Triad of infective endocarditis, splenic abscess, and septicemia caused by Brucella melitensis.

A 40-year-old farmer from the district of North Karnataka who had received treatment for high fever of 8 days duration was admitted with fever, dyspnea, and poor general condition. Ultrasonography and echocardiogram revealed multiple splenic abscesses, vegetation on atrioventricular valve, aortic regurgitation (Grade I-II), and mitral valve regurgitation (Grade II-III), respectively. Brucella melitensis was detected in blood culture, and high titers of IgM and IgG anti-Brucella antibodies were observed in Brucella specific serological tests. The patient developed fulminant septicemia and succumbed due to multi-organ failure.

Utility of Serological Tests in the Era of Molecular Testing for Diagnosis of Human Brucellosis in Endemic Area with Limited Resources.

BACKGROUND: The culture has always been the gold standard test for diagnosis of human brucellosis but the conventional Brucella diagnostic tests viz. serology and culture are often beset with poor specificity & sensitivity respectively. The culture positivity rates for Brucella vary from 92% for bone marrow to 10% for non-blood samples and also dependent on the type of sample. The primary immune-determinant for Brucella species is the cell wall surface lipopolysaccharide, which is antigenically similar to other gram-negative rods. Hence, Brucella serological tests cross react with Escherichia coli 0116 and 0157, Salmonella urbana, Yersinia enterocolitica 0:9, Vibrio cholerae, Xanthomonas maltophilia and Afipia clevellandensis infections, which are common in developing countries also having higher incidence of brucellosis. AIM: The aim of the study was evaluation of conventional serological techniques and PCR for diagnosis of human brucellosis in and around north Karnataka which is endemic for brucellosis and patients often present with elevated base line antibody titers and confounding clinical manifestations. MATERIALS AND METHODS: Blood/serum samples of 400 patients suffering from acute undifferentiated fever (AUF) were subjected to culture, Brucella slide agglutination test (SAT), standard tube agglutination test (STAT coupled with 2 ME) and PCR. RESULTS: Of the 400 AUF patients, anti-Brucella antibodies were detected by SAT and STAT in serum of 35 and 34 patients respectively. IS711 gene for Brucella was identified in 32 patients by PCR. Twenty samples yielded Brucella in culture on biphasic medium with average incubation period of 9 days. All patients having titer of ≥ 160IU / ml in STAT were found positive by PCR also. CONCLUSION: Brucella STAT corroborated well with PCR results in all those cases where antibodies were present at least one dilution above cut-off value of 80 IU/ml. We probably need to raise cut-off titers to ≥160 IU/ml because of endemic region. The SAT was upheld as very good quick, easy to perform and economical screening test for human brucellosis. SAT as rapid screening test and STAT as more definitive test can be very well adopted by laboratories working in resource scarce settings for diagnosis of human brucellosis in absence of PCR even for population with normally elevated antibodies levels due to residing in Brucella endemic areas.