Spinal cord compression due to Brucella granuloma

Case Report: Neurobrucellosis with Plastered Spinal Arachnoiditis: A Magnetic Resonance Imaging-Based Report

Diffuse spinal arachnoiditis in neurobrucellosis is a rare manifestation. We report a boy aged 17, presenting with hearing impairment and recurrent vomiting for 18 months, weight loss for 12 months, dysphagia, dysarthria, hypophonia for 6 months, and gait unsteadiness for 5 months. He had bilateral 5th (motor) to 12th cranial nerve palsy, wasting and weakness of limbs, fasciculations, absent tendon reflexes, and positive Babinski's sign. Cerebrospinal fluid (CSF) showed raised protein and pleocytosis. Magnetic resonance imaging (MRI) showed extensive enhancing exudates in cisterns and post-contrast enhancement of bilateral 5th, 6th, 7th, and 8th nerves. Spine showed clumping with contrast enhancement of the cauda equina roots and encasement of the cord with exudates. Serum and CSF were positive for anti-Brucella antibodies. He showed significant improvement with antibiotics. At 4 months follow-up, MRI demonstrated near complete resolution of cranial and spinal arachnoiditis. It is important to recognize such rare atypical presentations of neurobrucellosis.

ISOLATION AND CHARACTERIZATION OF A NOVEL MARINE BRUCELLA FROM A SOUTHERN SEA OTTER (ENHYDRA LUTRIS NEREIS), CALIFORNIA, USA

We characterize Brucella infection in a wild southern sea otter ( Enhydra lutris nereis) with osteolytic lesions similar to those reported in other marine mammals and humans. This otter stranded twice along the central California coast, US over a 1-yr period and was handled extensively at two wildlife rehabilitation facilities, undergoing multiple surgeries and months of postsurgical care. Ultimately the otter was euthanized due to severe, progressive neurologic disease. Necropsy and postmortem radiographs revealed chronic, severe osteoarthritis spanning the proximal interphalangeal joint of the left hind fifth digit. Numerous coccobacilli within the joint were strongly positive on Brucella immunohistochemical labelling, and Brucella sp. was isolated in pure culture from this lesion. Sparse Brucella-immunopositive bacteria were also observed in the cytoplasm of a pulmonary vascular monocyte, and multifocal granulomas were observed in the spinal cord and liver on histopathology. Findings from biochemical characterization, 16S ribosomal DNA, and bp26 gene sequencing of the bacterial isolate were identical to those from marine-origin brucellae isolated from cetaceans and phocids. Although omp2a gene sequencing revealed 100% homology with marine Brucella spp. infecting pinnipeds, whales, and humans, omp2b gene sequences were identical only to pinniped-origin isolates. Multilocus sequence typing classified the sea otter isolate as ST26, a sequence type previously associated only with cetaceans. Our data suggest that the sea otter Brucella strain represents a novel marine lineage that is distinct from both Brucella pinnipedialis and Brucella ceti. Prior reports document the zoonotic potential of the marine brucellae. Isolation of Brucella sp. from a stranded sea otter highlights the importance of wearing personal protective equipment when handling sea otters and other marine mammals as part of wildlife conservation and rehabilitation efforts.

Brucellar discitis as a cause of lumbar disc herniation: a case report

Brucellosis is an infectious disease spread by consumption of non-pasteurized milk products or through contact with infected animals. Spinal involvement is one of the most important complications and the lumbar area is the most frequently affected site. Among the neurological consequences, nerve root compression can be a result of epidural abscess, granuloma or discitis secondary to vertebral body involvement. In this case report we present a 50-year-old male patient with brucellar discitis without spondylitis which caused lumbar disc herniation. We want to emphasize that discitis should also be considered in differential diagnosis of nerve root compression in suspected cases.

Nonsurgically treated cervical brucellar epidural abscess causing spinal cord compression

Cervical spinal cord compression due to brucellar epidural abscess is extremely rare, with only 13 previously reported cases. We present another case of cervical spinal epidural abscess causing spinal cord compression. Diagnostic tools and treatment options are discussed.

