Discussion
Brucellosis is one of the most common zoonosis infection caused by the
bacteria of genus Brucella, and involving multisystem including liver,
nervous and musculoskeletal (5). It is transmitted by eating or drinking
contaminated animal products or with a direct contact with infected
animals(1). The neurobrucellosis is detected in 3-5% of the patients
that has been categorized as acute meningoencephalitis, chronic
meningitis with intracranial hypertension, meningovascular involvement,
neuropathy, radiculopathy, and myelitis (2,6). Sometimes neurological
findings may be the only symptoms of brucellosis and neurobrucellosis
should always be considered in the differential diagnosis of
neurological, rheumatologically, and neuropsychiatric presentation in
endemic regions for brucellosis(7,8). Chronic meningitis with increased
intracranial pressure has been rarely encountered as an initial
manifestation of neurobrucellosis and studies on this complications are
scarce and limited to case reports and series (9,10). Papilledema,
headache, vomiting, and blurred vision are the main presenting features
of intracranial hypertension due to chronic neurobrusellosis meningitis.
meningeal irritation, and focal neurological deficit are not seen in
these patients(2,11). Lumbar radiculopathy is detected in 9.1% of the
patients that often affects the lumbar (especially at the L4-L5 level)
and low thoracic vertebrae than the cervical spine. Back pain and
sciatica radiculopathy are the most common complaints about
patients(12,13). While it is endemic in many countries, it is frequently
misdiagnosed due to its nonspecific presentations, and it requires a
high index of suspicion and special care to be cured(14). Because
neuroberocellosis does not present a typical clinical picture, it is
suspected in patients with chronic neurological symptoms accompanied by
CSF lymphocytosis or compatible neuroimaging findings. It is confirmed
by positive serum brucella agglutination test, positive serological
tests (increased brucella antibody in the CSF), positive CSF wright
test, and isolation of brucella species or detection of brucella DNA in
the CSF with PCR test(5,15). The detection of high antibody
titers(>=1/160) is considered diagnostic together with a
compatible clinical presentation(16). In a study by Al-Sous et al. four
types of imaging have been reported: normal, inflammation, white matter
involvement, and vascular insult(17). There is no consensus on the
choice of antibiotic, dose and duration of antimicrobial treatment for
neurobrucellosis, and there are no randomized controlled trials. A
combination of four antibiotics including Rifampin, Doxycycline,
Streptomycin, and ceftriaxone for 3-6 months is commonly used until the
clinical manifestations vanish and the CSF returns to normal(5,18). One
–fifth of patients treated for neurobrucellosis experience lower limb
weakness. Conversation management is the most adopted method of
treatment across various studies for radiculopathy. The main reason for
the success of conservative management is early diagnosis, strict
adherence to the antibiotic protocol, and regular follow up(10,13). The
disease generally has a good prognosis if treated appropriately and is
curable within a few months with minimal risk of relapse and chronicity,
but severe neurological outcomes have been reported(14). Here, we have
presented a rare case of neurobrucellosis with concomitant intracranial
hypertension and L5-S1 radiculopathy without evidence of another
systemic symptoms of brucellosis while only two patients with
concomitant of these two complications have been reported (table 2).
This case and simultaneous cases highlight that in endemic areas of
Brucellosis, the possibility of neurobrucellosis must be considered in
patient with chronic headache or other common symptoms of intracranial
hypertension with or without radiculopathy.
.