Medical versus medical and surgical treatment for brucella endocarditis

Incidence and Outcomes of Brucella Endocarditis in a High-Prevalence Area: A Single-Center Study

OBJECTIVE

To analyze the clinical characteristics of Brucella endocarditis (BE) and observe the factors related to death to provide guidance for clinical treatment.

METHODS

This study examined all patients with BE admitted to The First People's Hospital of Kashi Prefecture between January 2017 and November 2023. Clinical characteristics and follow-up outcomes were collected for analysis.

RESULTS

This study revealed 774 cases of brucellosis and 14 cases of BE, with an overall incidence rate of 1.88%. Most of the patients were male (71.43%) and lived in areas where brucellosis is common. Patients ranged in age from 26 to 68 years. Common symptoms reported among patients included chest tightness and fatigue, and a significant portion also presented with congestive heart failure. Most patients exhibited normal white blood cell counts (WBC) but had elevated levels of C-reactive protein (CRP). Transthoracic ultrasound (TTE) revealed cardiac valve vegetation in all patients, along with positive blood cultures. Six patients (42.86%) completed heart surgery, and ten (71.43%) completed anti-infection treatment. Six patients died, five of whom did not undergo surgery. The other patient with Marfan syndrome died after surgery. Sex, WBC count, neutrophil (NEUT) and total bilirubin (TBIL) were significant factors associated with regression in BE patients (P < 0.05) according to univariate analysis.

CONCLUSIONS

Patients with BE in Kashi have a severe clinical presentation at diagnosis, but early detection with improved cardiac ultrasound and aggressive treatment can improve the prognosis.

Brucella aortitis managed with debridement, extra-anatomical bypass, and long-term antimicrobial therapy

OBJECTIVES

This report aims to review the management and outcomes of Brucella-associated mycotic aortic aneurysms.

METHODS

This is a retrospective chart review at a tertiary-level healthcare system. IRB approval was waived per policy.

RESULTS

We describe a case of Brucella aortitis acquired from habitual contact with wild hogs. Clinical presentation included lower back pain and elevated white blood cell count. Diagnosis was confirmed with imaging showing an infrarenal abdominal aortic aneurysm and serology revealing elevated Brucella antibodies titers. The patient was initially managed with endovascular aortic repair and combined oral and intravenous antibiotics therapy. He then underwent explanation and extra-anatomical bypass due to symptomatic periaortic infection and interval development of type I endoleak. The patient was asymptomatic after his final operation at 24 months of follow-up and remained on suppressive oral antibiotic therapy.

CONCLUSIONS

An aortic aneurysm secondary to Brucella is a rare entity. A detailed history of long-term exposure to animals may be a clue to obtain serologic testing. Operative debridement and re-establishing of reliable blood flow combined with long-term antibiotic suppression are the mainstay of treatment.

Re-do pericardial reconstruction of the aortic valve in Brucella endocarditis

We report a 12-year-old boy who had undergone an auto-pericardial aortic valve implantation 3 years ago for rheumatic aortic regurgitation. He presented with Brucella endocarditis of the auto-pericardial leaflets with new-onset severe aortic regurgitation, congestive cardiac failure and systemic sepsis. He had an aortic root abscess with multiple pseudoaneurysms in relation to the aortic sinus. Following medical stabilisation, he underwent re-do surgery with debridement of the root abscess, closure of the pseudoaneurysms, excision of the auto-pericardial aortic leaflets and reconstruction of the aortic valve with donor pericardium. He had an uneventful recovery and is asymptomatic on follow-up.

Brucella Prosthetic Valve Endocarditis: A Systematic Review

Objective

Brucella prosthetic valve endocarditis is a rare but a life-threatening complication of brucellosis. It remains a diagnostic challenge. Optimal treatment of Brucella prosthetic valve endocarditis is debated. Available data is limited to case reports or small case series. The purpose of this study was to systematically review all published cases of Brucella prosthetic valve endocarditis in the literature.

Method

A systematic review of PubMed database, Google, Google Scholar, and Scopus (From January 1974 to the present) for studies providing epidemiological, clinical and microbiological data as well as data on treatment and outcomes of Brucella prosthetic valve endocarditis was performed.

Results

A total of 51 reported cases were reviewed. Brucella melitensis (45%) and Brucella abortus (11.7%) were the most frequently isolated species. Most common type of prosthesis valve was mechanical prothesis (84.3%) and ten patients had double valve prosthesis (19.6%). Fever and dyspnea were present in 100% and 37.2% of the cases, respectively. The diagnosis was set with echocardiographic finding in 30 cases (93.7%), which revealed vegetation in 27 cases (84.3%). Most used antibiotics were rifampicin, doxycycline and aminoglycoside or cotrimoxazole. No deaths were noted in patients treated by combined medical and surgical treatment, but mortality was noted in 27.7% of the cases treated by antibiotics alone (p = 0.006).

