|Year : 2021 | Volume
| Issue : 4 | Page : 147-149
Brucella endocarditis of bicuspid aortic valve
Sujata Devi MBBS, MD (Medicine) 1, Nilanjan Kar MBBS, MD (Medicine) 1, Debananda Sahoo MBBS, MD (Medicine) 1, Tutan Das MBBS, MD, DM (Cardiology) 2, Debasis Acharya MBBS, MD, DM (Cardiology) 2, Debasish Das MBBS, MD, DM (Cardiology) 2
1 Department of Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
2 Department of Cardiology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
|Date of Submission||02-May-2021|
|Date of Decision||01-Sep-2021|
|Date of Acceptance||06-Oct-2021|
|Date of Web Publication||24-Dec-2021|
Dr. Debasish Das
Department of Cardiology, All India Institute of Medical Sciences, Bhubaneswar - 751 019, Odisha
Source of Support: None, Conflict of Interest: None
We present a rare case of Brucella endocarditis in a case of the bicuspid aortic valve in a 51-year-old male presenting with pyrexia of unknown origin for the last 2 months. Infective endocarditis caused by Brucella melitensis is rare to encounter in routine clinical practice. Although we routinely think of Mycoplasma, Legionella, and Coxiella in the cases of blood culture-negative endocarditis, one should think of Brucella melitensis and Scrub typhus as the last arrow to reach the final etiology of infective endocarditis in the subset of diseased aortic or mitral valve. We successfully treated the patient with a combined regimen of rifampicin, gentamicin, and doxycycline therapy; during follow-up, the vegetation of the aortic valve was shrunken and calcified and the patient was asymptomatic.
Keywords: Aortic, bicuspid, Brucella, endocarditis, valve
|How to cite this article:|
Devi S, Kar N, Sahoo D, Das T, Acharya D, Das D. Brucella endocarditis of bicuspid aortic valve. J Clin Prev Cardiol 2021;10:147-9
| Introduction|| |
Brucella endocarditis accounts for 2% of brucellosis with a high mortality rate. Heart failure is the leading cause of death in Brucella endocarditis. The bacteria get implanted on the valve with congenital abnormality like bicuspid aortic valve as in our case or the damaged valve of rheumatic heart disease. Brucella endocarditis predominantly involves the aortic valve. Brucellosis predominates in the Middle East and Mediterranean regions. This report suggests that the combination antibiotic therapy recovers Brucella endocarditis with a high success rate.
| Case Report|| |
A 51-year-old male came to the medicine outpatient department with intermittent low-to-moderate grade fever for 2 months. It was associated with low backache, breathlessness on exertion with occasional dry cough, and generalized weakness. He had empirically taken the antitubercular regimen for 1 month and showed partial response for few days. On presentation, his pulse rate was 76 per minute, regular, high volume. His blood pressure was 126/58 mmHg. The general survey showed mild pallor, Grade I clubbing, bipedal pitting edema, engorged, and pulsatile jugular venous pressure (11 cm of water). Cardiovascular system examination revealed apex shifted to THE left sixth intercostal space along the midclavicular line, hyperdynamic. Ejection systolic murmur was heard at the aortic area radiating to the apex, associated with carotid thrill. Grade 4 early diastolic murmur was heard over the neoaortic area. Respiratory, abdominal, and neurological system examinations were normal.
Blood investigations revealed hemoglobin 9 g/dl with mixed microcytic hypochromic and normocytic normochromic picture on the peripheral smear. Erythrocyte Sedimentation Rate (ESR) was 20 mm/h. The renal function test was within normal range. The liver function test revealed that hypoalbuminemia (2.4 g/dl) with altered albumin globulin ratio (0.53) and mild elevated alkaline phosphatase (206 U/l) were observed. Twelve-lead Electrocardiogram (ECG) demonstrated normal sinus rhythm. Routine urine microscopy was normal. Contrast Enhanced Computed Tomography(CECT) abdomen revealed mild splenomegaly with wedge-shaped splenic infarct in the upper and mid pole. Non Contrast Computed Tomography (NCCT) thorax delineated fibrobronchiectatic changes in right middle lobe, subsegmental atelectasis at the left upper lobe, and centrilobular nodules with the tree in bud pattern in the right lower lobe with few mediastinal lymph nodes. Transthoracic two-dimensional (2D) echocardiography revealed the presence of bicuspid aortic valve with moderate-to-severe aortic regurgitation (AR) with moderate aortic stenosis. Two sets of blood cultures did not show any growth. Escherichia coli (105 CFU) appeared in urine culture, but the fever did not subside despite optimal antibiotics as per sensitivity pattern.
