International Journal of Cardiology, 33 (1991) 328-329 0 1991 Elsevier Science Publishers B.V. All rights reserved 0167-5273/91/$03.50 ADONIS 0167527391002482
328
CARD10
13586
Brucella endocarditis G. Delvecchio, 0. Fracassetti and N. Lorenzi Infectious Diseases Department, Ospedali Riuniti, Bergamo, Italy
(Received 11 February 1991: revision accepted 28 May 1991)
Between 1987 and 1990, three patients with abscesses produced by Brucella endocarditis were admitted to the Department of Infectious Diseases, “Ospedali Riuniti”, Bergamo, Italy. In each case, the diagnosis was based on a history of ingestion of milk products, positive Wright serology, positive blood and valvar culture, and echocardiography. Medical therapy alone was not found to he effective in treatment, all patients requiring surgical intervention. One case required urgent surgical treatment and underwent three further operations up to the final implantation of a valved tube. According to our experience, Brucella endocarditis is a rare but serious disease which requires a combination of medical and surgical therapy.
Key words: Endocarditis;
Brucellosis; Abscess
Introduction
Brucellosis is still a major medical problem, particularly when associated with endocarditis [l-3]. In this report, we describe our experience at Bergamo. Materials
and Methods
Between January 1987 and July 1990, our department diagnosed 50 cases of infectious endocarditis and 27 patients with an infection due to Brucella. Three of these had both endocarditis and brucellosis, diagnosed on a history of ingestion of dairy products, clinical findings, Wright serology, positive blood and cultures of valvar tissues, as well as on Doppler cross-sectional echocardiographic assessment without recourse to cardiac catheterization. Case 1 A 16-year-old man had been treated for brucellosis in the summer of 1987 with cotrimoxazole for 20 days
Correspondence to: Dr G. Delvecchio, Ospedali Riuniti, Largo Barozzi, 24100 Bergamo, Italy.
before being admitted febrile to our department with cardiac failure due to acute and massive aortic regurgitation. The patient underwent valvar replacement using an aortic prosthesis as an emergency procedure. After surgery, he was treated with streptomycin 1 g/ day, doxicycline 200 mg/day and rifampicin 900 mg/ day for 20 days. In November 1987, periprosthetic regurgitation with multiple abscesses of the interatrial septum and on the framework of the prosthesis caused severe cardiac failure. Replacement of the prosthesis was necessary. The patient showed permanent electrocardiographic evidence of abnormal interatrial conduction and new periprosthetic regurgitation. Because of further progressive cardiac failure, and atria1 and ventricular extrasystolic arrhythmias, the patient underwent reconstruction of the outflow tract of the left ventricle in June 1989 along with implantation of a bovine pericardium and valve replacement. In the autumn, he showed further congestive cardiac failure because of still further periprosthetic regurgitation, and was diagnosed as having post-transfusional chronic hepatitis. In January 1990, the patient recovered only after complete resection of the subaortic outflow tract, replacement with a valved conduct, and reimplantation of the coronary arteries.
329
Case 2 A 60-year-old with arteriosclerosis was admitted to our department febrile with aortic regurgitation and large abscesses which divided the aortic orifice into two parts. After replacement of the aortic valve, he showed atrial flutter with Wenckebach periodicity in atrioventricular conduction and Dressler’s syndrome. Minimum periprosthetic regurgitation remained along with posttransfusional hepatitis. The antibiotic treatment included streptomycin I g/day for 20 days, doxicycline 200 mg and rifampicin 900 mg for 60 days.
Case 3
A S-year-old woman with mitral stenosis due to rheumatic fever and atrial fibrillation was treated for brucellosis with doxicycline 200 mg/day, and rifampicin 900 mg/day for 30 days in August 1989. In October 1989, because of uncertainty concerning mitral endocarditis and evidence of abscess of the mitral annulus, she was treated again with doxicycline, rifampicin and cotrimaxole for 40 days with apparent stabilization. In February 1990. further evidence of mitral vegetations and annular abscesses required valvar replacement. Treatment with the three antibiotics was needed for 60 days.
