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Ann Thorac Surg 2001;71:1160-1163
© 2001 The Society of Thoracic Surgeons

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Original article: cardiovascular

Surgical treatment of brucella endocarditis

^a Kouyolu Heart and Research Hospital, stanbul, Turkey

Accepted for publication November 28, 2000.

Address reprint requests to Dr Bozbuga , Kosuyolu Heart and Research Hospital, 81020 Kadiköy, Istanbul, Turkey
e-mail: kosuyolu{at}superonline.com

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. Brucella endocarditis (BE) is a lethal complication of human brucellosis, which is rarely seen and hardly described.

Methods. In the present report, six successfully treated cases of BE involving three native aortic valves, two native mitral-aortic valves, and a mitral bioprosthesis are described. The diagnosis of BE was based on clinical features, high brucella serologic titers, and positive blood cultures. Although the blood cultures were positive in all patients, all the resected valve materials and tissue cultures were negative. The patients received rifampicin, streptomycin, and doxycycline (in 3 patients), rifampicin, tetracycline, and cotrimoxazole (in 2 patients), and rifampicin, doxycycline, and cotrimoxazole (in 1 patient). Infected native valves and bioprosthesis were replaced by mechanical valves.

Results. There was no early or late mortality. No recurrent infection developed after management with a combination of antibiotherapy lasting 6 months postoperatively during a mean follow-up of 47 months (range 20 to 84 months).

Conclusions. This report suggests that the combination of valve replacement and antibiotic therapy produces successful results in the treatment of BE.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Brucellosis is still a frequently seen major infectious disease, particularly in the Mediterranean, the Middle East, and Central and South American countries [1, 2]. Although typical brucellosis is easily diagnosed in endemic areas, in other regions where the incidence of brucella is very low, definitive diagnosis of the infection is quite difficult. A patient presenting with a heart murmur who has a history of ingestion of unpasteurized milk and exposure to infected animals or animal products should be considered as having cardiac manifestations of brucellosis until proved otherwise. In infective endocarditis of brucellosis, most frequently isolated species are Brucella melitensis and B abortus; despite having an incidence of less than 2%, these two species are the etiologic factor in most of the mortal infections [3]. B suis and B canis are rare causative species [4]. Endocarditis and myocarditis are rare but the most serious complications of brucellosis [5]. Brucella appears to be a slowly destructive organism, with a marked tendency to tissue ulceration, the development of large vegetations carrying a significant risk of embolization, and difficulty in eradicating with medical therapy alone.

In the present report, six consecutive cases of Brucella endocarditis (BE) that were successfully treated with a combination of surgical and medical therapy are described.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Between 1993 and 1999, 4 male and 2 female patients between the ages of 26 and 60 years with suspection of BE were admitted to Kouyolu Heart and Research Hospital. Symptoms appeared 2 weeks to 8 months before their admission to the hospital. All patients demonstrated fever greater than 37.5°C. One patient had rheumatic aortic valve disease (case 3) and 1 patient underwent mitral valve replacement with a bioprosthesis for rheumatic mitral stenosis 6 years previously for rheumatic mitral stenosis (case 1). Two patients had a history of transient ischemic cerebral attack that resulted with aphasia (cases 2 and 5). The remaining clinical data are shown in Table 1.

In all patients, white blood cell counts were found within normal limits, between 4,900 and 7,600/mm³. All patients had elevated erythrocyte sedimentation rates (ESR) of 50 to 90 mm/h. Except for atrial fibrillation in 1 patient (case 1), conduction anomalies were not detected. All patients presented moderate cardiomegaly and pulmonary congestion on telecardiography.

The Brucella agglutination titers of over 1:320 were obtained in all of the patients. The sera tested from 3 patients (cases 3, 4 and 6) for anti-Brucella IgM antibodies by enzyme-linked immunosorbent assay (ELISA) and the titers were positive over 1:800. Despite the medical therapy, all titers remained high until the operation. Repeated blood cultures yielded growth of B melitensis in the patients.

