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Case Report
Open Access Peer-reviewed

Isolated Acute Pericarditis Revealing Brucellosis

Houcine Mrad, Wided Besleï, Warda Mahdhaoui, Salem Bouomrani
American Journal of Medical Case Reports. 2021, 9(12), 675-677. DOI: 10.12691/ajmcr-9-12-3
Received July 12, 2021; Revised August 17, 2021; Accepted August 26, 2021

Abstract

Cardiac complications of brucellosis are extremely rare with an overall frequency estimated at less than 1%. They are dominated by endocarditis and myocarditis, while pericarditis remains exceptional and unusual with only few sporadic cases in the world literature. Brucella pericarditis is exceptionally isolated. It is often associated with the involvement of other cardiac tunics (endocarditis and/or myocarditis) or is part of a complex cardiac involvement (brucella pancarditis). This clinical presentation of brucellosis is a real diagnostic challenge for clinicians. We report an original case of acute pericarditis as the first and only manifestation revealing septicemic brucellosis in 27-year-old Tunisian woman.

1. Introduction

Brucellosis is an anthropozoonosis still endemic in several countries around the world, representing a real public health problem 1. It is characterized by a great clinical polymorphism, hence its qualification of "disease with a hundred faces" 2. Unusual manifestations of brucellosis, the overall frequency of which does not exceed 5%, include myocarditis, peritonitis, neurobrucellosis, pericarditis, uveitis, orchitis, epididymitis, pancytopenia, and vasculitis 2, 3, 4, 5, 6.

Brucella pericarditis, first reported in French literature in 1982 7 and in English literature in 1985 8, remains an exceptional and poorly understood manifestation of this infection with only few sporadic cases in the world literature 9, 10, 11, 12.

We report an original case of acute pericarditis as the first and only clinical presentation revealing septicemic brucellosis.

2. Case Presentation

27-year-old Tunisian woman, with no medical history, was admitted in our department for chest pain associated with progressive dyspnea, palpitations, and vesperal fever evolving for one month.

The somatic examination noted a fever at 38.5°C, tachycardia at 110/min with a regular rhythm, and muffled heart sounds. The electrocardiogram confirmed the sinus tachycardia without other anomalies. The chest X-ray showed cardiomegaly without pulmonary parenchymal lesions (Figure 1).

Baseline biology showed marked biological inflammatory syndrome with erythrocyte sedimentation rate at 120mm/H1, C-reactive protein at 62mg/l, and polyclonal hypergammaglobulinemia at 21g/l, hyperleukocytosis at 14,500/mm3 with 80% of neutrophils, and moderate normochromic normocytic anemia with hemoglobin at 10.8g/dl.

The other laboratory tests were without abnormalities: platelets, creatinine, serum calcium, plasma ionogram, blood glucose, uric acid, transaminases, lipid parameters, muscle enzymes, thyroid hormones, and urinalysis.

Transthoracic cardiac ultrasonography (Figure 2) as well as thoracic CT (Figure 3) confirmed the moderate and circumferential pericardial effusion, without other cardiac or pulmonary injuries. The abdomino-pelvic CT-scan was normal.

The etiological investigation of this pericarditis concluded in acute septicemic brucellosis: blood cultures were positive for Brucella melitensis and Wright's serodiagnosis was positive at 1/640. The other specific investigations were negative ruling out connective tissue disease, hematologic malignancies, cancer, granulomatosis, systemic vasculitis, and tuberculosis.

Thus, the diagnosis was that of isolated acute pericarditis complicating septicemic brucellosis and antibiotic therapy combining doxycycline (200 mg/j) and Rifampicin (600 mg/j) was stared. The outcome was favorable with a rapid regression of clinical complaints and apyrexia from the second day, normalization of the white blood cells count and of the C-reactive protein in the second week, complete disappearance of the biological inflammatory syndrome after two months, and a normal cardiac ultrasound at three months. No recurrence has been noted for seven months.

3. Discussion

Cardiac complications of brucellosis are extremely rare. Their overall frequency is estimated at less than 1% 9, 12, but they represent the main cause of specific mortality from the disease 9, 13. Indeed, in the large Turkish series of 1080 cases of brucellosis, cardiac involvement was noted only in seven patients (0.7%) 14. These manifestations include myocarditis, pericarditis and endocarditis 9, 15, 16; While endocarditis is the most frequent cardiac presentation of brucellosis 9, 15, pericarditis is rare and unusual during this anthropozoonosis 3 with only a few sporadic cases 8, 9, 10, 12, 13, 16, 17, 18. Indeed, only two cases of acute pericarditis were noted in the two Turkish series of 240 cases of brucellosis of Hatipoglu CA et al (0.83%) 3, and of 283 cases of brucellosis of Gür A et al (0.70%) 18.