Conclusion

This systematic review highlights diagnostic challenges and demonstrates that surgery improved outcome by reducing mortality in patients treated with the combined surgical and medical treatment option. Brucellosis should be considered in the differential diagnosis of prosthetic valve endocarditis in patients residing in or traveling to areas of endemicity.

Short- and long-term follow-up outcomes of patients with Brucella endocarditis: a systematic review of 207 Brucella endocarditis Cases

Brucella endocarditis is a fatal complication and the most frequent cause of death for human brucellosis. This study aimed to systematically review the literature on the follow-up outcomes of Brucella endocarditis and analyze the determinants affecting the follow-up outcomes. The databases PubMed, Web of Science, Embase, and Cochrane were searched using keywords and suitable combinations. All studies reporting the follow-up outcomes of Brucella endocarditis were included. Finally, a total of 76 studies (207 patients), including cases or case series, were included. The event rate for patients who underwent short- and long-term follow-up was 12.0% (2 relapsed and 1 died) and 8.1% (6 relapsed and 8 died), respectively. The differences in outcomes between different age groups (18–39, 40–59, and ≥60) were significant (P < 0.05, P = 0.035). The outcomes of the 18–39 age group were worse than those of the 40–59 age group (OR, 0.277; 95% CI, 0.103–0.748; P = 0.011). Accordingly, follow-up (both short- and long-term follow-up) is essential for Brucella endocarditis patients, especially for younger patients (18–39 years) in the first 6 months after treatment. The burden of Brucella endocarditis related complications were immense. Further studies are needed to explore age-based epidemiology of Brucella endocarditis and the exact influencing factors of the follow-up outcomes.

Brucella cardiac implantable electronic device infection: A single-center case series

BACKGROUND

Cardiac implantable electronic devices (CIEDs), including implantable cardiac defibrillators, pacemakers, and cardiac resynchronization therapy devices, are lifesaving. However, device infections can lead to morbidity and mortality. The aim of this study was to describe the outcome of Brucella CIED infections treated at our center, and to identify risk factors for Brucella infection in patients with CIEDs. Study Settings: Single-center study, Prince Sultan Military Medical City, Riyadh, KSA.

METHODS

This case series included all Brucella-related CIED infections treated at a tertiary care center between 2009 and 2020. Data on patient demographics, clinical manifestations, predisposing factors, microbiology, treatment regimens, and outcomes were reviewed.

RESULTS

Fifteen patients met the Brucella CIED infection criteria. The mean age was 62.2 years, and 80% were males. Common comorbidities included hypertension (73%), diabetes mellitus (67%), ischemic heart disease (47%), and chronic kidney disease (60%). The mean time to infection following the device implantation was 4.8 years (range: 5 months to 13 years). Fever was detected in 53% of patients, device site swelling in 47%, purulent discharge in 33%, and pain in 27%. The blood culture and serology results were positive in 73% and 80% of patients, respectively. All patients were treated with antibiotics, and the infected device was removed. Seven (46.6%) patients underwent reimplantation with a new device. One patient with dual Brucella and methicillin-sensitive Staphylococcus aureus infection died, and the other 14 patients recovered, with no recurrent infections reported to date.

CONCLUSION

Brucella should be considered in CIED infections, particularly in endemic areas. Proper treatment and device removal are essential for good outcomes.

A case report of endocarditis and spondylitis caused by Brucella melitensis biovar 3

Background

This case report describes the clinical process of a shepherd who suffered brucellosis-related endocarditis (BE) and spondylitis (BS) and was infected with Brucella melitensis biovar 3 (B. melitensis biovar 3).

Case presentation

A 55-year-old male patient was admitted to The First Affiliated Hospital of Shihezi University on October 11, 2018, due to over 3 months of intermittent fever, back pain, and heart trouble. The Rose Bengal Plate test was positive, the standard agglutination test titer for brucellosis was 1/800, and the blood culture was positive for B. melitensis biovar 3. Three instances of transthoracic echocardiography examination at days 1, 25, and 376 after admission to the hospital and magnetic resonance imaging (MRI) and computed tomography (CT) checks at days 5 and 38 revealed that the size of the vegetation on the posterior leaflet of the mitral valve increased from 0.71.4cm to 1.21.5cm and that the left atrium and ventricle were enlarged. The MRI and CT results showed hyperplasia of the second and third vertebra, a cold abscess formed on both sides of the psoas major muscles, and the vertebra hyperplasia became aggravated at a later time point. The patients situation deteriorated, and heart failure was discovered on October 22, 2019. At the moment of submission of this manuscript, the patient remains in bed at home because of severe debility caused by brucellosis.