Large vegetations on the affected valves (native aortic and mitral valves, and also on the mitral bioprosthesis) were revealed by two-dimensional echocardiographically. Vegetation was pedinculated and prolapsed to the left ventricle outflow tract (LVOT), together with gross thrombus in the left atrium in case 1. Cardiac catheterization was not carried out in any patients so as not to cause the risk of embolism.

After the serological confirmation of BE, antibiotic therapy was maintained until the operation. The patients received a combination of rifampicin (900 mg bid), streptomycin (12 to 16 mg/kg/24 hours IM), and doxycycline (200 mg/kg bid); rifampicin, tetracycline (8 mg/kg tid), and cotrimoxazole (15 mg/kg bid); or rifampicin, doxycycline, and cotrimoxazole.

All patients were operated during the acute phase of BE after receiving a minimum of 6-week antibiotherapy. The indications for the operation were the prevention of cerebral embolism due to mobile vegetation, which was situated on the LVOT and bioprosthesis mitral valve in case 1, and on the aortic valve in Case 5; the prevention of acute left ventricular failure and pulmonary edema due to severe aortic and mitral insufficiency in case 2; severe aortic insufficiency in case 3; and moderate aortic stenosis and severe aortic insufficiency in cases 4 and 6.

Surgical findings were degenerative mitral bioprosthesis and pedinculated vegetation in case 1; vegetation and destruction of noncoronary cusp (NCC) of the aortic valve together with vegetation and laceration on the midsegment of the mitral anterior cusp in case 2, in whom coronary anomaly was observed where the right coronary artery originated from noncoronary sinus of Valsalva (Fig 1); fresh large vegetation (Fig 2) and deep ulceration in the Valsava sinus with abscess formation causing aortic stenosis and regurgitation facing the right coronary ostium of the right coronary cusp (RCC) and commissure of the left coronary cusp (LCC) and RCC (Fig 3) in case 3; large vegetation on the calcified aortic cusps and rupture of left sinus Valsalva in case 4; fibrocalcific thickness on free margins of all aortic cusps and vegetation on the NCC in case 5; and huge vegetation causing aortic stenosis and cusp perforation and severe mitral insufficiency on both the aortic and mitral valves in case 6.

View larger version (129K): [in this window] [in a new window]   Fig 1. Intraoperative view of aortic cusps (case 2).

View larger version (101K): [in this window] [in a new window]   Fig 2. Two-dimentional echocardiography. Left parasternal view, showing the vegetation on aortic valve (case 3).

View larger version (122K): [in this window] [in a new window]   Fig 3. Intraoperative view of aortic cusps (case 3).

The diagnostic, medical, and surgical data are summarized in Table 2.

	Results

Top Abstract Introduction Patients and methods Results Comment References

In all patients, Brucella titers, blood cultures, and echocardiography were repeated every 3 months within the first postoperative year. Decreasing Brucella titers were obtained by 6 months postoperatively. Therefore, antibiotic therapy was continued orally for 6 months after operation. In control echocardiography, neither vegetation nor paravalvular leak was detected. None of the patients with native valve endocarditis who underwent valve replacement subsequently had prosthetic valve endocarditis during a mean follow-up of 47 months (range 20 to 84 months). Standard deviation was ±23.2 and the median was 42 months.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
Endocarditis is an uncommon and a devastating complication of brucellosis. The rate of BE has been accepted as lower than other causes of infective endocarditis [3]. But the incidence was reported to be 10.9% by Al-Kasab and colleagues [6]. A review of 66 cases of native valve infective endocarditis at Kouyolu Heart and Research Hospital revealed an incidence of 9.1% of BE.

BE is a destructive process of the native valve that commonly leads to heart failure occurring within 3 to 11 months after the onset of symptoms [4]. The aortic valve is the most commonly affected cardiac valve, reported 75% of the cases, and a fearful complication is the formation of aortic root abscess [7, 8]. The involvement rate of prosthetic valves was found to be 8% [7].

