J Med Cases

Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Med Cases and Elmer Press Inc

Journal website https://jmc.elmerpub.com

Case Report

Volume 17, Number 4, April 2026, pages 176-182

Successful Conservative Management of Complicated Brucella Endocarditis

Figure 1. Admission brain computed tomography without contrast obtained on admission showing a well-defined hypodense lesion in the right (arrow), consistent with an acute embolic ischemic infarction (a). Cerebral angiography showed occlusion of the right middle cerebral artery (b).

Figure 2. Mid-esophageal view transesophageal echocardiogram (TEE) demonstrates: (a) pedunculated vegetation (lower arrow, measured 3 × 6 mm) on the bioprosthetic aortic valve cusp, and paravalvular aortic-root abscess (upper arrow), indicating advanced infective endocarditis. (b) Doppler echocardiogram shows left ventricular outflow tract (LVOT) fistula to the abscess cavity.

Figure 3. Transesophageal echocardiography (TEE) shows destructive prosthetic aortic valve endocarditis with peri-annular extension: (a) large mobile vegetation attached to the bioprosthetic aortic valve cusps, (b) extension of infection to the aortic annulus with paravalvular aortic root abscess formation, (c) destruction of the mitral–aortic intervalvular fibrosa (MAIVF) (arrow), and (d) a sinus of Valsalva pseudoaneurysm (arrow).

**Table 1.** Clinical Timeline of Events for the Admitted Case Before and After BE Presentation
Timeline	Clinical events and findings	Management	CRP (mg/L)	Procalcitonin (ng/mL)	Brucella serology titers	Outcome
BE: Brucella endocarditis; CRP: C-reactive protein; CT: computed tomography; Echo: echocardiography; TMP-SMX: trimethoprim-sulfamethoxazole.
5 months prior	Intermittent fever, lower back pain. Blood culture: Brucella melitensis	Rifampicin + ciprofloxacin for 6 weeks.	6	-	1:320	Symptom resolution
2 months post-treatment (admission)	Recurrent fever, malaise, 10 kg weight loss, followed by acute left-sided hemiparesis.	Hospital admission, diagnostic workup.	12	0.20	1:40 → 1:160	Embolic stroke confirmed on CT.
During inpatient phase (weeks 1–8)	Diagnosis of BE with paravalvular abscess and spondylitis. Patient declined surgery.	Initiated quadruple therapy: rifampicin, doxycycline, gentamicin, TMP-SMX. Inpatient monitoring.	14 → 10 → 3.37	0.01 → 0.03	1:320	Fever and back pain resolved. Neurological improvement. Echo: vegetation and abscess regressing.
Post-discharge (months 3–9)	Outpatient follow-up. Gentamicin was discontinued after the initial phase.	Continued oral therapy: rifampicin, doxycycline, TMP-SMX. Bi-weekly clinical and lab follow-up.	1.7	0.05	1:80	Clinically stable, afebrile. Independent in daily activities.
6-month follow-up	Asymptomatic. No signs of heart failure or infection relapse.	Completion of a prolonged antimicrobial course. Final echocardiogram.	Normal	Normal	1:40 (baseline)	Complete resolution: No vegetation/abscess on echo. Preserved valve function. No relapse.

Table 1. Clinical Timeline of Events for the Admitted Case Before and After BE Presentation

Timeline

Clinical events and findings

Management

CRP (mg/L)

Procalcitonin (ng/mL)

Brucella serology titers

Outcome

BE: Brucella endocarditis; CRP: C-reactive protein; CT: computed tomography; Echo: echocardiography; TMP-SMX: trimethoprim-sulfamethoxazole.

5 months prior

Intermittent fever, lower back pain. Blood culture: Brucella melitensis

Rifampicin + ciprofloxacin for 6 weeks.

1:320

Symptom resolution

2 months post-treatment (admission)

Recurrent fever, malaise, 10 kg weight loss, followed by acute left-sided hemiparesis.

Hospital admission, diagnostic workup.

0.20

1:40 → 1:160

Embolic stroke confirmed on CT.

During inpatient phase (weeks 1–8)

Diagnosis of BE with paravalvular abscess and spondylitis. Patient declined surgery.

Initiated quadruple therapy: rifampicin, doxycycline, gentamicin, TMP-SMX. Inpatient monitoring.

14 → 10 → 3.37

0.01 → 0.03

1:320

Fever and back pain resolved. Neurological improvement. Echo: vegetation and abscess regressing.

Post-discharge (months 3–9)

Outpatient follow-up. Gentamicin was discontinued after the initial phase.

Continued oral therapy: rifampicin, doxycycline, TMP-SMX. Bi-weekly clinical and lab follow-up.

1.7

0.05

1:80

Clinically stable, afebrile. Independent in daily activities.

6-month follow-up

Asymptomatic. No signs of heart failure or infection relapse.

Completion of a prolonged antimicrobial course. Final echocardiogram.

Normal

1:40 (baseline)

Complete resolution: No vegetation/abscess on echo. Preserved valve function. No relapse.