Localized CNS brucellosis: report of 7 cases

Prevalence of Brucella melitensis and Brucella abortus tetracyclines resistance: A systematic review and meta-analysis

INTRODUCTION

Brucellosis is a zoonotic disease that can be transmitted from animals to humans. Brucellosis is caused by bacteria of the genus Brucella, which are typically transmitted through contact with infected animals, unpasteurized dairy products, or airborne pathogens. Tetracyclines (tetracycline and doxycycline) are antibiotics commonly used to treat brucellosis; however, antibiotic resistance has become a major concern. This study assessed the worldwide prevalence of tetracycline-resistant Brucella isolates.

METHODS

A systematic search was conducted in Scopus, PubMed, Web of Science, and EMBASE using relevant keywords and Medical Subject Headings (MeSH) terms until August 13, 2022, to identify relevant studies for meta-analysis. A random effects model was used to estimate the proportion of resistance. Meta-regression analysis, subgroup analysis, and examination of outliers and influential studies were also performed.

RESULTS

The prevalence rates of resistance to tetracycline and doxycycline were estimated to be 0.017 (95% confidence interval [CI], 0.009-0.035) and 0.017 (95%CI, 0.011-0.026), respectively, based on 51 studies conducted from 1983 to 2020. Both drugs showed increasing resistance over time (tetracycline: r = 0.077, P = 0.012; doxycycline: r = 0.059, P = 0.026).

CONCLUSION

The prevalence of tetracycline and doxycycline resistance in Brucella was low (1.7%) but increased over time. This increase in tetracycline and doxycycline resistance highlights the need for further research to understand resistance mechanisms and develop more effective treatments.

Neurobrucellosis

PURPOSE OF REVIEW

Brucellosis is one of the most common zoonosis worldwide, affecting 500 000 people, annually. Neurobrucellosis incidence is approximately 4%, and it is almost always heterogeneous. As there are no typical clinical features, its diagnosis is frequently misdiagnosing by other infections.

RECENT FINDINGS

Neurobrucellosis picture includes meningitis, meningoencephalitis, encephalitis, cranial neuropathies, intracranial hypertension, sinus thrombosis, hemorrhages radiculitis, peripheral neuropathy, myelitis, and psychiatric manifestations. The diagnosis should be based on symptoms and signs suggestive of neurobrucellosis, not explained by other neurological disease, cerebrospinal fluid analysis, a positive Brucella serology or culture, and a response to specific antibiotics, with a significant improvement of cerebrospinal fluid parameters.

SUMMARY

Neurobrucellosis can be insidious, and despite its global distribution, it is still unrecognized and frequently goes unreported. The understanding of the current epidemiology is necessary for eradication of the disease in humans, as well as the disease control in animals and prevention based on occupational hygiene and food hygiene.

Neurobrucellosis: the great mimicker

Neurobrucellosis is caused by bacteria of the genus Brucella and is responsible for several clinical manifestations, making diagnosis challenging. The most common route of infection is through the consumption of unpasteurized or raw dairy products such as fresh milk, butter, and cheese. As neurological complications can develop chronically, they are frequently misdiagnosed as other infections, such as tuberculosis. This report reviews the clinical manifestations, diagnostic approach, treatment, and prognosis of neurobrucellosis, illustrating a case of chronic intracranial hypertension and meningoencephalitis secondary to brucellosis. The clinical presentation of brucellosis can mimic several systemic diseases, resulting in diagnostic delays and clinical complications. A high degree of suspicion is required, and neurobrucellosis should always be considered in the differential diagnosis of chronic meningitis.

Neurobrucellosis: a Case Report with an Unusual Presentation

BACKGROUND

Brucellosis is a highly infectious multi-systemic zoonosis, and it is caused by Gram-negative bacteria, Brucella. Despite the low incidence of neurobrucellosis, it is the most dangerous consequence of brucellosis.