Spinal brucellosis: Turkish experience based on 452 cases published during the last century

BACKGROUND

Spinal brucellosis continues to be the leading cause of morbidity from infectious disease in the infested regions of the world, particularly in the rural areas including Turkey. The purpose of this review was to present the Turkish experience by analyzing the literature on the management of spinal brucellosis during the last century.

MATERIALS AND METHOD

To establish new guidelines for the diagnosis and treatment of this disabling health problem, publications reported from Turkey in national (n = 27) and international (n = 37) journals during the last century and databases containing medical literature were analysed.

RESULTS

It was observed that the number of articles produced by Turkish authors regarding spinal brucellosis has tremendously increased throughout the study period. Although the total number of reported cases with spinal brucellosis from a total of 34 secondary or tertiary referral centers in Turkey was 452, only cases having detailed information were evaluated for further analysis according to inclusion/exclusion criteria. Despite the inherent limitations, this type of study clearly indicates that the incidence of brucellosis has not decreased in Turkey over recent years. The clinical and radiological findings of brucellosis involving the spine were mostly atypical and it was difficult to diagnose this infectious disease owing to its nonspecific and variable clinical picture. Therefore, it may easily lead to a misdiagnosis of lumbar disc herniation or other spinal infections and a high index of suspicion is required to diagnose this condition in endemic parts of the world. In addition to serological tests, CT and/or MRI techniques were found to be sensitive for diagnosis and follow-up because they provide early diagnosis of lesions involving the spine and more accurate localization of intraspinal and paraspinal infestation by means of multiplanar images. Histologically, noncaseating granulomatous tissue and chronic inflammation were characteristic features of cases of brucellosis with spinal involvement.

CONCLUSIONS

Based on this critical review of literature from Turkey, it is concluded that early diagnosis and correct management are important to prevent the harmful effects of brucellosis and its complications, and that the treatment of choice is antibiotic therapy alone in most cases of brucellosis involving the spine.

Spinal epidural abscess due to Brucella

BACKGROUND

Brucellar spinal epidural abscess (SEA) is a rarely encountered clinical entity during the course of the systemic Brucella infection.

METHODS

We reported 9 patients diagnosed with Brucellar SEA with a mean follow-up of 20 months. Spinal epidural abscess was detected by magnetic resonance imaging in all cases. Brucella diagnosis was established by specific blood tests. Patients were administered antibiotics for a duration of 6 to 12 weeks.

RESULTS

Spinal epidural abscess was localized in lumbar region in 6 patients, dorsal in 2 patients, and cervical in 1 patient. Abscess mimicked disk herniation clinically in 3 patients. Although neurologic examination was normal in 6 patients, we detected motor deficit in 3 patients. Symptoms regressed in all patients but 1 after the institution of antibiotic regimens, and all recovered fully without any sequel. Surgical drainage of abscess was performed in 1 patient.

CONCLUSIONS

Proper antibiotic regimens in required doses and duration should be the primary treatment in Brucellar SEA. The criteria for terminating antibiotic therapy are clinical recovery and dissolution of abscess images radiologically. Lastly, should any neurologic deterioration be detected during the course of medical treatment, surgical decompression is to be considered.

Neurobrucellosis as an exceptional cause of transient ischemic attacks

We report a series of four cases presented with transient ischemic attacks (TIA) or ischemic stroke as the predominant manifestation of neurobrucellosis (NB). Three of the patients were 20-28 years of age, and one patient was 53 years old. They all used to consume unpasteurized milk or its products. Two patients had systemic brucellosis in the past and received antibiotic treatment. Other causes of TIA including cardiac embolism, hypercoagulability, vascular malformations, systemic vasculitis, and infective endocarditis were excluded. NB was diagnosed with serological tests or cultures for Brucella in the cerebrospinal fluid. None of the patients had any further TIA after the initiation of specific treatment. NB should always be sought in young patients with TIA or ischemic stroke, especially if they have no risk factors for stroke and live in an endemic area for brucellosis, even if they do not have other systemic signs of brucellosis.

