Brucellosis With Multi-Organ Involvement in a Patient With History of Composite Aortic Graft and Hepatitis B
AbstractThe brucellosis with multi-organ involvement in a patient with a history of the composite aortic graft (Bentall procedure) and Hepatitis B infection is rare. A 35-year-old man presented to us with fever and loss of consciousness. Four years ago, he was IDU and underwent cardiac surgery because of endocarditis. Recently lumbar spondylodiscitis was diagnosed. The Wright (1/320) and Coombs Wright tests (1/640) were positive. After CNS imaging, lumbar puncture was done. The CSF pleocytosis was lymphocyte dominant. In cardiac echocardiography, large vegetation on prosthetic aortic valve leaflets was seen. The brain MRI was reported abnormal. Treatment of brucellosis started with Ceftriaxone, Doxycycline, Rifampin and Gentamycin. After 4 days, he became oriented, and fever was disappeared then we continued the treatment for 16 days. The patient discharged and followed by daily phone calls. As symptoms of abdominal pain and jaundice were presented on the fifth day, he re-admitted. The patient expired because of hepatorenal and cardiac insufficiency. Drug side effects, activation of Hepatitis B and embolism of cardiac vegetation to other organs were suspected causes of death. We do not suggest medical therapy without cardiac surgery in such cases. When combination therapy is necessary for brucellosis in an HBsAg-positive patient, hepatitis virus activity should be assess by HBV-DNA PCR and the dose of drugs with known hepatotoxic effects such as rifampin and co-trimoxazole should be adjust. Combination therapy with quinolones instead of hepatoxic drugs is one of our suggustions.
Sanaei Dashti A, Karimi A. Skeletal Involvement of Brucella melitensis in Children: A Systematic Review. Iran J Med Sci 2013;38:286-92.
Buzgan T, Karahocagil MK, Irmak H, Baran AI, Karsen H, Evirgen O, et al. Clinical manifestations and complications in 1028 cases of brucellosis: a retrospective evaluation and review of the literature. Int J Infect Dis 2010;14:469-78.
Sasmazel A, Baysal A, Fedakar A, Bugra O, Ozkokeli M, Buyukbayrak F, et al. Treatment of Brucella endocarditis15 years of clinical and surgical experience. Ann ThoracSurg 2010;89:1432-6.
Sharifkazemi MB, Moarref AR, Rezaian S, Rezaian GR.Brucella endocarditis of pseudoaneurysm of an aortic composite graft. J Cardiovasc Ultrasound 2013;21:183-5.
Fountain FF, Tolley EA, Jacobs AR, Self TH. Rifampin hepatotoxicity associated with thetreatment of latent tuberculosis infection. Am J Med Sci 2009;337:317-20.
Yetkin MA, Bulut C, Erdinc FS, Oral B, Tulek N.Evaluation of the clinical presentations in neurobrucellosis. Int J Infect Dis 2006;10:446-52.
Keshtkar-Jahromi M, Razavi SM, Gholamin S, Keshtkar- Jahromi M, Hossain M, Sajadi MM. Medical versus medical and surgical treatment for brucella endocarditis. Ann ThoracSurg 2012;94:2141-6.
Kaplowitz N. Drug-induced liver injury. Clin Infect Dis 2004;38:S44-8.
Bickford CL, Spencer AP. Biliary sludge and hyperbilirubinemia associated with ceftriaxone in an adult: case report and review of the literature. Pharmacotherapy 2005;25:1389-95.
Peker E, Cagan E, Dogan M. Ceftriaxone-induced toxic hepatitis. World JGastroenterol 2009;15:2669-71.
Andrade RJ, Tulkens PM. Hepatic safety of antibiotics used in primary care. J AntimicrobChemother 2011;66:1431-46.
Carrascosa MF, Lucena MI, Andrade RJ, Caviedes JR, Lavin AC, Mones JC, et al. Fatal acute hepatitis after sequential treatment with levofloxacin, doxycycline, and naproxen in a patient presenting with acute Mycoplasma pneumoniae infection. ClinTher2009;31:1014-9.
Kamali Aghdam M, Davari K, Eftekhari K. Recurrent Epistaxis and Bleeding as the Initial Manifestation of Brucellosis. Acta Med Iran 2016;54:218-19.
Alavi SM, Alavi L. Treatment of brucellosis: a systematic review of studies in recent twenty years. Caspian J Intern Med 2013;4:636-41.