Likewise, brucellosis remains an unusual and often unrecognized etiology of acute pericarditis 17.

Brucella pericarditis is exceptionally isolated 9, 10, 11, 12; only one case of isolated pericarditis was noted in the Spanish series of 530 acute brucellosis of Colmenero JD et al 19. It is often associated with the involvement of other cardiac tunics (endocarditis and/or myocarditis) 9, 11, 18, or is part of a complex cardiac involvement (brucella pancarditis) with fatal outcome as reported in the case of Chevalier P et al 16.

Pericarditis may, as in our observation, be the first and only manifestation of brucellosis representing a real diagnostic challenge for clinicians even in endemic areas 17.

Pericardial effusion during brucellosis is typically minimal to moderate 8, 13, 17; important effusion and tamponade are exceptional 20. It is classically a banal serofibrinous effusion; more rarely it may be fibrinohemorrhagic pericarditis 16.

Clinically, brucellar pericarditis can present as chest pain of varying intensity which can sometimes mimic ischemic heart disease, with or without dyspnea 9, 10, as it can remain totally asymptomatic and would be discovered incidentally on ultrasound or CT-scan 10, 13, 17.

The outcome of brucellar pericarditis is usually favorable under appropriate antibiotic therapy combining doxycyline and rifampicin 6, 12. Pericardiocentesis is required only in case of tamponade 8, 12, 20. Exceptional cases of recurrence have been reported 12, as have cases of secondary constriction (constrictive pericarditis) 21.

The exact mechanism of brucella pericarditis is not yet well understood. Pericardial involvement can result of a direct effect of the bacteria as suggested by positive culture of brucella melitensis from pericardial effusion in the two cases of Karagiannis S et al 20, or can be of dysimmune origin (immunological disorder reacting to bacterial infection) as evidenced by the demonstration of local deposits of circulating immune complexes in cardiac biopsies 12.

4. Conclusion

As rare as it is, this unusual and often forgotten clinical presentation of brucellosis deserves to be known by any healthcare professional.

Our observation is distinguished by the isolated and revealing character of the brucella pericarditis.

Thus, screening for brucellosis may be useful for any unproven acute pericarditis occurring in endemic countries.

References

[1]  Franco MP, Mulder M, Gilman RH, Smits HL. Human brucellosis. Lancet Infect Dis. 2007; 7(12): 775-86.
In article      View Article
 
[2]  Türksoy Ö, Tokgöz H, Toparli S. Unusual clinical presentations of brucellosis. Scand J Infect Dis. 2005; 37(10): 784-784.
In article      View Article  PubMed
 
[3]  Hatipoglu CA, Yetkin A, Ertem GT, Tulek N. Unusual clinical presentations of brucellosis. Scand J Infect Dis. 2004; 36(9): 694-7.
In article      View Article  PubMed
 
[4]  Bouomrani S, Belgacem N, Ben Hamad M, Regaïeg N, Baïli H, Lassoued N, et al. Bilateral Panuveitis Revealing Acute Septicemic Brucellosis. EC Ophthalmology. 2018; 9: 6.
In article      
 
[5]  Bouomrani S, Dey M, Ahmed A. Acute Renal Failure Complicating Septicemic Brucellosis. J Pathol Infect Dis. 2019; 2(2):1-2.
In article      View Article
 
[6]  Bouomrani S, Mrad H, Ben Teber S. Cutaneous leuckocytoclastic vasculitis revealing acute brucellosis. American Journal of Medical Case Reports. 2021; 6(9):335-338.
In article      
 
[7]  Cuisinier Y, Blanc P, Doumeix JJ, Virot P, Chabanier A, Delhoume B, et al. Pericarditis in brucellosis. Nouv Presse Med. 1982; 11(45): 3352-3.
In article      
 
[8]  Ugartemendía MC, Curós-Abadal A, Pujol-Rakosnik M, Pujadas-Capmany R, Escrivá-Montserrat E, Jané-Pesquer J. Brucella melitensis pericarditis. Am Heart J. 1985; 109(5 Pt 1):1108.
In article      View Article
 
[9]  Zorlu G, Uyar S, Ozer H, Esin M, Kir S, Tokuc A, et al. A Case of Brucellosis with a Rare Complication: Pericarditis. Eur J Case Rep Intern Med. 2017; 4(1): 000471.
In article      View Article  PubMed
 
[10]  Sabzi F, Faraji R. Brucella pericarditis: A forgotten cause of chest pain. Caspian J Intern Med. 2017; 8(2): 116-118.
In article      
 
