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.