Conclusions

This is the first reported case of endocarditis combined with spondylitis caused by B. melitensis biovar 3 in a shepherd. Brucellosis infection can cause work-power losses because of misdiagnosis or a lack of proper treatment. Early diagnosis and treatment are essential for a successful outcome.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06142-3.

The current therapeutical strategies in human brucellosis

Prompt and adequate treatment of human brucellosis continues to be the most important strategy in its management, as eradication of animal brucellosis is not possible so far, and there is no adequate vaccine for humans. The goal of antibrucellar treatment is to alleviate and shorten the symptomatic period and reduce complications, relapses, and chronicity. Contemporary trends in the treatment of human brucellosis are postulated on the ability of Brucellae to persist in host macrophages through the inhibition of phagolysosome fusion and to survive for prolonged periods intracellularly without restricting basic cellular functions. As a result of this and despite satisfactory antibiotic treatment, relapses and therapeutical failures are inevitable to a certain degree. The current principles for the treatment of brucellosis advocate for a long enough treatment duration combined with antimicrobial regimens that possess activity in the intracellular acidic environment. In the future, other antimicrobial agents, immunomodulation, decrease in the intracellular acidic environment, or development of agents that would act on well-defined molecular bacterial targets, might be incorporated to improve the therapeutical effects.

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.

Brucella Endocarditis in Persons Who Inject Drugs

We report 2 cases of infective endocarditis in injection drug users due to Brucella infection. Although cardiac involvement is a frequent sequela of brucellosis and endocarditis is often seen with injection drug use, Brucella endocarditis in persons who inject drugs without zoonotic exposure has not been reported to date.

Successful Management of Prosthetic Valve Brucella Endocarditis with Antibiotherapy Alone

Objectives

To report a case of mechanical aortic prosthesis Brucella endocarditis successfully treated with antibiotics alone.Materials and methods: We describe a clinical case and present a review of the literature.

Results

A 60-year-old female farmer with a mechanical aortic prosthetic valve presented with low back pain and fever. She was diagnosed with prosthetic valve Brucella mellitensis endocarditis and was cured with antibiotic therapy alone. Few cases of successfully treated prosthetic valve Brucella endocarditis without surgery have been reported.

Conclusion

Prosthetic valve Brucella endocarditis usually requires surgical valve replacement. However, selected patients may be successfully treated with antibiotic therapy alone.

LEARNING POINTS

Brucella endocarditis is responsible for most fatal cases of brucellosis.Brucellosis relapse after treatment in patients with a cardiac valve prosthesis should arouse suspicion for endocarditis.Long-term medical treatment alone can be successful in selected patients with Brucella endocarditis, even in those with prosthetic valve endocarditis..

The clinical features of 590 patients with brucellosis in Xinjiang, China with the emphasis on the treatment of complications

BACKGROUND

This study aims to analyze the clinical characteristics and treatment outcomes of 590 patients with brucellosis in Xinjiang, China.

METHODOLOGY AND PRINCIPAL FINDINGS

The clinical characteristics, laboratory findings, complications and prognosis of 590 patients infected with brucellosis were retrospectively analyzed. These patients had a mean age of 44.24 ± 15.83 years with 60.5% having a history of close contacting with cattle and sheep. Of them, 53.6% (316 /590) were in acute phase and 21.5% were in chronic phase. Agglutination test showed 98.5% positive with 34% blood culture positive of Brucella. The major symptoms were fatigue (91%), hyperhidrosis(88.1%), fever(86.9%), and joint pain(81%) with 29.8% having enlarged liver, 26.1% having enlarged spleen and 23.2% having osteoarticular complications. Combination of doxycycline plus rifampicin for 12 weeks was an effective regimen for patients without complications. The 3-drug regimen (doxycycline+rifampicin+levofloxacin) for 12 weeks was recommended for these with complications. There were 6 patients died (1.02%) with overall relapse rate of 5.98%.

CONCLUSIONS

Brucellosis is mostly associated with contacting with domestic animal production in Xinjiang, China. Clinical symptoms include fever, fatigue, hyperhidrosis, and joint pain with common complication of osteoarticular involvement. Three-drug-regimen of doxycycline+rifampicin+levofloxacin for 12 weeks was effective for these patients with complications.

