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286 Journal of Medical Microbiology, (2006) 24 (4):286-8 Indian

Case Report

INFECTIVE ENDOCARDITIS DUE TO BRUCELLA *S Purwar, SC Metgud, A Darshan, MB Mutnal, MB Nagmoti

Abstract One of the complications of brucellosis is infective endocarditis, which carries a high mortality rate if undiagnosed or misdiagnosed. We report a case of Brucella infective endocarditis, which was diagnosed serologically and by polymerase chain reaction. After Brucella specific treatment, patient showed dramatic improvement clinically, as evident by echocardiogram findings and other investigations. Key words: Brucella, endocarditis, polymerase chain reaction

m o fr d ns a On examination, the patient was found to be breathless at o edema, l iotender hepatomegaly, pulsatile rest, with pedal t n precordium, wJVP raised caand murmurs of MR and AR. i o l On significant findings in the patient were: dinvestigation, b normal u Haemogram-within limits, except raised total leukocyte e (8900/cmm). . P e count QBC for malarial parasite, Widal test and ) r ASLOwwere negative. f Brucella slide agglutination test was m r o Brucella co1:80.standard tube agglutination test titers - 5120I n and 2MEfo kpositive, . U/ml w chain reaction (PCR) was positive for Brucella le ed Polymerase o b n (Fig. 1) and blood culture was negative after la M dmelitensis k i a by e incubation till 30 days. v a Echocardiogram showed vegetations of 16 x 16 mm on si ted w.m papillary muscles and 10 x 10 mm on anterior mitral leaflet with pericardial effusion and severe AR and MR. s w F o Patient was put on WHO regimen for treatment of PD te h (w is si h T a

Brucella infection is a zoonosis and the organism most commonly implicated is Brucella melitensis which is found in the Mediterranean, the Arabian Gulf, Latin America, Asia, parts of Mexico and the Indian sub continent. Brucellosis continues to be of great health significance and economic importance in many countries. No data is available about its prevalence in India but various studies conducted by different authors have reported the seropositivity ranging from 0.8% in general population to 58-72% in occupationally exposed personnel like veterinarians.1 In humans, brucellosis behaves as a systemic infection with a very heterogeneous clinical spectrum. The disease usually presents as fever with no apparent focus, although in 20 to 40% of the cases there are focal forms. These focal forms of brucellosis have been described in almost all organs and systems, with the osteo articular forms being more common and those affecting the heart and the central nervous system being more severe. Cardiovascular complications of Brucellosis include endocarditis, myocarditis, pericarditis, aortic root abscess, thrombophlebitis with pulmonary aneurysm and pulmonary embolism.2 Endocarditis and cardiac failure is a leading cause of mortality in 3-5% of cases. Brucella endocarditis may develop on valves, previously damaged by rheumatic fever or congenitally malformed, but may also occur on previously normal valves. The clinical features are indistinguishable from those of endocarditis caused by other organisms. High degree of suspicion, especially in susceptible population is essential for early diagnosis of Brucellosis and its complications, one of them being infective endocarditis.

last six months. The patient was a student and gave history of consuming raw milk and assisting in delivery of cattle at home since childhood (handling of afterbirths with bare hands).

Case Report A male patient, aged 20 years, was admitted to the medical ward, in the department of medicine of KLE Hospital and Medical Research Center with complaints of intermittent fever with chills and rigors for a month and cardiac discomfort for *Corresponding author (email: ) Department of Microbiology, JN Medical College, Belgaum - 590 010, Karnataka, India Received : 23-08-05 Accepted : 03-04-06

279 bp

Figure 1: Gel photograph of PCR showing specific band at 279 bp. Lane1 is patient’s blood DNA, lane 2 is positive control, lane 3 is negative control and lane M is molecular weight marker

www.ijmm.org 286 CMYK

300 bp

October 2006

Purwar et al – Brucella Endocarditis

brucellosis consisting of rifampicin, doxycycline and streptomycin for 45 days and then reviewed on follow up. Significant improvement was observed in general condition of the patient which was substantiated by investigations (Table 1). Breathlessness and palpitation were only on exertion. There was no edema, no organomegaly and no murmurs. Investigations on follow up revealed significant improvement: Total leukocyte count was 7000/cmm compared to 8900/cmm, Brucella tube agglutination test titers - 2560 IU/ ml, 2ME- 1:320 and Echocardiogram showed vegetations of 2.0 x 1.2 mm (compared to of 16 x 16 mm at the time of admission) on papillary muscles and of 1.2 x 1.2 mm (compared to 10 x 10 mm at the time of admission) on anterior mitral leaflet. Severe AR, moderate MR and minimal rim of pericardial effusion was observed. Patient improved clinically following the treatment and this improvement was evident on clinical examination and supported by ECHO findings, serology and haemogram.

