Neurobrucellosis: report of 54 cases

Abstract

Background Brucellosis is among the most widespread zoonotic diseases worldwide. Although rare, nervous system involvement due to Brucella infection is a major diagnostic challenge in endemic regions. Patients and methods This study was a cross-sectional investigation of hospitalized adults with neurobrucellosis from March 2007 to February 2017. We described the clinical characteristics, radiographical and laboratory features, and clinical outcomes of patients with neurobrucellosis. Results Fifty-four patients with neurobrucellosis were included. The median age was 35 (interquartile range, 25–50) years, and 32 (59%) cases were male. Thirty-four (63%) patients were stockmen or shepherds. The most common clinical manifestations were fever in 49 (91%) cases, headache in 47 (87%), decreased consciousness in 12 (22%), and seizures in 6 (11%). Meningeal signs were detected in 36 (67%) cases. Brucella species were isolated in five cases from blood or cerebrospinal fluid (CSF). The median of CSF leukocytes was 75 per µL, CSF protein 83 mg/dL, and CSF glucose 39 mg/dL. Only two cases had severe hypoglycorrhachia and one CSF protein ≥ 500 mg/dL. No patient died during hospitalization. Conclusions The symptoms of neurobrucellosis could be mild and nonspecific and the classic triad of meningitis is uncommon. Mild CSF pleocytosis of fewer than 50 leukocytes per microliter of CSF was common but severe hyperproteinorrhachia and severe hypoglycorrhachia were rare in neurobrucellosis. Differentiation between neurobrucellosis and systemic brucellosis is important, because more prolonged treatment is indicated for neurobrucellosis, and it could be associated with a broad spectrum of complications that require close follow-up.

Neurobrucellosis

“…Mild to moderate lymphocytic pleocytosis was frequent [37]. High protein and reduced glucose levels are also observed, but severe hypoglycorrhachia is unusual [19 ▪ ]. CSF oligoclonal bands may be present in some patients [27,38].…”

“…Behavioral changes 60% [29] Meningitis 50% [18] Peripheral neuropathy 18--35.2% [33,34] Cranial neuropathies 19% [16] Myelopathy 5--17% [16,31,32] Cerebrovascular complications 16% [23] Seizures 3--11% [16,19 mycotic aneurysms or thrombotic obliteration or septic emboli from endocarditis [16,24,25]. Most importantly, brucellosis should be considered in the differential diagnosis of acute vascular lesions in endemic areas [16].…”

“…1) [18]. Headache, fever, nausea and vomiting are frequent, and meningeal signs are observed in one-third of cases, but the full meningitis triad is seen in only 13% [19 ▪ ]. Cranial neuropathies occurred in 19% of 187 patients, being the VIII nerve the most affected, followed by VI and VII nerves [16].…”

“…Papilledema can occur either by papillitis secondary to inflammatory and vascular changes at optic nerves or by pseudotumor cerebri, when raised CSF pressure is observed in association with minimal or absent disturbance of other parameters (cells, protein, and glucose levels) [20]. Seizures are uncommon and occur in 3–11% of patients [16,19 ▪ ,21].…”

“…CSF abnormalities were detected in more than 90% of patients with neurobrucellosis [19 ▪ ]. Mild to moderate lymphocytic pleocytosis was frequent [37].…”