An Interesting Case of Neurobrucellosis Mimicking Neuropsychiatric Lupus

Abstract

This case describes a patient presenting with acute onset papilledema, subacute strokes resulting in upper extremity weakness and numbness, arthritis, maculopapular rash, depressed C4 and CH50, and a high titer anti-double-stranded DNA antibody. The patient was given the diagnosis of probable systemic lupus erythematosus, which was supported by the Systemic Lupus International Collaborating Clinics (SLICC) criteria. He was aggressively treated for neuropsychiatric lupus (NPSLE) with pulse dose steroids and a dose of intravenous cyclophosphamide. Blood cultures drawn on admission later grew out 2/4 bottles of Gram-variable bacteria, speciated as Brucella melitensis by PCR. Serum Brucella serologies were also positive. On further evaluation, the patient noted a history of eating unpasteurized cheese in Mexico. Given these additional findings, the patient's presentation was most consistent with a diagnosis of neurobrucellosis. Steroids were tapered off, no further doses of cyclophosphamide were given, and a prolonged course of intravenous and oral antibiotic therapy was administered, resulting in complete resolution of the patient's presenting symptoms.

Unusual presentation of neurobrucellosis in Jeddah, Kingdom of Saudi Arabia

“…The acute manifestations of brucellosis are sometimes unspecific and may mimic certain neurological and psychiatric conditions. 1 We have found in the literature approximately 18 case reports of brucellosis presented with psychosis. Similar to our case, there was a previously mentioned case report of brucellosis where the patient presented with abnormal behavior and hearing loss.…”

“…3 Neurobrucellosis occurs in 0.5-25% of brucellosis cases and affects the central or peripheral nervous systems with serious complications. 1 Various presentations of neurobrucellosis are encountered including psychiatric symptoms such as behavioral changes, psychosis, dementia, insomnia, restlessness and episodic crying and neurological manifestations such as meningitis, encephalitis, sensorial and motor abnormalities, polyradiculoneuritis, cranial nerve involvement, epilepsy, brain abscess, blurring of vision and optic neuritis, numbness, subarachnoid hemorrhage, and finally coma. 1,4 Psychosis as a presentation of neurobrucellosis is a very unusual condition.…”

“…1 Various presentations of neurobrucellosis are encountered including psychiatric symptoms such as behavioral changes, psychosis, dementia, insomnia, restlessness and episodic crying and neurological manifestations such as meningitis, encephalitis, sensorial and motor abnormalities, polyradiculoneuritis, cranial nerve involvement, epilepsy, brain abscess, blurring of vision and optic neuritis, numbness, subarachnoid hemorrhage, and finally coma. 1,4 Psychosis as a presentation of neurobrucellosis is a very unusual condition. There are only a few previous brucella reports with neuropsychiatric manifestations such as psychosis and abnormal behavior; therefore, we report a case of neurobrucellosis with agitation, abnormal behavior, and inappropriate speech.…”

“…O ne of the most common bacterial zoonoses in the world is brucellosis, it is endemic in Kingdom of Saudi Arabia (KSA) and the Mediterranean region and is also present in many other countries. 1 Brucella can bypass the immune response and quickly spread across the body into multiple systems. 2 Brucellosis can be acquired through several routes including direct inoculation through cuts and scratches (especially during handling animal tissues or secretions), inhalation of infected aerosols, through conjunctiva, or consumption of contaminated foods such as raw milk, unpasteurized milk cheeses, or raw meat.…”

“… 2 Brucellosis can be acquired through several routes including direct inoculation through cuts and scratches (especially during handling animal tissues or secretions), inhalation of infected aerosols, through conjunctiva, or consumption of contaminated foods such as raw milk, unpasteurized milk cheeses, or raw meat. 1 It has been also described to have human-to-human transmission including vertical and sexual transmission. 3 The clinical presentations of brucellosis are diverse including systemic manifestations like fever, sweating, chills, and fatigue syndrome or localized such as epididymo-orchitis and spondylodiscitis and it can present also by serious manifestations such as neurobrucellosis and endocarditis.…”