[11]  Andriopoulos P, Tsironi M, Deftereos S, Aessopos A, Assimakopoulos G. Acute brucellosis: presentation, diagnosis, and treatment of 144 cases. Int J Infect Dis. 2007; 11: 52-7.
In article      View Article  PubMed
 
[12]  Kaya S, Eskazan AE, Elaldi N. Brucellar pericarditis: a report of four cases and review of the literature. Int J Infect Dis. 2013; 17(6): e428-32.
In article      View Article  PubMed
 
[13]  Pedro FL, Franchini FP, Wildner LM. Brucellosis presenting with pericarditis: case report and literature review. Case Rep Infect Dis. 2013; 2013: 796437.
In article      View Article  PubMed
 
[14]  Buzgan T, Karahocagil MK, Irmak H, Baran AI, Karsen H, Evirgen O, et al. Clinical manifestations and complications in 1028 cases of brucellosis: a retrospective evaluation and review of the literature. Int J Infect Dis. 2010; 14(6): e469-78.
In article      View Article  PubMed
 
[15]  Shetty RK, Madken M, Naha K, Vivek G. Successful management of native-valve Brucella endocarditis with medical therapy alone. BMJ Case Rep. 2013: 2013.
In article      View Article  PubMed
 
[16]  Chevalier P, Bonnefoy E, Kirkorian G, Touboul P. Brucella pancarditis with fatal outcome. Presse Med. 1996; 25(13): 628-30.
In article      
 
[17]  Anguita M, Díaz V, Bueno G, López-Granados A, Vivancos R, Mesa D, et al. Brucellar pericarditis: 2 different forms of presentation for an unusual etiology. Rev Esp Cardiol. 1991; 44(7): 482-4.
In article      
 
[18]  Gür A, Geyik MF, Dikici B, Nas K, Cevik R, Sarac J, et al. Complications of brucellosis in different age groups: a study of 283 cases in southeastern Anatolia of Turkey. Yonsei Med J. 2003; 44: 33-44.
In article      View Article  PubMed
 
[19]  Colmenero JD, Reguera JM, Martos F, Sa´nchez-De-Mora D, Delgado M, Causse M, et al. Complications associated with Brucella melitensis infections: a study of 530 cases. Medicine (Baltimore) 1996; 75: 195-211.
In article      View Article  PubMed
 
[20]  Karagiannis S, Mavrogiannaki A, Chrissos D, Papatheodoridis GV. Cardiac tamponade in Brucella infection. Hell J Cardiol 2003; 44: 222-5.
In article      
 
[21]  Malikova MS, Dombrovskaia AV, Shapieva AN, Fedorov DN, Aksiuk MA. The constrictive pericarditis of the brucellar etiology. Khirurgiia (Mosk). 2012; (10): 52-3.
In article      
 

Published with license by Science and Education Publishing, Copyright © 2021 Houcine Mrad, Wided Besleï, Warda Mahdhaoui and Salem Bouomrani

Creative CommonsThis work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/

Cite this article:

Normal Style
Houcine Mrad, Wided Besleï, Warda Mahdhaoui, Salem Bouomrani. Isolated Acute Pericarditis Revealing Brucellosis. American Journal of Medical Case Reports. Vol. 9, No. 12, 2021, pp 675-677. http://pubs.sciepub.com/ajmcr/9/12/3
MLA Style
Mrad, Houcine, et al. "Isolated Acute Pericarditis Revealing Brucellosis." American Journal of Medical Case Reports 9.12 (2021): 675-677.
APA Style
Mrad, H. , Besleï, W. , Mahdhaoui, W. , & Bouomrani, S. (2021). Isolated Acute Pericarditis Revealing Brucellosis. American Journal of Medical Case Reports, 9(12), 675-677.
Chicago Style
Mrad, Houcine, Wided Besleï, Warda Mahdhaoui, and Salem Bouomrani. "Isolated Acute Pericarditis Revealing Brucellosis." American Journal of Medical Case Reports 9, no. 12 (2021): 675-677.
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  • Figure 3. Chest CT-scan, coronal section, without (A) and with (B) contrast injection: circumferential pericardial effusion (arrows)
[1]  Franco MP, Mulder M, Gilman RH, Smits HL. Human brucellosis. Lancet Infect Dis. 2007; 7(12): 775-86.
In article      View Article
 
[2]  Türksoy Ö, Tokgöz H, Toparli S. Unusual clinical presentations of brucellosis. Scand J Infect Dis. 2005; 37(10): 784-784.
In article      View Article  PubMed
 
