Introduction

Brucellosis continue to be reported from, the Mediterranean and Middle-East countries (₁,₂). 10 to 15% of the patients,have complicated brucellosis(₁).Although endocarditis is seen in less than 2% of the cases, it is responsible from the half of the deaths due to brucellosis(₃). We're presenting a case who had severe cardiac damages due to brucella endocarditis.

Case Presentation

Our patient was a 44 years old man.His job was animal husbandry. He admitted to another health facility with chief complaints of fatigue, weight loss and shivering. With the use of blood agglutination test for Brucella species, it was revealed that his titer was 1/640. Transthoracic echocardiography was performed pointing out that there was severe aortic valve insufficiency with giant vegetations on valve leaflets. He was accepted into the Intensive Care Unit of Cardiology (Figure 1).

Figure 1

Figure 1: The TTE image of giant vegetation and aortic regurgitation at the time of first admission to another institution.

He received triple combination antibiotherapy with doxycyclin + rifampicin +and streptomycin for 3 weeks while under therapy to control cardiac failure. After a partial clinical improvement he was referred to our department for further investigation and operation.The transthoracic echocardiography (TTE) which was performed in admittance to our institution, showed that his severe aortic insufficiency progressed and a 23x17mm giant vegetation developed at right and left coronary leaflets. An image corresponding to right coronary artery leaflet perforation was suspected (Figure 2).

Figure 2

Figure 2: Image of TTE at first admittance to our institute.

End- systolic diameter of the left ventricle was calculated as 44 mm whereas its end-diastolic diameter was 65 mm. Coronary angiography revealed no lesion where aortography showing severe aortic regurgitation (Figure 3).

Figure 3

Figure 3: Image of severe aortic regurgitation in his aortography.

During receiving his triple medical therapy before one month[doxycycline (200 mg/d), rifampin (600 mg/d), and streptomycin (2 g/d)], we took him urgently to operation. We carefully performed median sternotomy and routine canulation with minimal manuplation.Arrest was achieved with moderate hypothermia of 28°c,and incompressive retrograde isothermic potassiumed blood cardioplegia.Following aortotomy we explored; that left coronary leaflet had a highly fragile vegetative mass of 3x3 centimeters in diameter on its side facing the ventricle. Coronary angiography revealed no lesion while aortography showing severe aortic regurgitation. Right coronary leaflet also contained a vegetative mass of 2x2 centimeters in diameter on its ventricular face. The common commissure of these two leaflets was perforated. Non-coronary leaflet remained intact (Figure 4 and 5).

Figure 4

Figure 4: The image of giant vegetation settled on right and left coronary leaflets.

Figure 5

Figure 5: The complication of perforation located at the commissure between right and left coronary leaflets.

Native aortic valve was resected.We performed an AVR (23 no Carbomedics bileaflet mechanical valve) with separate sutures. No additional problem was seen postoperatively and he was discharged on 10 ^th postoperative day with surgical cure and outpatient clinic follow was recommended. It was planned to continue the triple antibiotherapy regimen of doxycyclin+rifampicin+streptomycin for 4 more weeks. He is still symptom-free and the valve functions are good in control TTE.

Discussion

Brucellosis is caused by Brucella organisms and acquired by direct contact of infected animals or indirectly by ingesting unpasteurized milk and products of milk (₁,₂). Our patient was infected directly,because he was a livestock producer.

Aglutination (Wright) test is a very important serological test method for diagnosis.Many cases have titers of 1:320 or higher (₄). Our case was diagnosed by history,occupation,positive serology and his echocardiography showed a big vegetation on aortic valve.

Echocardiography is very important to determine the treatment protocol,and the morbidity and mortality rates in all infective endocarditis,including Brucellosis(₂,₅).It is a cheap,easy to use, noninvasive and reproducible method. Most frequently, vegetation is searched in echocardiography and usually it causes insufficiency due to valve damage.If they're big enough and unstabile,can be determined easily by TTE. On native valves,imaging rate is 25% for vegetations smaller than 5 mm and 70% fort he ones larger than 6 mm(₆).

Such as Staph. Aureus, Serratia sp, Pseudomonas sp and Candida sp, Brucella sp also injure the tissues (₁,₅). Infective endocarditis injures the valve and causes insufficiency flow (₇,₉). Situations like leaflet perforation (ranging from small perforations to flail leaflets), rupture of paravalvular abscess, cardiac fistula and leaflet prolapsus due to rupture of commissure are responsible for acute valve insufficieny (₇,₈) . One to 2 degrees insufficiency flow is negligable in normal valves and severe increase is an important symptom for diagnosing infective endocarditis.If there is important valve insufficiency, new flow records of severe aort valve insufficiency is accepted as major endocaedial symptom as in our case.

Embolization risk due to vegetation is in close relation with mortality and morbidity. Clinical symptom rate is 10-50% for vegetations (₁₀).

Medical treatment alone is unsuccessful for Brucella endocarditis and surgery is necessary(₁,₁₃). Brucella endocarditis had been first reported in 1906, but surgical approach as a treatment modality has been introduced in 1964 (₁).

The most effective option is antibiotic and surgery combination.Two main approaches of surgery are; controlling the infection by debriding the infected and necrotic tissue and reconstructing the cardiac morphology by repairing or replacing the damaged valves. Although homografts are ideal due to low infection risk, it is hard to produce them (₁₁). Combination of antibiotic therapy and mechanical valve replacement has a satisfactory result. Early and late reinfection incidence of mechanical valve replacement can be compared with the results and survival expectations of homografts and tissue valves (₁₂).

. If the endocarditis is limited only to the valve leaflets, as in our case, aortic valve is replaced as a usual manner. Mechanical valve replacement was used for Brucella endocarditis in a study with 6 cases and there wasn't any mortality and late recurrence during 47 weeks of follow-up (₁₃). During the postoperative period, at least 4 weeks of duration of antibiotic use has a positive effect on survival (₁₄). We used surgical debridment and mechanical valve replacement and add triple antibiotherapy for 8 weeks.

In conclusion; brucella endocarditis is a rare form of infective endocarditis and its diagnostic rate and surgical therapy practices increased due to availability of echocardiography. Brucella endocarditis does not show remission and has a high mortality if not treated. It must be known that surgical approach increases the quality of life for a long period in this type endocarditis (₉).

Correspondence to

Doç.Dr.Ufuk YETKİN 1379 Sok. No:9, Burç Apt.D:13 35220, Alsancak/İZMİR Tel:0 505 3124906 - Fax:0 232 2434848 E-mail:ufuk_yetkin@yahoo.fr