Paraplegia associated with brucellosis involving the anterior lumbrosacral nerve roots

Acute Brucellosis with a Guillain-Barre Syndrome-Like Presentation: A Case Report and Literature Review

INTRODUCTION

Brucellosis is a zoonotic disease that can affect the central and peripheral nervous system and it has variable neurological manifestation. However, brucellosis infection that presents with acute peripheral neuropathy mimicking Guillain-Barre syndrome (GBS) is rarely reported in the literature.

OBJECTIVE AND METHOD

We report a 56-year-old man who was initially diagnosed with GBS, and then he was confirmed to have acute Brucella infection. We also did a systematic literature review to study the natural history and management of previously reported cases of brucellosis that presented with manifestations consistent with GBS.

RESULTS

We found 19 (including our patient) cases of brucellosis that presented with GBS-like manifestations. The age range was 9-62 years. Eight (42.1%) patients had a history of fever. Seven (36.8%) patients had no constitutional symptoms. Five (26.3%) patients had splenomegaly. Brucella serological tests were positive in all patients, while blood Brucella culture was positive in three (37.5%) out of eight patients. Albuminocytological dissociation was present in nine (64.3%) out of 14 patients. Nerve conduction studies and electromyography were consistent with demyelination polyneuropathy in eight (42.1%) patients, with axonal polyneuropathy in six (31.6) patients, and with mixed axonal and demyelinating polyneuropathy in one (5.3%) patient. Spine MRI showed root enhancement in three (42.9%) patients.

CONCLUSION

In regions endemic with brucellosis, acute peripheral neuropathy presentation may warrant investigations for Brucella infection.

Guillain-barré syndrome during active brucellosis

It has been reported that approximately two thirds of patients diagnosed with Guillain-Barré syndrome (GBS) have had a prodromal illness within a four-week period preceding the onset of GBS. This prodromal illness is most commonly an upper respiratory tract illness or, secondly, gastroenteritis. However, specific infectious agents, such as mycoplasma, cytomegalovirus, Ebstein-Barr virus, vaccinia, variola, campylobacter, varicella-zoster, measles, mumps, hepatitis A and B viruses, rubella, influenza A and B viruses, coxackie and echoviruses, have also been reported to be certain or probable etiologic antecedent agents of GBS. In contrast, GBS during active brucellosis has rarely been reported. This article presents the case of a 28 year-old male patient with GBS during active brucellosis who responded fully to treatment directed to brucellosis. and it is stressed that brucellosis should be considered as a probable etiologic agent in patients with GBS who live in areas where brucellosis is endemic.

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.

Brucella melitensis infection associated with Guillain-Barré syndrome through molecular mimicry of host structures

Brucella melitensis is a facultative intracellular bacterium that can survive inside macrophages and the causative agent of brucellosis. In the present study, we found that a lipooligosaccharide of B. melitensis has a GM1 ganglioside-like structure and shows a strong antibody response in mice. The cholera toxin B subunit, which binds to GM1 ganglioside specifically, reacted with the surface of B. melitensis. Immunization with B. melitensis induced the production of anti-GM1 ganglioside antibodies in mice and serum from immunized mice showed a cross-reaction with Guillain-Barré syndrome (GBS)-associated Campylobacter jejuni, but not non-GBS-associated C. jejuni. When B. melitensis was treated with a neuraminidase, antibody responses disappeared. B. melitensis immunization induced the production of anti-GM1 ganglioside antibodies in BALB/c mice but not in C57BL/6 and ddY mice, and for BALB/c mice, immunization with B. melitensis induced much greater production of anti-GM1 ganglioside than GBS-associated C. jejuni. Flaccid limb weakness was observed in B. melitensis immunized mice. These results suggest that B. melitensis is a new etiological agent for GBS and that immunological responses between it and GBS-associated C. jejuni in the mouse model may be different.