[3]  Hatipoglu CA, Yetkin A, Ertem GT, Tulek N. Unusual clinical presentations of brucellosis. Scand J Infect Dis. 2004; 36(9): 694-7.
In article      View Article  PubMed
 
[4]  Bouomrani S, Belgacem N, Ben Hamad M, Regaïeg N, Baïli H, Lassoued N, et al. Bilateral Panuveitis Revealing Acute Septicemic Brucellosis. EC Ophthalmology. 2018; 9: 6.
In article      
 
[5]  Bouomrani S, Dey M, Ahmed A. Acute Renal Failure Complicating Septicemic Brucellosis. J Pathol Infect Dis. 2019; 2(2):1-2.
In article      View Article
 
[6]  Bouomrani S, Mrad H, Ben Teber S. Cutaneous leuckocytoclastic vasculitis revealing acute brucellosis. American Journal of Medical Case Reports. 2021; 6(9):335-338.
In article      
 
[7]  Cuisinier Y, Blanc P, Doumeix JJ, Virot P, Chabanier A, Delhoume B, et al. Pericarditis in brucellosis. Nouv Presse Med. 1982; 11(45): 3352-3.
In article      
 
[8]  Ugartemendía MC, Curós-Abadal A, Pujol-Rakosnik M, Pujadas-Capmany R, Escrivá-Montserrat E, Jané-Pesquer J. Brucella melitensis pericarditis. Am Heart J. 1985; 109(5 Pt 1):1108.
In article      View Article
 
[9]  Zorlu G, Uyar S, Ozer H, Esin M, Kir S, Tokuc A, et al. A Case of Brucellosis with a Rare Complication: Pericarditis. Eur J Case Rep Intern Med. 2017; 4(1): 000471.
In article      View Article  PubMed
 
[10]  Sabzi F, Faraji R. Brucella pericarditis: A forgotten cause of chest pain. Caspian J Intern Med. 2017; 8(2): 116-118.
In article      
 
[11]  Andriopoulos P, Tsironi M, Deftereos S, Aessopos A, Assimakopoulos G. Acute brucellosis: presentation, diagnosis, and treatment of 144 cases. Int J Infect Dis. 2007; 11: 52-7.
In article      View Article  PubMed
 
[12]  Kaya S, Eskazan AE, Elaldi N. Brucellar pericarditis: a report of four cases and review of the literature. Int J Infect Dis. 2013; 17(6): e428-32.
In article      View Article  PubMed
 
[13]  Pedro FL, Franchini FP, Wildner LM. Brucellosis presenting with pericarditis: case report and literature review. Case Rep Infect Dis. 2013; 2013: 796437.
In article      View Article  PubMed
 
[14]  Buzgan T, Karahocagil MK, Irmak H, Baran AI, Karsen H, Evirgen O, et al. Clinical manifestations and complications in 1028 cases of brucellosis: a retrospective evaluation and review of the literature. Int J Infect Dis. 2010; 14(6): e469-78.
In article      View Article  PubMed
 
[15]  Shetty RK, Madken M, Naha K, Vivek G. Successful management of native-valve Brucella endocarditis with medical therapy alone. BMJ Case Rep. 2013: 2013.
In article      View Article  PubMed
 
[16]  Chevalier P, Bonnefoy E, Kirkorian G, Touboul P. Brucella pancarditis with fatal outcome. Presse Med. 1996; 25(13): 628-30.
In article      
 
[17]  Anguita M, Díaz V, Bueno G, López-Granados A, Vivancos R, Mesa D, et al. Brucellar pericarditis: 2 different forms of presentation for an unusual etiology. Rev Esp Cardiol. 1991; 44(7): 482-4.
In article      
 
[18]  Gür A, Geyik MF, Dikici B, Nas K, Cevik R, Sarac J, et al. Complications of brucellosis in different age groups: a study of 283 cases in southeastern Anatolia of Turkey. Yonsei Med J. 2003; 44: 33-44.
In article      View Article  PubMed
 
[19]  Colmenero JD, Reguera JM, Martos F, Sa´nchez-De-Mora D, Delgado M, Causse M, et al. Complications associated with Brucella melitensis infections: a study of 530 cases. Medicine (Baltimore) 1996; 75: 195-211.
In article      View Article  PubMed
 
[20]  Karagiannis S, Mavrogiannaki A, Chrissos D, Papatheodoridis GV. Cardiac tamponade in Brucella infection. Hell J Cardiol 2003; 44: 222-5.
In article      
 
[21]  Malikova MS, Dombrovskaia AV, Shapieva AN, Fedorov DN, Aksiuk MA. The constrictive pericarditis of the brucellar etiology. Khirurgiia (Mosk). 2012; (10): 52-3.
In article