Case presentation
A 55-year-old man was admitted to the emergency department with new-onset tonic-clinic generalized seizures. At the time of admission, he was in the postictal phase. Soon after, his consciousness level deteriorated, and he was intubated. His symptoms began one week prior to presentation with a mild headache and low-grade fever, malaise, anorexia and vomiting. Four days before admission, he developed his first convulsive episode and was hospitalized. However, he was discharged with personal consent. He had no history of recent trauma, drug overdose, or travel. The patient was a butcher and had been treated for brucellosis two times in recent two years. Neurologic examination was unreliable due to decreased level of consciousness. Hypoglycemia and opium overdose were excluded for the patient at admission, and he was started on anticonvulsive therapy and broad-spectrum antibiotics.
Routine laboratory tests had normal results, except for a positive Wright and 2-mercaptoethanol (2ME) tests results (Wright: 1:80, normal range: ≤ 1/160; 2ME: 1:40, normal range: ≤ 1/160). Thyroid function tests, vitamin B12 and folate, creatine kinase (CK), and C-reactive protein (CRP) levels and erythrocyte sedimentation rate (ESR) were in normal ranges. Autoantibodies, anti-HIV antibodies, and rapid plasma reagin (RPR) tests were also negative. Chest computed tomography (CT) scan demonstrated centrilobular opacities at the lower segments of both lungs, indicative of aspiration pneumonia. A brain CT scan showed a subarachnoid cyst in the left cerebellar hemisphere and opacification and air-fluid levels in both maxillary paranasal sinuses. Brain magnetic resonance imaging (MRI) revealed bilateral hypersignal changes on the parietal lobes. Cerebrospinal fluid (CSF) examination showed white blood cells (WBCs) of 380/mL (normal range: < 5/mL) with 68% lymphocytes, an elevated protein level (82 mg/dL, normal range: 15-60 mg/dL), and a normal glucose level. CSF gram stain, culture, and polymerase chain reaction (PCR) tests were negative for HSV andMycobacterium tuberculosis . The patient was first suspected to be a case of neurobrucellosis.
Nonetheless, the presence of CSF pleocytosis with lymphocyte dominance and inconclusive Wright and 2ME tests results ruled out this diagnosis, and therefore, we suspected Lyme disease. Thus, we requested serologic tests, which were positive for IgG and IgM antibodies to B. burgdorferi . Because of the high prevalence of cardiac and ocular involvement in the settings of Lyme disease, we requested a cardiology and an ophthalmology consultation. However, no abnormality was found. The patient was started on ceftriaxone at a dose of 2 g daily. His condition improved dramatically during the following days, and he was discharged three weeks after admission with a favorable general condition.