Brucella-mediated prosthetic valve endocarditis with brachial artery mycotic aneurysm

A 39-year-old female with a Hall-Kaster mitral prosthesis developed fever, general malaise and arthralgia 15 years after valve replacement for rheumat ic mitral valve disease. Prosthetic valve endocarditis was identified after serial laboratory, clinical and echocardiographic examinations. Penicillin G (40 x 10(6) units/day, i.v.) + gentamicin (240 mg/day, i.v.) was started as initial therapy. The patient showed no signs of recovery, and penicilli n G was replaced with vancomycin (1,000 mg/day, i.v.). There was a gradual reduction in spiking fever, and prominent reductions in erythrocyte sedimen tation rate and white cell count. Meanwhile, a tender and pulsatile mass de veloped in the anterior surface of the left arm; peripheral angiography yie lded a diagnosis of brachial artery aneurysm. A successful aneurysmectomy w ith saphenous vein interposition was performed. Histopathology of the lesio n revealed mycotic aneurysm. An initial control SAT for Brucella of 1/80(+) was found to increase. A detailed history showed the patient to have consu med unpasteurized dairy products. Doxycyline (200 mg/day, oral) + co-trimox azole (2,700 mg/day, oral) + rifampicin (600 mg/day, oral) was administered to treat brucellosis. Later, doxycyline caused intolerable gastrointestina l side effects and was replaced by ciprofloxacin (1,000 mg/day, oral). Subs equently, the patient made an uneventful recovery within one week. Antibiot ic treatment was continued for 12 months, with complete resolution of veget ation and paravalvular leakage. During a four-year follow up, the patient s howed no signs of relapse.