CASE REPORT

A 30-year-old Sudanese male patient presented to our hospital with a complaint of fever associated with confusion for three days. He had signs of meningeal irritation in the form of neck stiffness, positive Kernig's, and Lesage's sign. The computerized tomography of the brain was normal. The CSF analysis showed a clear colorless sample with normal tension, decreased glucose, and slightly increased CSF protein level. We reviewed his occupational history; the patient was a farmer with regular contact with cattle and camels. The patient had positive Brucella antibodies for both B.Abortus and B. melitensis with a high titer (1/640). As described in various patents, we administrated triple therapy for brucellosis for two weeks. A marked improvement of the conscious level was observed, and the patient was back to normal within a few days post-treatment.

CONCLUSIONS

We encourage physicians to consider the diagnosis of neurobrucellosis with any neurologic sign without a known cause. Our case highlights the importance of occupational history in clinical medicine.

Vasculitis and neurobrucellosis: Evaluation of nine cases using radiologic findings

BACKGROUND

Brucellosis is an important multisystemic disease with many different clinical symptoms, and its early diagnosis and treatment are possible. Neurobrucellosis (NB) is a rare but serious finding of brucellosis. Brucella can be seen as meningitis and encephalopathy, and it can cause cranial nerve pathologies, vascular syndromes, myopathy, spinal diseases, and psychiatric disorders. In NB, vascular syndromes secondary to inflammation are rarely seen. Here, we present nine young patients with vascular and nonspecific neuropsychiatric findings who had NB as the etiology of stroke.

METHODS

Nine patients who were admitted to our Neurology Clinic between 2012 and 2017 for various reasons in whom brucellosis was found in the etiology were retrospectively studied. The patients' symptoms, physical examination, laboratory and radiographic findings, treatments, and treatment responses are discussed.

RESULTS

Of the nine patients who presented to our clinic in the 4-year period, five were female. The average age was 49 years. Five patients had small vessel vasculitis, three had great vessel vasculitis, and one had meningoencephalitis and pons abscess. Two patients had granuloma, and one had an aneurysm.

CONCLUSIONS

We aimed to present our cases due to the fact that this disease should be kept in mind in the differential diagnosis of patients with stroke and similar neuropsychiatric findings.

Epidemiological and clinical characteristics of neurobrucellosis case patients in Tunisia

OBJECTIVE

We aimed to identify epidemiological, clinical, therapeutic, diagnostic, and outcome characteristics of neurobrucellosis case patients in Tunisia.

PATIENTS AND METHODS

We conducted a retrospective and descriptive study over a 17-year period (January 1997-December 2013). We included all neurobrucellosis patients hospitalized in the infectious disease department of La Rabta Hospital of Tunis during the study period.

RESULTS

A total of 13 patients were included in the study: 9 men and 4 women. Mean age was 31.6 years. Six patients presented with meningitis, three with encephalitis, two with meningoencephalitis, and two with meningo-myeloradiculitis. All patients had a lumbar puncture performed. Eleven patients had an abnormal cerebrospinal fluid (CSF) (84.6%): lymphocytic pleocytosis in seven patients, high level of CSF proteins in 11, and low level of CSF glucose in seven. All patients had a positive Brucella serological test in blood. A Brucella serological test was also performed in CSF and was positive for 10 patients (77%). A total of nine patients had a cerebral CT scan and/or MRI performed and abnormalities were observed in six patients. Antibiotic therapy was prescribed to all patients: a combination of rifampicin and co-trimoxazole (n=9) or doxycycline (n=4) for an average duration of eight months. Two patients also received steroids. A positive outcome was observed in 10 patients. Three patients were lost to follow up.

CONCLUSION

Brucellosis may be severe when neurological involvement occurs. Brucellosis should be considered in the event of any neurological involvement associated with suggestive epidemiological features.

Brucella-related multiple cerebral aneurysms: Report of a case and review of the literature

BACKGROUND

Mycotic cerebral aneurysms are uncommon. We intend to report the first case of multiple mycotic cerebral aneurysms due to Brucella infection that were treated surgically.