Because of high clinical suspicion, transesophageal echocardiography (TEE) was performed. It demonstrated a bicuspid aortic valve [Figure 1] with large vegetation of 9 mm × 7 mm in size attached to the right coronary cusp [Figure 2] and [Figure 3] causing moderate AR with two eccentric jets [Figure 4]. 3D TEE also revealed the presence of large vegetation attached to the right coronary cusp [Figure 5]. Repeat sets of blood cultures also did not yield any growth. High-grade fever persisted even with the injection of empirical antibiotics: vancomycin, gentamicin, and meropenem. Considering the possibility of culture-negative organisms in the background of protracted fever with low backache and partial response with antitubercular therapy, IgM Brucella antibody was sent which came strongly positive. The patient was started on gentamicin, doxycycline, and rifampicin combination. The patient improved with treatment, became afebrile, and ultimately discharged on request to continue treatment on a domiciliary basis.
|Figure 1: Transesophageal echocardiography showing bicuspid aortic valve with raphe|
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|Figure 2: Transesophageal echocardiography showing large vegetation attached to right coronary cusp|
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|Figure 5: Three-dimensional transesophageal echocardiography showing large vegetation in right coronary cusp|
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| Discussion|| |
Brucellae are the most common cause of zoonotic infection across the world. They are Gram-negative Coccobacilli with three species: Brucella melitensis, Brucella abortus, and Brucella suis which cause human infection. Brucellosis is also known as Mediterranean fever, Malta fever, gastric remittent fever, and undulant fever. Brucellosis is transmitted to humans through secretions, aerosol, or intake of unpasteurized dairy products. Brucellosis is endemic in the Middle East, Mediterranean, and South Asia including India and South America.
Brucellosis often manifests with nonspecific symptoms for which many often diagnosis becomes difficult. Brucella may involve the gastrointestinal system, hepatobiliary system, nervous, musculoskeletal, genitourinary, skin, and hematological system. Cardiovascular involvement accounts for 80% of mortality in Brucella infection. Median duration of symptoms in brucellosis is for 3–5 months. The mean age of presentation of brucellosis is 55 years and is predominant in males. The most common presenting symptom in brucellosis is fever which is seen in 60% of cases. The aortic valve is most commonly affected in 75% of cases. Multivalvular Brucella endocarditis affecting both the mitral and aortic valve is seen in 8.3% of cases. If Brucella endocarditis of diseased valve in the form of bicuspid valve or rheumatic valve is considered, it has a predilection of aortic valve involvement than mitral valve, but native valve Brucella endocarditis occurs more over the mitral valve. The myocardial abscess occurs in up to 43% of cases of brucellosis. The myocardial abscess is more common in Brucella endocarditis than due to any other causative organism. Infective endocarditis and heart failure account for the highest cause of mortality in brucellosis, which may be up to 30% in endemic and untreated or maltreated cases.
Diagnostic methods for Brucella endocarditis include blood culture, serology, immunohistology, and PCR of infected material. Although blood culture is the gold standard, it has a low diagnostic yield of 22.2% as described by Esmailpour et al. Serological tests in the form of Brucella IgG and IgM have a higher sensitivity; Wrights agglutination titer of 1:160 is very specific and sensitive.
European Society of Cardiology guideline recommends the combined use of doxycycline, cotrimoxazole, and rifampicin for 3 months with optimal aminoglycosides for 2 months. There is no role of antithrombotic medications in the acute phase of endocarditis unless coexistent left atrial thrombus, atrial fibrillation, or venous thromboembolism is there. Most people recommend an early surgical approach in Brucella endocarditis due to a high degree of tissue destruction with a high rate of recurrence. Keshtkar-Jahromi et al. described the beneficial effect of combined medical and surgical approach in Brucella endocarditis substantially reducing the mortality of 32.7% in medical treatment alone group to 6.7% in combined medical and surgical arm across 308 cases of Brucella endocarditis.
| Conclusion|| |
Our case is an extremely rare presentation of Brucella endocarditis in a bicuspid aortic valve causing moderate AR where vegetation was well picked up by TEE and was successfully treated with doxycycline, rifampicin, and gentamycin combination therapy. Blood culture-negative endocarditis is not always due to conventional Mycoplasma, Legionella, or Coxiella; Brucella endocarditis can be a possibility even.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]