis Clin North Am. 1993; 7: 135-141PubMed Google Scholar, 18Cisneros JM Pachon J Cuello JA Martinez A Brucella endocarditis cured by medical treatment.J Infect Dis. 1989; 160: 907Crossref PubMed Scopus (23) Google Scholar, 19Pazderka E Jones JW Brucella abortus endocarditis: successful treatment of an infected valve.Arch Intern Med. 1982; 142: 1567-1568Crossref PubMed Scopus (16) Google Scholar]. A combination of antimicrobial agents and valve replacement is the most accepted treatment for brucella endocarditis [4Peery TM Belter LF Brucellosis and heart disease: II. Fatal brucellosis.Am J Pathol. 1960; 36: 673-697PubMed Google Scholar, 5Jacob F Abramowicz D Vereerstraeten P Le Clerc JL Zech F Thys JP Brucella endocarditis. The role of combined medical and surgical treatment.Rev Infect Dis. 1990; 12: 740-744Crossref PubMed Scopus (81) Google Scholar]. Our first patient with native valve brucella endocarditis was cured with medical treatment alone. Antimicrobial agents can achieve sterilization of valve vegetations, and several cases of cure of native valve brucella endocarditis with medical therapy alone have been reported [15Fernandez‐Guerrero ML Zoonotic endocarditis.Infect Dis Clin North Am. 1993; 7: 135-141PubMed Google Scholar, 20Hudson RA Brucella abortus endocarditis. A case.Circulation. 1957; 16: 411-413Crossref PubMed Scopus (13) Google Scholar, 21Quinn RW Brown JW Bacterial endocarditis.Arch Intern Med. 1954; 94: 629-648Crossref Scopus (3) Google Scholar, 22Al‐Mudallal DS Mousa ARM Marafie AA Apyrexic Brucella melitensis aortic valve endocarditis.Trop Geogr Med. 1989; 41: 372-376PubMed Google Scholar]; however, because of the risk of relapse and the catastrophic consequences of a relapsing infection, it is of the utmost importance to carefully monitor the patient so that complications necessitating valve replacement are detected as early as possible [18Cisneros JM Pachon J Cuello JA Martinez A Brucella endocarditis cured by medical treatment.J Infect Dis. 1989; 160: 907Crossref PubMed Scopus (23) Google Scholar]. Medical therapy for brucella endocarditis consists of a combination of antibiotics used for a long period. The optimal combination and duration are unknown. In our patients, different combinations of doxycycline, rifampin, streptomycin and co-trimoxazole were used, so definite recommendations regarding the best combination could not be made. A prolonged course of antibiotics to prevent relapse seems to be advisable [15Fernandez‐Guerrero ML Zoonotic endocarditis.Infect Dis Clin North Am. 1993; 7: 135-141PubMed Google Scholar]. In different reports, the duration of antibiotic therapy ranged from 6 weeks to 12 months, and in our series from 10 to 20 weeks. The decision to stop treatment must be determined in each case after thorough clinical observation [15Fernandez‐Guerrero ML Zoonotic endocarditis.Infect Dis Clin North Am. 1993; 7: 135-141PubMed Google Scholar]. The other three patients with prosthetic valve endocarditis were treated with a combination of antibiotics and valve replacement. Prosthetic valve endocarditis caused by Brucella is cited as a primary indication for surgery [8Fernandez‐Guerrero ML Martinell J Aguado JM Del Carmen Ponte M Fraile J De Rabago G Prosthetic valve endocarditis caused by Brucella melitensis: a report of four successfully treated with tetracycline, streptomycin, and sulfamethoxazole and trimethoprim plus valve replacement.Arch Intern Med. 1987; 147: 1141-1143Crossref PubMed Scopus (22) Google Scholar]; there is only one case report of cure of brucella prosthetic valve endocarditis with antibiotics alone [13Cakalagaoglu C Keser N Alhan C Brucella mediated prosthetic valve endocarditis with brachial artery mycotic aneurysm.J Heart Valve Dis. 1999; 8: 586-590PubMed Google Scholar]. Valve replacement may be performed during the active phase of the disease, as the risk of recurrent infection in the new prosthesis is low [5Jacob F Abramowicz D Vereerstraeten P Le Clerc JL Zech F Thys JP Brucella endocarditis. The role of combined medical and surgical treatment.Rev Infect Dis. 1990; 12: 740-744Crossref PubMed Scopus (81) Google Scholar, 23Baumgartner WA Miller DC Reitz BA et al.Surgical treatment of prosthetic valve endocarditis.Ann Thorac Surg. 1983; 35: 87-104Abstract Full Text PDF PubMed Scopus (88) Google Scholar], as was the case in two of our patients. The outcome was good in our series, which may be because none of our patients had heart failure during the course of their illness. In conclusion, brucella endocarditis remains a rare but serious complication of brucellosis. In our region, brucella endocarditis should be seriously considered in the differential diagnosis of patients with abnormal valves presenting with endocarditis, especially in those at risk for brucellosis. Brucella endocarditis of native valves may be treated with antibiotics alone, with careful monitoring for complications. A prolonged course of antibiotics is necessary. Brucella prosthetic valve endocarditis should be treated with a combination of antibiotics and valve replacement. Early surgical intervention during the active phase of infection is safe, since the risk of infection of the new prosthesis is low." @default.
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• W1520771189 title "Brucella infective endocarditis: a report of four successfully treated patients" @default.
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