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endemic.5 Increased diagnostic and therapeutic vigilance is required for timely and efficient treatment of Brucella endocarditis. Diagnostically, high degree of suspicion is required, especially in patients with cardiac symptoms with a history of consumption of non-pasteurized dairy products, occupation associated with animal breeding or simply of living in rural areas. About half a million cases of brucellosis have been reported world wide, though detection rate varies around 30 40% of actual incidence.6 Although Brucella endocarditis is a rare entity, it is associated with high mortality rates, hence high degree of suspicion is essential, specially in endemic areas. Serology plays a very important role in diagnosis of brucellosis for its ease of performance with good specificity and sensitivity.7 Culture, though considered as gold standard, is not being always positive, isolation rates varying from 20 to 50% and may take up to one month and molecular techniques like PCR, though sensitive and specific,8 are not available at all places due to limitation of resources.

m o fr d ns a ltheo opinion io that all sera from febrile patients We are of t n should bewscreened a for Brucella antibodies, as it does not Blood culture being negative, diagnosis was confirmed by c i cost much. If Brucella slide agglutination test is positive, it o l PCR, using Brucella melitensis specific primers. High titers d b should be followed by standard tube agglutination test. It is of IgM component coupled with IgG in serology indicated e Pthatu the serum suggested tested positive may also be . SATsample acute exacerbation of chronic infection, which coupled with e ) subjected for modified with 2 ME to distinguish between r PCR results, history of persistent exposure and excellent f m infection by knowing IgM and IgG acutew and chronic r response to Brucella specific therapy helped us to diagnose o o titers. This is especially important in n .cof total fo kcomponents this case as infective endocarditis caused by Brucella. endemic areas, because of presence of basal titers. Large Because of early detection and specific therapy this lepatiented numberowof samples can be screened quickly. In our institute had a good clinical outcome. b this policy and report almost two cases per month, nfollow la M dwemost k i of which are not suspected by clinicians. Discussion a by e v Other authors have reported similar cases of Brucella References a parts m dof the world . infective endocarditis from different s e i t where itwis still including Asia, Middle East and Latin America s F w o findings D w Table 1: Clinical features and laboratory h ( of the Padmission patient at the time of and at follow-up e s sit On follow-up i At the time of admission Th a General clinical examination 3,4

Breathlessness at rest, Paedal edema(+), Hepato splenomegaly(+) Total leukocyte count 8900/cmm Brucella tube agglutination test SAT- 5120 I.U/ml 2ME- 1:80 ECHO Findings 1. Size of vegetations on Papillary muscle- 16 x 16 mm Anterior mitral leaflet- 10 x 10 mm 2. Pericardial effusionConsiderable

Only on exertion, Paedal edema (-), No organomegaly

1.

Kumar P, Singh DK, Barbuddhe SB. Sero-prevalence of brucellosis among abattoir personnel of Delhi. J Commun Dis 1997;29:131-7.

2.

Monir M, Madkour. ‘Brucellosis’. Chapter-162. In: Harrison’ Principles of Internal Medicine. 14th ed.

3.

Schvarcz R, Svedenhag J, Radegran K. A case of Brucella melitensis endocarditis successfully treated by a combination of surgical resection and antibiotics. Scand J Infect Dis 1995;27:641-2.

4. Hadjinikolaou L, Triposkiadis F, Zairis M, Chlapoutakis E, Spyrou P. Successful management of Brucella mellitensis endocarditis with combined medical and surgical approach. Eur J Cardiothorac Surg 2001;19:806-10.

7000/cmm SAT-2560 I.U./ml 2ME- 1:320

5. Corbel MJ. Brucellosis: An overview. Emerg Infect Dis 1997;3:313-21.

2.0 x 1.2 mm 1.2 x 1.2 mm Minimum rim of pericardial effusion

6. World Health organization; Fact sheet N173. World Health Organization: Geneva; 1997. 7. Al Dahouk S, Tomaso H, Nockler K, Neubauer H, Frangoulidis D. Laboratory-based diagnosis of brucellosis: A review of the


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literature. Part I: Techniques for direct detection and identification of Brucella spp. Clin Lab 2003;49:487-505. 8. Probert WS, Schrader KN, Khuong NY, Bystrom SL, Graves MH. Real-time multiplex PCR assay for detection of Brucella

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spp, B. abortus and B. melitensis. J Clin Microbiol 2004;42:1290-3. Source of Support: Nil, Conflict of Interest: None declared.

m o fr d ns a lo tio n w lica o d ub e rf e w P m). r fo kno .co le ed ow b la M dkn i a by e v a si ted w.m F os w D P te h (w is si h T a arevised article Author Help: Sending 1)

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Include the original comments of the reviewers/editor with point to point reply at the beginning of the article in the ‘Article File’. To ensure that the reviewer can assess the revised paper in timely fashion, please reply to the comments of the referees/editors in the following manner.

• There is no data on follow-up of these patients. Authors’ Reply: The follow up of patients have been included in the results section [Page 3, para 2]

• Authors should highlight the relation of complication to duration of diabetes. Authors’ Reply: The complications as seen in our study group has been included in the results section [Page 4, Table]
