Brucella melitensis in a married couple after a trip through Sicily.

To the Editor: Brucellosis, which has dramatically decreased in France, remains a public health problem in Mediterranean countries. We report the case of a 59-year-old man who presented with isolated fever one month after returning from Italy. He related the consumption of local products in Sicily. Laboratory tests showed inflammation, thrombocytopenia, and cytolysis. The agglutination test for Brucella was positive. Serology for Yersinia was negative. The patient was given a one-month course of tetracycline with improvement. One month later, he presented again with fever. On heart auscultation, a systolic murmur was noted. Laboratory findings showed platelets [158.10.sup.9]/L, sedimentation rate 17 mm/h, C-reactive protein 54 mg/dL, (normal range < 10 mg/dL), and cytolysis 2 (5 X normal range). Echocardiography showed aortic valve vegetation. A blood culture was positive for Brucella melitensis. The patient was prescribed ceftriaxone for four weeks, doxycycline and rifampicin for seven weeks, and made an uneventful recovery. His 50-year-old wife also presented with fever four months after their return. She, too had consumed local products in Sicily, but had a negative brucellosis serology when her husband's agglutination test revealed a positive finding. At this time, however, although the examination was normal, laboratory tests indicated inflammation and thrombocytopenia, and a blood culture identified B melitensis. Cardiac echocardiography was normal. She responded well to a one month course of cyclin.

Brucellosis is a zoonosis that poses health risks. The main source of infection is through direct contact or consumption of milk products from infected animals. It remains one of the most important zoo-noses in the Mediterranean region (1) with Sicily having the highest prevalence of bovine brucellosis. (1)

Brucella endocarditis (BE) observed in our case is unusual. BE constitutes a severe complication, observed in less than 2% of cases. (2) Prosthetic valves were involved in less than 10% of cases, and complications occur in up to 40%. BE appears to be a destructive process, resulting in congestive cardiac failure in up to 80% of cases, and is often fatal. Although the mortality rate for brucellosis is less than 1%, endocarditis is one of the main causes of brucellosis mortality, being responsible for up to 80% of deaths. Brucella isolation from a clinical specimen is difficult because of the fastidiousness of the organism. Blood culture constitutes the only specific test, but its sensitivity varies from 15 to 85%, and is usually negative in uncomplicated chronic brucellosis. The specificity of the slide agglutination test is 90%, and its sensitivity is approximately 95% in acute brucellosis but only 50% in chronic brucellosis. (3) In most cases, BE requires cardiac surgery following the initiation of antibiotics. Conservative antibiotic treatment is not recommended and should be reserved for selected patients with uncomplicated forms. Only about 20 cases of cure of native valve BE with medical therapy alone have been reported. (4,5) Most clinicians suggest the use of a three to six month combination of rifampicin-cyclin with aminoglycoside for the first two to three weeks. (4,5)

V. Chanet, MD

F. Gourdon, MD

O. Baud, MD

J. Beytout, PD

J. P. Romaszko, MD

Infectious Diseases Department

Hotel-Dieu, University Hospital of Clermont-Ferrand

Clermont-Ferrand, France

References

1. Picciotto D, Verso MG, Lacca G, et al. The epidemiological trend of brucellosisin the provinces of Sicily. Med Lav 1999;90:786-790.

2. Castillo Dominguez JC, Anguita Sanchez M, Ramirez Moreno A, et al. Abscess of the mitral-aortic confluence and perforation of the mitral valve in a patient with Brucella endocarditis. Rev Esp Cardiol 1998;51:1002-1005.

3. Hadjinikolaou L, Triposkiadis F, Zairis M, et al. Successful management of Brucella mellitensis endocarditis with combined medical and surgical approach. Eur J Cardiothorac Surg 2001;19:806-810.

4. Cohen N, Golik A, Alon I, et al. Conservative treatment for Brucella endocarditis. Clin Cardiol 1997;20:291-294.

5. Alsoub H. Brucella infective endocarditis: a report of four successfully treated patients. Clin Microbiol Infect 2001;7:382-385.