Infected aneurysms are a challenging clinical problem and associated with significant morbidity and mortality. An unfamiliar cause of these infections is brucellosis. Although cardiovascular complications in human brucellosis comprise only 3%, they are the principal cause of mortality. Endocarditis covers the majority of these cases. Other clinical presentations, such as infected aneurysms and ulcerative processes of the aorta, can be life-threatening as well. However, limited information is available about aorto-iliac involvement in brucellosis. This review aimed to give an overview of current literature, including possible pitfalls and treatment outcomes.

A PubMed, Web of Science and AccessMedicine search (without restriction on language or year of publication) was performed to identify relevant articles on aorto-iliac involvement in brucellosis. Case reports were eligible for inclusion if they reported on thoracic, abdominal or iliac aorta pathology caused by Brucella. Different types of manifestations, such as infected (pseudo-)aneurysms, dissections, abscesses or ulcerative processes were included.

In total, 71 cases were identified in the last 70 years, with an overall mortality rate of 22%. Most of the patients were male (86%) and had a relevant history of Brucella exposure (66%). The geographical distribution of patients was spread across the globe, but mainly centered in Mediterranean countries (figure 1). Approximately one-fourth (23%) contracted Brucella while travelling in an (hyper)endemic region. Almost half of the infections were located in the abdominal aorta (49%), followed by the ascending (37%) and descending (13%) thoracic aorta. Infected aneurysms (61%) and ulcerative processes (16%) were most frequently seen. An aortic rupture was present in 31% of cases, and occurred mainly in the abdominal (49%) and descending thoracic aorta (44%). The majority of all patients (59%) underwent open surgery combined with long-term antibiotics. In the last fifteen years, a trend towards endovascular treatment was observed (figure 2).

Although aortic and iliac involvement in brucellosis is rare, it can be a life-threatening manifestation. The primary surgeon should be particularly vigilant in patients originating or travelling from hyperendemic regions. Also patients consuming unpasteurized products or working on (cattle) farms have increased risks of contracting brucellar infection. The therapeutic cornerstone in these cases remains open surgery combined with antibiotics. The role of endovascular treatment is yet to be decided, in which the condition of the patient and the risks of long-term complications need to be considered. Due to low awareness and limited resources in developing countries, aortic and iliac involvement in brucellosis possibly represents an underreported disease.