Spinal epidural abscess caused by brucellosis. Two case reports

Brucellosis is still an important public health problem in the Mediterranean countries, including Turkey, and is most probably underdiagnosed or underreported. Two rare cases of extradural brucellar granuloma causing spinal cord compression in the thoracic and cervical regions were identified by magnetic resonance imaging. The abscesses were totally excised surgically. Medical treatment was given immediately after diagnosis, but delayed neurosurgical intervention resulted in partial neurological recovery in one patient although the other showed complete neurological recovery. Abscess formation may cause myelopathy due to extradural compression of the spinal cord. Failure to correct this condition may cause irreversible impairment of motor functions. Magnetic resonance imaging should be performed periodically in patients with brucellosis and suspected vertebral involvement to monitor for epidural granuloma formation and prevent extradural cord compression.

Neurobrucellosis and a demonstration of its involvement in spinal roots via magnetic resonance imaging

OBJECTIVE

To present a neurobrucellosis case with spinal root involvement by means of magnetic resonance imaging (MRI).

METHODS

A case of neurobrucellosis resembling Guillain-Barré syndrome is being reported. This case is unique in a way that spinal root involvement because of brucellosis was for the first time confirmed by MRI.

SETTING

Spinal cord unit of a rehabilitation and care center in Ankara, Turkey.

RESULTS

The correct diagnosis was made with cerebrospinal fluid culture. The patient showed a significant improvement with antimicrobial therapy and rehabilitation.

CONCLUSION

Polyradiculopathy because of neurobrucellosis may mimic neurological syndromes. Rehabilitation should also be a part of its treatment.

Human neurobrucellosis with intracerebral granuloma caused by a marine mammal Brucella spp

We present the first report of community-acquired human infections with marine mammal-associated Brucella spp. and describe the identification of these strains in two patients with neurobrucellosis and intracerebral granulomas. The identification of these isolates as marine mammal strains was based on omp2a sequence and amplification of the region flanking bp26.

Liposarcoma in the epidural space

STUDY DESIGN

A patient with myxoid liposarcoma in the lumbar epidural space is reported.

OBJECTIVE

The subject was treated with marginal resection and posterior instrumentation.

SUMMARY OF THE BACKGROUND DATA

Liposarcoma is a malignant tumor of the soft tissues. It is commonly seen in the thigh. Lumbar extradural space is an unusual localization. Two cases have been reported with this localization in the literature.

METHODS

The authors have treated a female patient with myxoid liposarcoma in lumbar extradural space with marginal resection and posterior instrumentation.

RESULTS

The histopathologic examination showed myxoid liposarcoma. Two cases have been reported in the literature.

CONCLUSION

Myxoid liposarcoma is a malignant tumor of the soft tissues. The extradural tumor was probably originated from the epidural fat tissue. Although wide resection is advised in the thigh localization, extradural localization of the tumor can be treated with marginal resection if there is no invasion to the surrounding tissue.

Medically treated intraspinal "Brucella" granuloma

BACKGROUND

Although there have been reports of Brucella granuloma or abscess in the literature, they were all localized extradurally except one, and most patients underwent surgery.

CASE REPORT

A 40-year-old female presented with urinary and fecal incontinence and a two-month history of progressive weakness of the right leg and numbness of the left leg. Four months previously, she had been diagnosed with systemic brucellosis with a period of radiculomeningoencephalitis; she was treated successfully with rifampicin, doxycycline, trimethoprim/sulfamethoxazole (TMP/SMZ), and streptomycin, and was discharged symptom-free on rifampicin and doxycycline. Neurological examination revealed spastic paraparesis, globally hyperactive deep tendon reflexes (DTRs) and sensory level at T6. Magnetic resonance imaging (MRI) of the spinal cord revealed a 10 x 30 mm intradural-intramedullary mass lesion at the T5 level with surrounding edema that enhanced with contrast. The cerebrospinal fluid (CSF) was xanthochromic with lymphocytic pleocytosis and elevated levels of albumin, immunoglobulins, and antibody titers for Brucella. The medications were modified to rifampicin 1200 mg, doxycycline 400 mg, and TMP/SMZ 480/2400 mg daily, and methylprednisolone 100 mg in decremental doses (for 6 weeks). After 2 months, the patient was almost symptom-free and her medication doses were decreased. After 5 months, the mass lesion resolved almost completely. The treatment was discontinued after 2 years.

