A 74-year-old male was admitted to the SSCS on June 29, 2007.
She had a morbid history of having undergone cystectomy and surgery for inguinal hernia.
He was married, retired and had worked, most of his life, in poultry breeding sites in rural areas of the Metropolitan Area.
Her clinical picture had started approximately three months earlier with moderate general malaise, evening fever and weight loss, which at that time quantified in ten kilos.
She sought medical care on an outpatient basis on several occasions and underwent several tests without reaching a diagnosis.
Abdominal ultrasound and computed axial tomography (CAT) showed "no significant findings" and a transthoracic echocardiogram showed mild aortic regurgitation with dilatation of left cavities.
She was referred to SSCS to complete the study.
On admission, the patient reported no specific discomfort and the physical examination did not contribute to guide the diagnosis.
He had no heart murmur, visceromegaly, skin or mucosal lesions, abnormal pulmonary examination or other systems.
Only irregular fever, around 38°C, and decay were found.
A study of prolonged febrile syndrome was initiated.
The complete blood count showed moderate anemia (hepatocyte count 3), hemoglobin 11.3 g, leukocytes in normal range, neutrophilia 76%) without left shift and ESR 36 mm/h.
Liver and kidney function were normal, decreased albumin (3.3 gr%), moderately elevated C-reactive protein and normal urine test.
The chest X-ray showed no abnormalities in the lung parenchyma or cardiac silhouette.
Spiritism nodules were observed in both abdominal ultrasound and abdominal CT performed during hospitalization.
A transesophageal echocardiogram was requested.
Due to the absence of expectoration, smears of gastric content were negative.
Urocultiva was also negative and hemocultives taken at admission showed no development.
As part of the study of a prolonged febrile syndrome, immunological tests were also requested: antinuclear antibodies, rheumatold factor eo, quantification of C3 and C4, anticardiolipin antibodies, all of which were normal.
Protein electrophoresis showed mild hypoalbuminemia and moderate diffuse hypergammaglobulinemia.
On the 11th day of hospitalization, subconjunctival petechiae appeared.
With this new finding on physical examination, the diagnostic hypothesis of infective endocarditis was raised and, after taking a new series of hemocultives, treatment with intravenous penicillin and gentamicin was started.
The patient remained stable in his condition, with irregular fever and subsequently a heart murmur was investigated.
On day 14, bacterial growth was detected in the hemocultives taken to the patient three days before.
In the first Gram stain performed directly from the culture vial, gram-positive cocci were visualized.
It was later clarified that these were gram-negative cocci and on the 17th day of admission a precondition of the Gram-negative bacillus was issued, probably accounting for the development of a gram-negative bacillus,
Due to the difficulty in reaching a microbiological diagnosis, the strain was sent to the ISP for identification.
The result of this test changed the antimicrobial scheme to ampicillin, gentamicin and ceftriaxone.
On the 22 day of hospitalization, a transesophageal echocardiogram was performed at the cardiology service of the Luco Trudeau Hospital.
This examination showed multiple vegetations in the aortic valve with formation of aneurysm and dilatation of the right coronary sinus, aortic insufficiency, left atrial dilatation with eccentric hypertrophy and mild systolic abscess.
This same day, he was admitted to the National Institute of Respiratory Diseases and Thoracic Surgery (INERYCT) for surgical treatment.
Upon admission to this care center, a patient who did not refer specific aortic discomfort, stable, he-modynamic, with no signs of heart failure, with heart murmur 4/6 was found.
At 48 hours, the patient worsened abruptly, presenting retrosternal pain, dyspnea, jugular engorgement, hypotension, shock and consciousness compromise.
She was admitted to the intensive care unit and the next day underwent emergency surgery.
During surgery, a bicuspid aortic valve was found with great destruction of the coronary leaflets and ring, with a cavity of 2 × 3 cm in relation to the left coronary sinus and large amount of vegetation.
A valve replacement was performed with Edwards Lifesciences prosthesis of 23 mm, and repair of the ring with bovine pericardial patch.
In the postoperative period, the patient remained very severe for four to five days, had to be re-operated for local bleeding, had acute renal failure, paroxysmal atrial fibrillation, received intravenous cefacillin for five days.
On the 33th day of hospitalization, the identification of the gram-negative bacillus isolated from blood cultures in SSCS was known; it was Brucella abortus.
At that time, the antimicrobial regimen was changed to the combination of rifampicin and gentamicin.
The culture of the surgical specimen was negative.
The patient was discharged in a torpid way but with a tendency to progressive improvement, so that, after 54 days of hospitalization, he was discharged in relative good conditions and with indication of continue antimicrobial treatment with doxi.
On the 88th day after admission, the patient was controlled by cardio-cirrhion and was in good general condition.
A control echocardiogram was requested and the antimicrobials were suspended.
Five months after discharge, the patient was evaluated in SSCS.
The patient was asymptomatic, in very good general condition, with no signs of heart failure.
He had tests obtained one month before: creatininemia: 1.01 mg/dL, albuminemia: 4.62 g/%, ESR: 15 mm/h, complete urine: normal and a recent blood count indicated a hematocrit of 36.500 g 9.
She was referred for follow-up with a cardiologist.
In subsequent controls at INERYCT, symptoms and signs of heart failure were investigated and echocardiogram showed reflux through the prosthetic valve.
