Dehghan Manshadi Seyed Ali, Rezahosseini Omid, Abdi Liaei Zahra
Department of Infectious and Tropical Diseases, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran.
Acta Med Iran. 2016 Nov;54(11):750-753.
The 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.
一名有复合主动脉移植术（Bentall手术）病史且感染乙型肝炎的患者出现多器官受累的布鲁氏菌病较为罕见。一名35岁男性因发热和意识丧失前来就诊。四年前，他曾注射毒品并因心内膜炎接受心脏手术。最近被诊断为腰椎椎体骨髓炎。wright试验（1/320）和库姆斯wright试验（1/640）呈阳性。经中枢神经系统成像检查后，进行了腰椎穿刺。脑脊液细胞增多以淋巴细胞为主。心脏超声心动图显示人工主动脉瓣叶上有大量赘生物。脑部磁共振成像报告异常。布鲁氏菌病的治疗开始使用头孢曲松、多西环素、利福平和庆大霉素。4天后，他意识恢复，发热消退，随后我们继续治疗16天。患者出院，通过每日电话随访。在第五天出现腹痛和黄疸症状后，他再次入院。患者因肝肾和心脏功能不全死亡。药物副作用、乙型肝炎激活以及心脏赘生物栓塞到其他器官被怀疑是死亡原因。我们不建议在此类病例中不进行心脏手术而仅进行药物治疗。当HBsAg阳性患者的布鲁氏菌病需要联合治疗时，应通过HBV-DNA PCR评估肝炎病毒活性，并调整利福平和复方新诺明等已知有肝毒性作用药物的剂量。用喹诺酮类药物替代肝毒性药物进行联合治疗是我们的建议之一。