CASE DESCRIPTION

A 34-year-old man with neurobrucellosis presented with intracerebral haemorrhage (ICH). Three mycotic aneurysms were detected in the vicinity of middle cerebral artery (MCA). Medical treatment failed to treat them and aneurysms had to be managed surgically.

CONCLUSION

Brucella-related cerebral mycotic aneurysm has rarely been reported. This is the first report of three mycotic aneurysms occurring in a young man with neurobrucellosis treated surgically.

Progressive multifocal leukoencephalopathy and idiopathic CD4 lymphocytopenia

Idiopathic CD4 lymphocytopenia (ICL) is a syndrome described in patients with low counts of CD4 cells and no other causes for immunosuppression. A few cases of progressive multifocal leukoencephalopathy (PML) have been described in association with this entity. There is no effective treatment for any of them, and the clinical course and outcome are unpredictable. We report on a case of ICL with PML and review the literature, trying to identify the clinical features and the prognosis clues associated to these entities together. A 72-year-old man presented with acute onset gait instability that progressed to a severe cerebellar syndrome with cognitive decline. A cranial MRI showed findings consistent with PML, this diagnosis being confirmed by CSF analyses. Absolute number of CD4+ was 242 cells/μL. An extensive work-up including HIV tests was negative. Ten cases of PML and ICL have previously been reported. Factors contributing to the different outcomes are unknown. Although an effective treatment does not exist for PML, it has been recently demonstrated in vitro that several 5HT2A-receptor antagonists block the JC virus infection. Our patient greatly improved and remains stable 34 months after onset; we describe the potential role of mirtazapine in the treatment of PML.

Unusual presentations of pediatric neurobrucellosis

Neurobrucellosis is an uncommon complication of pediatric brucellosis. Acute meningitis and encephalitis are the most common clinical manifestations, however symptoms may be protean and diagnosis requires a high index of suspicion in patients from endemic areas. Diagnosis is often based on neurological symptoms, serology, and suggestive brain imaging because cerebrospinal fluid culture yields are low. Two cases of pediatric neurobrucellosis with unusual clinical and radiologic findings are presented.

Neurobrucellosis developing unilateral oculomotor nerve paralysis

Brucellosis is a zoonotic infectious disease that is common around the world. Its clinical course demonstrates great diversity as it can affect all organs and systems. However, the central nervous system is rarely affected in the pediatric population. Neurobrucellosis is most frequently observed with meningitis and has numerous complications, including meningocephalitis, myelitis, cranial nerve paralyses, radiculopathy, and neuropathy. Neurobrucellosis affects the second, third, sixth, seventh, and eighth cranial nerves. Involvement of the oculomotor nerves is a very rare complication in neurobrucellosis although several adult cases have been reported. In this article, we present the case of a 9-year-old girl who developed unilateral nerve paralysis as a secondary complication of neurobrucellosis and recovered without sequel after treatment. This case is notable because it is a very rare, the first within the pediatric population. Our article emphasizes that neurobrucellosis should be considered among the distinguishing diagnoses in every case that is admitted for nerve paralysis in regions where Brucella infection is endemic.