Discussion
The most frequent and serious sequel of infection with Brucella is endocarditis (Tables 1 and 2). This usually occurs in the left side of the heart, with elective involvement of valves altered by congenital or acquired diseases. Acute left ventricular failure also occurs, along with bradyarrhythmia or fistulous tracts connecting with various cardiac chambers [4]. These complications require urgent surgical treatment. Treatment with multiple antibiotics is rarely sufficient to eradicate the infection.
TABLE
1
Brucella
endocarditis.
Epidemiological risk Predisposing cardiac lesions (congenital or acquired valvular Positive blood culture Positive explanted valve culture Positive serology Diagnostic role of Doppler cross-sectional echocardiogram Extra valvar lesions Electric and haemodynamic cardiac complications Urgency of surgical therapy
yes anomaly)
yes yes yes yes ye< yes yes yes
Necessity of combined medical yes ntr
and surgical therapy Re-infections of prosthesis
TABLE
2
Brucella
endocarditis:
1. Timing of surgical 2. Medical treatment:
unsolved
therapeutic
problems.
operation. Early? Late? Which antibiotics? For how long?
Acknowledgement The authors thank Dr A. Gamba. M.D.. Cardiosurgery Department, Ospedali Riuniti, Bergamo. for his kind cooperation. References Mikolich Douglas
DJ, Boyce JM. Brucella species. In: Mandell GL, RG. Bennett JE, eds. Principle and practice of infectious diseases. 3rd ed. New York: Churchill Livingstone, lYYO;1735-1742. Al-Harthi SS. The morbidity and mortality pattern of Brucella endocarditis. Int J Cardiol 1989;25:321-324. Magilhgan DJ, Quinn EL. Endocarditis: medical and surgical management. New York: Marcel Dekker. 1986:13Y-152. Al-Kasab S, Al-Fagih MR, Al-Yousef S et al. Brucella infective endocarditis. J Thorac Cardiovasc Surg 1988:95: 862-867.
328
CARD10
13586
Brucella endocarditis G. Delvecchio, 0. Fracassetti and N. Lorenzi Infectious Diseases Department, Ospedali Riuniti, Bergamo, Italy
(Received 11 February 1991: revision accepted 28 May 1991)
Between 1987 and 1990, three patients with abscesses produced by Brucella endocarditis were admitted to the Department of Infectious Diseases, “Ospedali Riuniti”, Bergamo, Italy. In each case, the diagnosis was based on a history of ingestion of milk products, positive Wright serology, positive blood and valvar culture, and echocardiography. Medical therapy alone was not found to he effective in treatment, all patients requiring surgical intervention. One case required urgent surgical treatment and underwent three further operations up to the final implantation of a valved tube. According to our experience, Brucella endocarditis is a rare but serious disease which requires a combination of medical and surgical therapy.
Key words: Endocarditis;
Brucellosis; Abscess
Introduction
Brucellosis is still a major medical problem, particularly when associated with endocarditis [l-3]. In this report, we describe our experience at Bergamo. Materials
and Methods
Between January 1987 and July 1990, our department diagnosed 50 cases of infectious endocarditis and 27 patients with an infection due to Brucella. Three of these had both endocarditis and brucellosis, diagnosed on a history of ingestion of dairy products, clinical findings, Wright serology, positive blood and cultures of valvar tissues, as well as on Doppler cross-sectional echocardiographic assessment without recourse to cardiac catheterization. Case 1 A 16-year-old man had been treated for brucellosis in the summer of 1987 with cotrimoxazole for 20 days
Correspondence to: Dr G. Delvecchio, Ospedali Riuniti, Largo Barozzi, 24100 Bergamo, Italy.
