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Brucella-mediated prosthetic valve endocarditis with brachial artery mycotic aneurysm
C Cakalagaoglu1, N Keser, C Alhan
1Department of Cardiovascular and Thoracic Surgery, Siyami Ersek Heart and Research Hospital, Turkey.
Abstract:
A 39-year-old female with a Hall-Kaster mitral prosthesis developed fever, general malaise and arthralgia 15 years after valve replacement for rheumatic mitral valve disease. Prosthetic valve endocarditis was identified after serial laboratory, clinical and echocardiographic examinations. Penicillin G (40 x 106 units/day, i.v.) + gentamicin (240 mg/day, i.v.) was started as initial therapy. The patient showed no signs of recovery, and penicillin G was replaced with vancomycin (1,000 mg/day, i.v.). There was a gradual reduction in spiking fever, and prominent reductions in erythrocyte sedimentation rate and white cell count. Meanwhile, a tender and pulsatile mass developed in the anterior surface of the left arm; peripheral angiography yielded a diagnosis of brachial artery aneurysm. A successful aneurysmectomy with saphenous vein interposition was performed. Histopathology of the lesion revealed mycotic aneurysm. An initial control SAT for Brucella of 1/80(+) was found to increase. A detailed history showed the patient to have consumed unpasteurized dairy products. Doxycyline (200 mg/day, oral) + co-trimoxazole (2,700 mg/day, oral) + rifampicin (600 mg/day, oral) was administered to treat brucellosis. Later, doxycyline caused intolerable gastrointestinal side effects and was replaced by ciprofloxacin (1,000 mg/day, oral). Subsequently, the patient made an uneventful recovery within one week. Antibiotic treatment was continued for 12 months, with complete resolution of vegetation and paravalvular leakage. During a four-year follow up, the patient showed no signs of relapse.
Insights
This case highlights a rare instance of prosthetic valve endocarditis complicated by a mycotic aneurysm in a patient with brucellosis. Early diagnosis and comprehensive antibiotic therapy led to a full recovery and no relapse.
Area of Science:
- Cardiology
- Infectious Diseases
- Vascular Surgery
Background:
- Prosthetic valve endocarditis (PVE) is a serious complication following cardiac valve replacement.
- Rheumatic heart disease is a common indication for mitral valve replacement, particularly in younger patients.
- Brucellosis, a zoonotic disease, can manifest with diverse clinical presentations, including vascular complications.
Observation:
- A 39-year-old female presented with symptoms of PVE 15 years after mitral valve replacement.
- The patient developed a brachial artery aneurysm, later diagnosed as mycotic.
- Elevated Brucella serology suggested an underlying brucellosis infection, linked to unpasteurized dairy product consumption.
Findings:
- Initial antibiotic therapy for PVE was ineffective, necessitating vancomycin.
- Surgical intervention for the mycotic aneurysm was successful.
- A combination antibiotic regimen (doxycycline, co-trimoxazole, rifampicin, later ciprofloxacin) effectively treated brucellosis.
- Long-term antibiotic treatment (12 months) resolved PVE and paravalvular leakage.
Implications:
- This case underscores the importance of considering brucellosis in patients with PVE and unusual vascular manifestations.
- Aggressive and tailored antibiotic treatment is crucial for managing complex PVE and associated infections.
- Multidisciplinary management involving cardiology, infectious diseases, and vascular surgery is essential for optimal patient outcomes.