Neuropsychiatric evaluation of patients with brucellosis

Brucellosis is a multisystem disease that may present with a broad spectrum of clinical manifestations. Neurobrucellosis is one of the complications. The objective of this study was to determine neuropsychiatric manifestations among patients with brucellosis. Twenty-seven consecutive patients with brucellosis (14 patients with manifest neurological manifestation and 13 patients without apparent neurological manifestation) were recruited from Assiut University hospital and compared with 50 healthy controls matched with respect to age, sex, and social economic and educational levels. They were subjected to systemic, meticulous neuropsychiatric evaluations, laboratory, radiological, neurophysiology, and psychometric assessment with Mini-Mental State Examination, Wechsler Memory Scale-Revised. and Hamilton Depression Rating. Overt or apparent neurological manifestation was recorded in 14 patients (51.85%) and 13 patients (48.15%) with brucellosis without apparent neuropsychiatric involvement. Central nervous system (CNS) involvement (vascular stroke, meningeoencephalitis, and dementia) was recorded in 9 patients (33.3%) and 6 patients (22.2%) had peripheral nervous sytem (PNS) involvement (polyneuropathy, radiculoapathy, and polyradiculoneuropathy). Depression was recorded in 7 (29.2%) patients; 3 patients (21.4%) of the neurobrucellosis group and 4 patients (30.8%) with brucellosis without neurological manifestations. Patients with brucellosis (neurobrucellosis and patients without neurological manifestations) reported highly significant impairment in some cognitive function measures (mental control, logical memory, visual reproduction) and higher scores on depressive symptoms compared with controls. Patients with a Brucella infection usually manifest central nervous system involvement. Clinicians, especially serving in endemic areas or serving patients coming from endemic areas, should consider the likelihood of neurobrucellosis in patients with unexplained neurological and psychiatric symptoms, and should perform the necessary tests, including cognitive function and depression tests.

Ophthalmoparesis, papillitis and premacular hemorrhage in a case with endocarditis: a rare presentation of Brucellosis

We report a rare presentation of brucellosis as bilateral optic nerve and right abducent nerve involvement, and endocarditis complicated by right premacular hemorrhage in a 28-year-old white female. The patient showed improvement with both medical and surgical therapy. Brucellosis should be considered in the differential diagnosis of papillitis, gaze palsy and endocarditis complicated with premacular hemorrhage in endemic regions.

Neurobrucellosis: an evaluation of a rare presentation of brucellosis from a tertiary care centre in Central Anatolia, Turkey

Nervous system involvement is a rare manifestation of brucellosis. We describe our experience of the diagnosis, treatment and final outcome of patients with neurobrucellosis at the Erciyes University Gevher Nesibe Hospital, a tertiary referral centre in Central Anatolia, Turkey. Thirty-six adult patients were diagnosed with neurobrucellosis from January 1997 to December 2006. Headache and fever were the most common symptoms. Neck stiffness was present in 25 patients. Brucella spp was isolated from the blood of nine patients and from the cerebrospinal fluid of 11. Doxycycline (by mouth) plus rifampin (by mouth) with ceftriaxone (intravenously) were the most common treatment choices. Three patients died as a result of problems other than neurobrucellosis and relapse occurred in one patient. Neurobrucellosis presents with hetoregenous clinical signs.

Multiple cranial nerve involvement caused by Brucella melitensis

A case of neurobrucellosis complicated by optic, abducens and vestibulocochlear nerve palsies is reported. Brucella melitensis was isolated in the cerebrospinal fluid, and the patient was diagnosed with retrobulbar neuritis. Despite medical treatment, the patient developed optic atrophy. Multiple cranial nerve involvement should be kept in mind in patients presenting with blurred vision and double vision, especially in regions where brucellosis is endemic.

Toxic-febrile neurobrucellosis, clinical findings and outcome of treatment of four cases based on our experience

Central nervous system (CNS) involvement is uncommon in brucellosis. Neurological complications of brucellosis may be divided into 2 major groups: 1) those related to the acute-febrile state that occurs in acute disease (toxic-febrile neurobrucellosis), and 2) those related to actual invasion and localization of the pathogen in the CNS (classical neurobrucellosis). In this paper, we present 4 cases of toxic-febrile neurobrucellosis and discuss clinical findings and outcome of treatment in these cases. All patients had fever, headache, stupor or coma with neuropsychiatric symptoms such as hallucination, delirium, convulsion, dysarthria, psychosis, and night raving. Peripheral and cranial vasculitis was present in case 3 and bilateral sensorioneural hearing loss in case 4. Neither pleocytosis nor hyperproteinorrachia was present in any patient in lumbar puncture. Brucella melitensis was isolated in case 3 from bone marrow, and in case 4 both from blood and bone marrow. All patients received combined treatment consisting of ceftriaxone, rifampicin, and doxycycline. They were discharged from the hospital with full recovery. No recurrence or any complaint was observed during the follow-up. In conclusion, despite the rapid course and serious complications, outcome from febrile-toxic neurobrucellosis is excellent especially when effective antimicrobial therapy is started early in the course of illness.