CONCLUSIONS

The case is presented because of its uniqueness. In cases of Brucella granuloma, the authors recommend a trial of medical treatment with adequate dosages for a reasonable length of time before considering surgical intervention.

Central nervous system brucellosis: presentation, diagnosis and treatment

Although neurological symptoms in brucellosis are frequent, central nervous system (CNS) involvement is uncommon. Five patients with neurobrucellosis are presented. Three patients presented with meningoencephalitis, one with polyradiculoneuritis and one with myelitis and an eighth nerve palsy. All patients had lymphocytic pleocytosis, low glucose and elevated levels of protein in the cerebrospinal fluid (CSF). Gamma-globulin and IgG values in the CSF were also increased. Results of agglutination tests for Brucella in serum and CSF were positive for all patients, although titres were less in the CSF. Brucella melitensis was cultured from two patients. Treatment included concurrent administration of three of the following drugs: doxycycline, rifampicin, streptomycin, co-trimoxazole, ceftriaxone or ciprofloxacin. The three patients with meningoencephalitis fully recovered; the other two patients were left with minor disability.

Lumbar spinal root compression caused by Brucella granuloma

STUDY DESIGN

A case report of rarely seen extradural brucellosis granuloma causing spinal root compression in the lumbar region.

OBJECTIVE

To point out the possibility of extradural compression caused by brucellosis.

SUMMARY OF BACKGROUND DATA

Many investigators have indicated that myelopathy or radiculopathy caused by irritation or compression by tiny abscess, disc herniation, or extradural granuloma may occur in brucellosis. Failure to make the correct diagnosis is possible because of the absence of such symptoms of brucellosis as fever, sweating, or fatigue and because findings of physical examination, radiography, and myelography indicate intervertebral disc herniation.

METHODS

Review and discussion of the case history are presented.

RESULTS

Brucella granuloma compressing the right L5 root and dural sac was diagnosed on computed tomographic scans and was excised subtotally after laminectomy and facetectomy.

CONCLUSION

The possibility of extradural compression caused by brucellosis should be considered in endemic areas and must be differentiated from an intervertebral disc herniation by means of agglutination testing and bone scan.

Clinical course and prognosis of Brucella spondylitis

A multicentre prospective study of 593 patients with brucellosis, of whom 58 (9.7%) had spondylitis, was performed in order to evaluate the possible clinical, radiological and evolutionary differences in the different segments of the spinal column. Five of the patients with cervical spondylitis (71%) had compression of the medulla or roots, versus just two (11%) in the dorsal group and nine (21%) in the lumbar group (p less than 0.05). There were no other clinical, haematological or biochemical differences between the three spinal segments, and both the serological response and the percentage of positive blood cultures were also similar in the three groups. The patients with cervical and dorsal spondylitis had a significantly higher number of paravertebral and/or epidural masses than those with lumbar spondylitis (p less than 0.05). Seventy-one percent of the patients with cervical spondylitis made unsatisfactory progress, versus 11% and 5% of those in the dorsal and lumbar groups, respectively (p less than 0.05 and p less than 0.001). In conclusion, given the high incidence of paravertebral and/or epidural masses, the neurological involvement, and the high rate of important functional disabilities, cervical spondylitis should be considered to be a very severe complication of brucellosis, and its treatment and follow-up must therefore be energetic and rigorous in order to detect and correct as early as possible compressions of the neural axis and its roots.

Brain abscess caused by Brucella abortus and Staphylococcus aureus in a child

A case of a 12-year-old male with Fallot's tetralogy and brain abscess due to Brucella and Staphylococcus is presented. The abscess was aspirated and Brucella abortus and Staphylococcus aureus were isolated.