before being admitted febrile to our department with cardiac failure due to acute and massive aortic regurgitation. The patient underwent valvar replacement using an aortic prosthesis as an emergency procedure. After surgery, he was treated with streptomycin 1 g/ day, doxicycline 200 mg/day and rifampicin 900 mg/ day for 20 days. In November 1987, periprosthetic regurgitation with multiple abscesses of the interatrial septum and on the framework of the prosthesis caused severe cardiac failure. Replacement of the prosthesis was necessary. The patient showed permanent electrocardiographic evidence of abnormal interatrial conduction and new periprosthetic regurgitation. Because of further progressive cardiac failure, and atria1 and ventricular extrasystolic arrhythmias, the patient underwent reconstruction of the outflow tract of the left ventricle in June 1989 along with implantation of a bovine pericardium and valve replacement. In the autumn, he showed further congestive cardiac failure because of still further periprosthetic regurgitation, and was diagnosed as having post-transfusional chronic hepatitis. In January 1990, the patient recovered only after complete resection of the subaortic outflow tract, replacement with a valved conduct, and reimplantation of the coronary arteries.
329
Case 2 A 60-year-old with arteriosclerosis was admitted to our department febrile with aortic regurgitation and large abscesses which divided the aortic orifice into two parts. After replacement of the aortic valve, he showed atrial flutter with Wenckebach periodicity in atrioventricular conduction and Dressler’s syndrome. Minimum periprosthetic regurgitation remained along with posttransfusional hepatitis. The antibiotic treatment included streptomycin I g/day for 20 days, doxicycline 200 mg and rifampicin 900 mg for 60 days.
Case 3
A S-year-old woman with mitral stenosis due to rheumatic fever and atrial fibrillation was treated for brucellosis with doxicycline 200 mg/day, and rifampicin 900 mg/day for 30 days in August 1989. In October 1989, because of uncertainty concerning mitral endocarditis and evidence of abscess of the mitral annulus, she was treated again with doxicycline, rifampicin and cotrimaxole for 40 days with apparent stabilization. In February 1990. further evidence of mitral vegetations and annular abscesses required valvar replacement. Treatment with the three antibiotics was needed for 60 days.
Discussion
The most frequent and serious sequel of infection with Brucella is endocarditis (Tables 1 and 2). This usually occurs in the left side of the heart, with elective involvement of valves altered by congenital or acquired diseases. Acute left ventricular failure also occurs, along with bradyarrhythmia or fistulous tracts connecting with various cardiac chambers [4]. These complications require urgent surgical treatment. Treatment with multiple antibiotics is rarely sufficient to eradicate the infection.
TABLE
1
Brucella
endocarditis.
Epidemiological risk Predisposing cardiac lesions (congenital or acquired valvular Positive blood culture Positive explanted valve culture Positive serology Diagnostic role of Doppler cross-sectional echocardiogram Extra valvar lesions Electric and haemodynamic cardiac complications Urgency of surgical therapy
yes anomaly)
yes yes yes yes ye< yes yes yes
Necessity of combined medical yes ntr
and surgical therapy Re-infections of prosthesis
TABLE
2
Brucella
endocarditis:
1. Timing of surgical 2. Medical treatment:
unsolved
therapeutic
problems.
operation. Early? Late? Which antibiotics? For how long?
Acknowledgement The authors thank Dr A. Gamba. M.D.. Cardiosurgery Department, Ospedali Riuniti, Bergamo. for his kind cooperation. References Mikolich Douglas
DJ, Boyce JM. Brucella species. In: Mandell GL, RG. Bennett JE, eds. Principle and practice of infectious diseases. 3rd ed. New York: Churchill Livingstone, lYYO;1735-1742. Al-Harthi SS. The morbidity and mortality pattern of Brucella endocarditis. Int J Cardiol 1989;25:321-324. Magilhgan DJ, Quinn EL. Endocarditis: medical and surgical management. New York: Marcel Dekker. 1986:13Y-152. Al-Kasab S, Al-Fagih MR, Al-Yousef S et al. Brucella infective endocarditis. J Thorac Cardiovasc Surg 1988:95: 862-867.