Overview of neurobrucellosis: a pooled analysis of 187 cases

Central nervous system involvement is a serious complication of brucellosis; data found in the literature are generally restricted to case reports and case series. In this study we pooled the data from Turkish medical practice in order to gain a thorough understanding of the subject. A search of Turkish publications on chronic neurobrucellosis was made using both Turkish and international databases. A total of 35 publications were analyzed and 187 neurobrucellosis cases were evaluated. Headache, fever, sweating, weight loss, and back pain were the predominant symptoms, while meningeal irritation, confusion, hepatomegaly, hypoesthesia, and splenomegaly were the most frequent findings. The major complications in patients were cranial nerve involvement, polyneuropathy/radiculopathy, depression, paraplegia, stroke, and abscess formation. Antibiotics were used in different combinations and over different intervals. The duration of antibiotic therapy reported ranged from 2 to 15 months (median 5 months). The mortality was 0.5% with suitable antibiotics. Neurobrucellosis may mimic various pathologies. For this reason, a thorough evaluation of the patient with probable disease is crucial for an accurate diagnosis and proper management of the disease.

Brucella-related cerebral aneurysms/subarachnoidal hemorrhage: a short review featuring a case report

Brucellosis is a multisystem disease that may present with a large spectrum of clinical manifestations. Only five cases of intracranial aneurysm formation and/or subarachnoidal hemorrhage associated with brucellosis have been reported. In this paper, we take the opportunity to review these reports and present a new case of basilar artery aneurysm and subarachnoidal hemorrhage due to brucellosis.

Therapeutic options for human brucellosis

Worldwide, human brucellosis is the most common zoonotic disease and it has gained increasing interest because of the potential use of Brucella as a biological weapon. Monotherapy for brucellosis is associated with a high relapse rate and dual therapy in different combinations is more efficacious. The combination regimen of intramuscular streptomycin with an oral tetracycline resulted in fewer relapses than the doxycycline-rifampin combination in meta-analysis and prospective studies, although the use of doxycycline and rifampin is a reasonable choice in certain conditions. Longer duration and triple antimicrobial therapy appear to improve outcome and prevent relapses, especially in patients with focal disease. Recently, the use of gentamicin-loaded microparticles and the use of new antibiotics, such as tigecycline, may hold future promise. In addition, there are a few studies of the enhanced effect of immune response stimulators, such as levimasole and IFN-2, in the treatment of brucellosis. The development of an effective subcellular Brucella vaccine would be an important step forward to curtail the disease. However, currently and for the near future, only the control of animal disease is possible using vaccine strategies.

Magnetic resonance spectroscopy features of normal-appearing white matter in patients with acute brucellosis

We aimed to evaluate whether the subtle metabolic cerebral changes are present in normal-appearing white matter on conventional MRI, in patients with acute brucellosis, by using MR spectroscopy (MRS). Sixteen patients with acute brucellosis and 13 healthy control subjects were investigated with conventional MRI and single-voxel MRS. Voxels were placed in normal-appearing parietal white matter (NAPWM). N-Acetyl aspartate (NAA)/creatine (Cr) and choline (Cho)/Cr ratios were calculated. There was no significant difference between the study subjects and the control group in NAA/Cr ratios obtained from NAPWM. However, the Cho/Cr ratios were significantly higher in patients with acute brucellosis compared to controls (p=0.01). MRS revealed metabolic changes in normal-appearing white matter of patients with brucellosis. Brucellosis may cause subtle cerebral alterations, which may only be discernible with MRS. Increased Cho/Cr ratio possibly represents an initial phase of inflammation and/or demyelination process of brucellosis.

