brucellosis with multi-organ involvement in a patient with history of composite aortic graft and hepatitis b

the brucellosis with multi-organ involvement in a patient with a history of the composite aortic graft ( bentall procedure) and hepatitis b infection is rare. a 35-year-old man presented to us with fever and loss of consciousness. four years ago, he was idu and underwent cardiac surgery because of endocarditis. recently lumbar spondylodiscitis was diagnosed. the wright (1/320) and coombs wright tests (1/640) were positive. after cns imaging, lumbar puncture was done. the csf pleocytosis was lymphocyte dominant. in cardiac echocardiography, large vegetation on prosthetic aortic valve leaflets was seen. the brain mri was reported abnormal. treatment of brucellosis started with ceftriaxone, doxycycline, rifampin and gentamycin. after 4 days, he became oriented, and fever was disappeared then we continued the treatment for 16 days. the patient discharged and followed by daily phone calls. as symptoms of abdominal pain and jaundice were presented on the fifth day, he re-admitted. the patient expired because of hepatorenal and cardiac insufficiency. drug side effects, activation of hepatitis b and embolism of cardiac vegetation to other organs were suspected causes of death. we do not suggest medical therapy without cardiac surgery in such cases. when combination therapy is necessary for brucellosis in an hbsag-positive patient, hepatitis virus activity should be assess by hbv-dna pcr and the dose of drugs with known hepatotoxic effects such as rifampin and co-trimoxazole should be adjust. combination therapy with quinolones instead of hepatoxic drugs is one of our suggustions.