A case of Brucella melitensis endocarditis in a patient with cardiovascular implantable electronic device

Wasl Al-Adsani, Ali Ahmad, Mohammad Al-Mousa Department of Internal Medicine, Mubarak Al-Kabeer Hospital, Jabriya, Kuwait Background: Brucellosis is a bacterial infection, caused by the nonmotile gram-negative aerobic coccobacilli. The clinical manifestation of brucellosis is variable, ranging from mild disease to severe disease. The gold standard test to confirm the diagnosis of brucellosis is assaying blood, bone marrow, or other body fluids or by tissue culture. Preferred first-line treatment in adults with uncomplicated, nonlocalized disease consists of doxycycline–aminoglycoside combination. The recommended duration of treatment is 6 weeks. Cardiovascular implantable electronic device (CIED) infection caused by brucellosis is rare and has been reported in a few case study series. We report a case of Brucella melitensis infection of CIED where, contrary to most authorities recommending removal of device, because of the patient’s multiple comorbid conditions and age, an attempt was made to keep the device and place the patient on lifelong prophylaxis treatment.Case report: A 70-year-old Kuwaiti male, with a background history of Type 2 diabetes mellitus, atrial fibrillation, hypertension, and sick sinus syndrome with a pacemaker fixed 1 year prior to his presentation, was diagnosed as having brucellosis. He was initially started on rifampicin and doxycycline. A transesophageal echo showed no evidence of vegetations seen at aortic valve or mitral valve. The two pacing leads, one in right atrium appendage and the other in right valve apex, looked smooth and clean with no clear adherence. Cotrimoxazole and gentamicin were added, per the 2015 European Society of Cardiology Guidelines for the management of infective endocarditis. The plan was to treat the patient with an aminoglycoside for the first 3 weeks, and then de-escalate to three drugs. The patient’s fever subsided for several days following treatment, and subsequent blood cultures showed sterilization of bloodstream. He developed an acute kidney injury from aminoglycosides, which required 2 months of inpatient dialysis treatment. He was later discharged after completing a total of 3 months of antibiotic treatment. At the time of discharge, the patient’s Brucella titer was <1:160. The patient was discharged with a 2-month supply of rifampin and doxycycline.Conclusion: In all published studies on Brucella infective endocarditis with a cardiovascular implantable device, the recommendation was for device removal and extended treatment with doxycycline combined with rifampin and/or trimethoprim–sulfamethoxazole, plus parenteral aminoglycosides for the first 3 weeks. There have been two cases in the literature that have studied CIED infected with brucellosis where an attempt was made to retain the device. In both cases, relapse occurred upon discontinuation of treatment. It is not clear whether lifelong antibiotic suppression treatment would prevent relapse. Keywords: brucellosis melitensis, CIED infection, ELISA, brucellosis endocarditis, Brucella melitensis endocarditi

Understanding the Jus Cogens Debate : The Pervasive Influence of Legal Positivism and Legal Idealism

Although, today, jus cogens is a recognized element of international law and international legal discourse alike, many issues of vital importance to a well-functioning jus cogens regime remain unsettled. The current debate centres on the following six questions: (1) What is the source of jus cogens obligations? (2) What is the role of consent in the creation and modification of jus cogens norms? (3) How do we identify norms belonging to this category? (4) What does the category comprise? Are there such things, for example, as regional jus cogens or jus cogens principles? Are jus cogens rules necessarily rules of conduct? (5) What are the function and effects of the international jus cogens regime? (6) What is the function of jus cogens in international legal discourse? Overall, the intense scholarly debate had on peremptory international law over the last ten to twenty years has not been terribly productive. One important reason for this would seem to be the general failure of discussants to fully understand the relevance of some basic assumptions that they bring to bear on their respective analysis and consideration of the topic. To facilitate future constructive debate, this essay aims to clarify the relevance for any thoughtful consideration of jus cogens issues of legal positivism and legal idealism. While legal positivism and legal idealism are sets of theories offered to explain the concept of law, it is not surprising that lawyers of different camps will have different answers to questions (1) and (2). As argued in this essay, however, the influence of different theoretical approaches to the concept of law goes further than this - it permeates the entire jus cogens debate. Consequently, depending on whether lawyers take the position of a legal positivist or a legal idealist, they will be inclined to answer differently all questions (1)-(6)