Abducens nerve palsy and optic neuritis as initial manifestation in brucellosis

Cranial nerve involvement in brucellosis is rare. We present a case of brucellosis presenting with optic neuritis and abducens nerve palsy on the left side. Cerebrospinal fluid findings indicated Brucella meningitis with high protein count, low sugar level and pleocystosis. In addition, Brucella agglutination test (Wright test) was found to be 1/128 in cerebrospinal fluid. Serum agglutination test for Brucella was also positive at 1/1280. This case was diagnosed as brucellosis involving optic and abducens nerves. The patient was treated by ceftriaxone (intravenous), rifampicin (orally) and doxycycline (orally). Two months later the patient's vision acuity in the left eye had moderately improved and the patient's left abducens palsy had almost disappeared. In conclusion, cranial nerve involvement in brucellosis can have good prognosis if anti-Brucella treatment is undertaken early.

Evaluation of the clinical presentations in neurobrucellosis

BACKGROUND

Brucellosis is a multisystem disease that may present with a broad spectrum of clinical manifestations and complications. Neurobrucellosis is one of the complications.

METHODS

In this study, we describe our experience in the diagnosis, treatment, and the final outcomes of 20 patients with neurobrucellosis out of 305 patients with brucellosis, within a five-year period between January 1999 and June 2004.

RESULTS

The rate of neurobrucellosis was 6.6%. Twelve males and eight females with a mean age of 37.4 years were investigated. Fever, headache, confusion, and gait disorders were the main complaints. The duration of their complaints varied between one week and six months. On physical examination, 13 patients had fever, six had neck stiffness and confusion, three had motor deficit on either their upper or lower extremities, and four of them had diplopia. The Rose-Bengal test and standard tube agglutination tests were positive in all of the patients. Brucella melitensis was isolated from the blood of six of the 20 (30%) patients. Cerebrospinal fluid (CSF) was analyzed in 18 patients. Pleocytosis with a mean value of 244x10(6)cells/L, and high protein levels were detected in all. A low glucose level in the CSF was detected in ten patients. Patients were treated medically and a complete resolution was achieved in all.

CONCLUSION

Patients with a Brucella infection occasionally manifest central nervous system involvement. Clinicians, especially serving in endemic areas or serving patients coming from endemic areas should consider the likelihood of neurobrucellosis in the patients with unexplained neurological and psychiatric symptoms, and should perform the necessary tests on blood and CSF.

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.

Recurrent transverse myelitis following neurobrucellosis: Immunologic features and beneficial response to immunosuppression

The authors report the clinical course and immune system response of a patient with disease-associated recurrent transverse myelitis (TM) following cerebral infection with Brucellosis melitensis. The patient suffered four recurrences of his TM (each at a distinct spinal cord level) over the course of 2 years following his initial presentation, which ultimately progressed to quadriplegia. He had progressively declining cerebrospinal fluid (CSF) brucella antibody titers, suggesting a postinfectious, rather than an infectious, etiology. The authors simultaneously examined the expression of multiple cytokines in the CSF of this patient using cytokine antibody arrays and found a marked elevation of interleukin (IL)-6, IL-8, and macrophage chemoattractant protein (MCP)-1 levels relative to controls. Quantitative enzyme-linked immunosorbent assay (ELISA) analysis of the CSF confirmed a 1700-fold elevation of IL-6 and more modest elevations of IL-8 and MCP-1. IL-6 levels returned to baseline following treatment of the patient with intravenous cyclophosphamide and plasma exchange and the patient experienced a significant and sustained recovery of function.