Mycotic aortic aneurysm due to brucellosis

Brucellosis is a multisystem zoonotic disease. Mycotic aneurysm due to Brucella is rare and has no clear management approach. Here, we present two cases of mycotic aortic aneurysm due to Brucella. The first patient was treated with surgical resection of a symptomatic infrarenal abdominal aortic aneurysm combined with lifelong doxycycline and rifampicin. The second patient improved with conservative treatment including a 6-month course of antibiotics and regular clinical and radiologic monitoring. Through these cases, we hope to draw attention to this serious adverse effect of Brucella and the importance of management of its local arterial complications, especially in endemic areas.

Silent Fistula of the Ascending Aorta to Pericardium by Brucella Endocarditis

We report the case of a 26-year-old male patient with 2-week history of Brucella aortic valve endocarditis that was referred from general hospital to our hospital emergency room with pallor of the skin and mucous membranes accompanied by systemic hypotension and chest pain. Trans esophageal echocardiography (TEE) revealed a 30-mm ascending aorta at the pulmonary trunk with no evidence of the false lumen or intimal flap. TEE also showed a large vegetation of the aortic valve that limited to noncoronary sinus with moderate pericardial effusion. TEE did not showed fistula tract of nonaortic coronary sinus ring to intra mural of aorta and to pericardial cavity. The patient underwent open heart surgery with resection of destructed aortic valve and vegetation and replacement of aortic valve with prosthetic valve (Carbomedics, Sorin group. 23 mm sizes) with separated pledged suture. Debridement of aortic intra mural fistula tract and its replacement with fresh pericardial patch than performed. The pericardial cavity had moderate bloody effusion. The patient recovered uneventfully and was discharged in the 15th postoperative day. In this case, we report a rare silent clinical presentation of aortic wall fistula by vegetation and aortic ring abscess and periaortic wall hematoma, and reviewed its medical and surgical treatment.

Brucella endocarditis as a late onset complication of brucellosis

Brucella endocarditis (BE) is a rare but life threatening complication of brucellosis. We present a case report of a patient with relapsing brucellosis complicated with aortic valve endocarditis. The patient underwent valve replacement and required prolonged antibiotic treatment because of rupture of the noncoronary leaflet and development of congestive heart failure. Since the onset of endocarditis in patients with brucellosis is not known, proper follow-up is required in order to identify any late onset complications, especially in endemic areas.

Successful Medical Treatment of Prosthetic Mitral Valve Endocarditis Caused by Brucella abortus

Although Brucella endocarditis is a rare complication of human brucellosis, it is the main cause of the mortality in this disease. Traditionally, the therapeutic approach to endocarditis caused by Brucella species requires a combination of antimicrobial therapy and valve replacement surgery. In the literature, only a few cases of mitral prosthetic valve endocarditis caused by Brucella species have been successfully treated without reoperation. We present a case of a 42-year-old man with a prosthetic mitral valve infected by Brucella abortus who was cured solely by medical treatment.

Brucella arteritis: clinical manifestations, treatment, and prognosis

Brucellosis is the most common bacterial zoonosis, and causes a considerable burden of disease in endemic countries. Cardiovascular involvement is the main cause of mortality due to infection with Brucella spp, and most commonly manifests as endocarditis, peripheral and cerebrovascular aneurysms, or arterial and venous thromboses. We report a case of brucellosis presenting as bacteraemia and aortic endarteritis 18 years after the last known exposure to risk factors for brucella infection. The patient was treated with doxycycline, rifampicin, and gentamicin, and underwent surgical repair of a penetrating aortic ulcer, with a good clinical recovery. We review the signs and symptoms, diagnostic approach, prognosis, and treatment of brucella arteritis. We draw attention to the absence of consensus about the optimum therapy for vascular brucellosis, and the urgent need for additional studies and renewed scientific interest in this major pathogen.

Brucella endocarditis: an occupational hazard!

A young man presented with a 2-month history of fever and malaise. Cardiac auscultation revealed the presence of a diastolic murmur. Subsequently, a cardiac echocardiogram was done, which showed a large vegetation adherent to an anterior mitral leaflet. The blood culture was positive for Brucella species. The patient was given antibiotic therapy for brucellosis and referred for surgery. Brucella endocarditis is one of the rarest, yet most notorious complications of this infection. This condition requires a high degree of clinical suspicion in order to facilitate prompt diagnosis and treatment.