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A farmer with artificial valve endocarditis
  1. H Alsoub,
  2. S S El-Shafie
  1. Hamad Medical Corporation, PO Box 3050, Doha, Qatar
  1. Dr Alsoub

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Answers on p 136.

A 29 year old Yemeni man, a farmer, with St Vincent aortic and mitral prosthesis replaced in April 1996, was admitted to hospital in February 1997 with a nine month history of intermittent fever, general weakness, and loss of appetite. Three months before admission he developed right sided hemiparesis for which he was admitted to another hospital. No details of that admission could be obtained, however he had significant improvement in his weakness. Physical examination on admission revealed: temperature 39oC, blood pressure 120/60 mm Hg, pulse 104 beats/min, an early diastolic murmur at the left sternal border, and mild right facial, right upper, and lower limb weakness. Laboratory investigations revealed the following: haemoglobin 99 g/l, white cell count 4.3 × 109/l, platelet count 288 × 109/l, erythrocyte sedimentation rate (ESR) 33 mm in the first hour, and brucella agglutination test and mercaptoethanol test were positive to titres of 1: 5120 and 1:2560 respectively. Liver and renal function tests were normal. A transoesophageal echocardiogram revealed small vegetation at the aortic prosthesis with moderate paravalvular leak, the mitral prosthesis was normal (fig 1). Six blood cultures grew Brucella melitensis. He was treated with oral doxycycline 100 mg twice daily, rifampin 450 mg twice daily, and intravenous co-trimoxazole 960 mg three times daily. Four days later he was taken for operation, two ring abscesses were found, they were drained, and the infected valve was replaced by a new one. Culture of specimenstaken during surgery yielded B melitensis. He had an uneventful postoperative course and was discharged two weeks later on oral doxycycline, rifampin, and co-trimoxazole, which he took for a total of 20 weeks.

Figure 1

Two dimensional echocardiogram, parasternal long axis view showing prosthetic aortic and mitral valves. Note the separation between the aortic wall and the prosthesis ring (arrow); LV = left ventricle; RV = right ventricle; LA = left atrium.

Questions

(1)
What are the most common organisms causing artificial valve endocarditis? What are other less common organisms should be considered?
(2)
How should the diagnosis be established?
(3)
What would be the best therapeutic approach?

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