Brucellar Spine Infection-Four Case Reports-

Brucellosis can be difficult to diagnose because of the nonspecific and variable clinical picture. This systemic disease is still an important public health problem in the Mediterranean Basin. These four cases of brucellar spine infection originated from rural areas around Aydin, Turkey. The systemic complaints of fever, profuse sweating, malaise, polyarthromyalgia, and weight loss indicated the final diagnosis of brucellosis and presumptive diagnoses were made based on agglutination testing for brucellosis. Computed tomography and magnetic resonance imaging indicated signs of bone infection and soft tissue involvement. Good outcomes were obtained with prolonged treatment with antibrucellar drugs including streptomycin, rifampicin, and tetracycline. Early diagnosis is important and prompt antibrucellar chemotherapy is effective in most cases, but prolonged follow up is necessary in all patients with spinal brucellosis.

Neurobrucellosis presenting as leukoencephalopathy: the role of cytotoxic T lymphocytes

A 65-year-old man developed a leukoencephalopathy associated with neurobrucellosis. The disease followed a 15-month progressive course with neurologic symptoms, and magnetic resonance imaging revealed bilateral symmetrical T2 signal hyperintensities in the white matter. Biopsy of the cerebral cortex and white matter was significant for nongranulomatous meningoencephalitis with reactive microgliosis and astrogliosis. The inflammatory infiltrate was predominantly composed of T lymphocytes, including numerous cytotoxic T cells. There was no evidence of significant myelin destruction. No organisms were detected microscopically, but elevated immunoglobulin G titers to Brucella were found in the cerebrospinal fluid. An abscess formed at the biopsy site, and Brucella melitensis was cultured from abscess contents. Neurobrucellosis is difficult to diagnose outside endemic regions and is associated with leukoencephalopathy-like pathology. Cytotoxic T lymphocytes and microglia activation play an immunopathogenic role in this rare disease.

Abducent nerve palsy during treatment of brucellosis

Brucellosis is an infectious disease with multisystem involvement caused by the genus Brucella. Neurological complications including meningitis, meningoencephalitis, myelitis-radiculoneuritis, brain abscess, epidural abscess, and meningovascular syndromes are rarely encountered. We present here a patient with sixth cranial nerve palsy that occurred during treatment for brucellosis, a form of presentation rarely been reported in English-language literature. We conclude that neurobrucellosis, pseudotumor cerebri, and side effects of tetracyclines which are frequently used in brucellosis should be kept in mind when considering intractable headaches and cranial nerve palsies in patients with brucellosis.

Neurobrucellosis in an endemic area of brucellosis

Central nervous system involvement occurs less than 5% of patients with brucellosis. A prospective analysis of 73 patients with brucellosis identified 13 (17.8%) neurobrucellosis cases from February 2001 to May 2002. 10 patients had chronic meningitis and 3 acute meningitis. Two patients had only psychiatric disorders. Cranial nerve involvement was observed in 3 patients (6th, 7th and 8th nerves). Three patients had positive blood cultures and 3 others had positive cerebrospinal fluid (CSF) cultures. 12 patients had positive agglutination titres in CSF. All patients received antibiotic therapy with ceftriaxone, rifampicin and doxycycline initially, and after 1 month they were continued with rifampicin and doxycycline up to 4 months. All patients were completely cured. Hearing loss developed in 1 patient as a sequela.

Paraplegia associated with brucellosis involving the anterior lumbrosacral nerve roots

We report the case of a 21-year-old man with paraplegia due to brucellosis involvement of lumbosacral anterior roots. Lumbosacral magnetic resonance imaging showed contrast enhancement of anterior roots and the anterior part of duramater. Conduction block was found at the level of the lumbosacral anterior roots by electrophysiological studies, including magnetic stimulation study. Wright agglutination, Rose Bengal tests and bacterial culture obtained from cerebrospinal fluid confirmed the diagnosis of neurobrucellosis. Oral administration of ceftriaxon with additional rifampin was effective, and after 3 months of treatment, laboratory data resolved and clinical signs partially improved.