Myocarditis is another rare complication of adult brucellosis, which is associated with a prolonged P-R wave interval and T segment changes initially [5]. Gross abscesses of myocardium or their consequent aneurysm are apparently more frequent in Brucella endocarditis than in endocarditis caused by any other bacteria [8]. Peery and Belter found endocarditis in 80% and myocardial abscess in 43% of a series including 44 necropsies on cases of fatal brucellosis [9].

The diagnosis of brucellosis is based on epidemiological evidence and positive culture or serology. The manifestations of the disease, especially in the chronic stage, make the diagnosis difficult, and most of the conventional diagnostic methods have their limitations. Blood culture is the only specific test; its sensitivity ranges from 17% to 85% depending on culture conditions, antibiotic therapy, and the length of interval between the onset of symptoms and diagnosis. Thus, culture of Brucella species from body specimens is often unsuccessful [2, 4, 10]. The laboratory diagnosis is usually established by a positive blood culture and/or fourfold increase in Brucella titers or a single serum agglutination test titer of less than 1:320 or by an ELISA titer of IgM of less than 1:800 alone or together with IgG of less than 1:1600 and IgA of less than 1:200 [5].

It is difficult to differentiate acute brucellosis from acute rheumatic fever, especially if cardiac involvement is prominent. Both diseases may present with fever, arthralgia, splenomegaly, and high erythrocyte sedimentation rate, but acute brucellosis only occasionally shows leukocytosis [7]. Echocardiography is usually helpful in detecting valvular vegetations and may increase the ability to establish the diagnosis of infective endocarditis.

The accepted treatment for BE is a combination of medical and surgical interventions [6, 8, 11, 12]. Although conservative antibiotic treatment alone has not been recommended by most authors, as it has been considered ineffective, the complete cure with antibiotic treatment alone has been reported in only a few cases of BE [13, 14]. The patients with relatively mild extravalvular involvement and a short symptomatic period before the onset of the antibiotic therapy and congestive heart failure may be suitable for medical therapy alone. Otherwise, surgery should be considered for patients with endocarditis and/or prosthetic heart valves, or abscesses that are antibiotic resistant [15].

The treatment of BE still raises the problem of selecting the correct antibiotic and the duration of treatment. Treatment of brucellosis must effectively control acute illness and prevent complications and relapse. The choice of regimen and duration of antimicrobial therapy should be based on the presence of focal disease and underlying conditions that contraindicate certain specific antibiotics [15]. Indeed, requirements may be complex because one must select antibiotics that are active in vitro and that diffuse readily into the tissues and into the cells without developing bacterial resistance. Intracellular localization of the microorganism makes it refractory to the activity of various antibiotics [1]. The combinations of doxycycline and rifampicin or doxycycline and streptomycin have been used with variable success rates [15–17]. Tetracycline and gentamicin as well as intravenous cotrimoxazole have been found to be effective [1]. Tetracyclines are generally contraindicated for pregnant patients and children under 8 years old [15].

Timing of surgical intervention and the duration of medical therapy after surgical intervention in BE remains controversial. There is no indication in published reports on how long the antibiotic treatment should be continued after the operation, but 6 months seems to be adequate if Brucella titers are decreasing. No sign of recurrence was observed in our patients within the follow-up period of 74 months.

Optimal treatment of prosthetic valve endocarditis due to BE should achieve the sterilization of infected cardiac tissue and extensive surgical debridement without delay to control acute illness and prevent complications and relapse.

Conclusion
We concluded that due to the characteristics of either native or prosthetic BE, medical therapy alone is not sufficient in treating the disease and best results are achieved in combination with multiple bactericidal antibiotics and radical surgical therapy.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Keles, C. Articles by Yakut, C. Search for Related Content PubMed PubMed Citation Articles by Keles, C. Articles by Yakut, C. Related Collections Valve disease