Chronic meningoencephalitis associated with Brucella sp. infection in live-stranded striped dolphins (Stenella coeruleoalba)

A chronic, non-suppurative meningoencephalitis was found in three young striped dolphins (Stenella coeruleoalba) during routine neuropathological examination of marine mammals live-stranded on the Scottish coast. In all three dolphins the lesions were associated with the isolation of a Brucella sp. from the brain and with the immunohistochemical detection of brucella antigen. Moreover, antibodies to Brucella spp. were detected in the two dolphins that were subjected to serological examination. Immunohistochemical and serological examinations for morbillivirus antigen and antibodies, respectively, were negative in all cases. Although brucella infection of marine mammals has been extensively documented in recent years, its association with lesions and disease is less well recognized. The present report provides the first description of an association between Brucella sp. infection and neuropathological changes in a cetacean species.

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.

Complications associated with Brucella melitensis infection: a study of 530 cases

We carried out a prospective study of 530 patients older than 14 years of age with brucellosis. We describe the incidence and clinical features of the focal forms of the disease, analyzing some of the possible factors associated with their appearance. One hundred sixty-nine patients (31.9%) had a focal form or complication. Osteoarticular complications were the most frequent, totaling 113 cases (66%), followed by genitourinary with 18 cases (5.1% of males), hepatic (2.5%), neurologic (1.7%), and heart (1.5%). Nine patients (1.7%) had more than 1 complication. In a multivariate analysis, diagnostic delay greater than 30 days (OR 2.0), ESR > 40 mm/hr (OR 1.9), and levels of alpha-2 globulin > 7.5 g/L (OR 6.8) were statistically significant independent variables associated with the presence of focal forms. Twenty-five patients with complications (14.8%) required surgical treatment. The relapse rate was 3.6% for those patients without complications and 4.1% for patients with focal forms (p > 0.05). However, when therapeutic failure, relapses, and mortality were considered together, the risk of an unfavorable evolution was significantly greater in patients with focal forms (10.6% versus 3.6% in patients without complications; OR 1.9, 95% CI 1.4-7.1, p < 0.005). Given the worse prognosis, knowledge and early diagnosis of the focal forms of B. melitensis infection is especially important.

Clinical and therapeutic features of childhood neurobrucellosis

Brucellosis is a multisystem disease with diverse clinical presentations, and involvement of the nervous system is considered to be rare in childhood. Five children with meningitis (n=2), meningoencephalitis (n=1), meningomyelitis (n=1), or cerebellar ataxia (n=1) are described, all of whom had a history of exposure to a possible source of brucellosis. Examination of cerebrospinal fluid (CSF) revealed lymphocytic pleocytosis in 4 patients, high protein concentration in 5 and low glucose concentration in 3. Reciprocal brucella agglutination titers were significantly elevated in serum (> or = 160) and in CSF (> or = 80) of all patients. Brucella melitensis was isolated from blood and CSF in one patient, from blood only in 2, and from bone marrow only in another one. All patients were treated successfully by a three-drug combination of streptomycin (4 patients) or doxycycline (one patient) with trimethoprim-sulfamethoxazole and rifampin, and in one patient dexamethasone was also added. In endemic areas, neurobrucellosis should be suspected in the evaluation of patients with unexplained neurologic symptoms.

Brucella melitensis growth on Loewenstein-Jensen egg medium from a case of Brucella meningitis

Bacteriologic investigation of a cerebrospinal fluid (CSF) specimen for mycobacteria on Lowenstein-Jensen egg medium revealed the presence of Brucella organisms. This coincided with a significant antibody titer against Brucella spp. This is the first documented report of the ability of B. melitensis organisms to grow on Loewenstein-Jensen egg medium.

Chronic neurobrucellosis due to Brucella melitensis

A 20-year-old male Turkish immigrant to Norway suffering from severe chronic neurobrucellosis with spastic paraplegia and deafness is presented. The diagnosis was established by isolation of Brucella melitensis from cerebrospinal fluid (CSF) culture. Brucella antibody agglutination titers were high in serum and CSF. In spite of intensive, prolonged treatment with a combination of trimethoprim-sulfamethoxazole (TPM-SMZ), rifampicin and doxycycline, the course of the illness was characterized by relapses and severe neurological defects.