Chronic meningitis neurobrucellosis: case report

Case presentation: A 46-year-old man presented with a 4-month history of headache and fatigue, a 10-kilogram weight loss over the previous 3 months, low-grade fever, night sweats, and blurred vision. He had recently traveled to Lebanon, where he consumed unpasteurized dairy and raw meat. Upon examination, the patient was alert but confused, exhibiting bilateral papilledema without other neurological deficits. Brain magnetic resonance imaging revealed gadolinium enhancement in the leptomeningeal compartment, particularly pronounced in the basal cisterns, accompanied by hydrocephalus and signs of CSF transudation. Cerebrospinal fluid analysis showed an opening pressure of 31 cm H2O, 149 white cells/mm3 (70% lymphocytes), low glucose (24mg/dl), high lactate (30mg/dl), and elevated total protein (160mg/dl). A comprehensive diagnostic workup, including metagenomic next-generation sequencing of CSF, was negative for syphilis, sarcoidosis, tuberculosis and other infectious and autoimmune etiologies. The patient was started on empirical anti-tuberculosis treatment, prednisone, and acetazolamide. Brucella agglutination tests were positivein the CSF (titer, 1:20) and serum (1:40). Tuberculostatics were discontinued, and replaced with an empirical anti-brucella treatment with ceftriaxone, doxycycline, and rifampicin. The patient‘s symptoms improved steadily over the 3-week course of antibiotics, which paralleled improvement of CSF parameters. The patient was discharged with a good clinical recovery Discussion: Brucellosis is a bacterial infection caused by Brucella spp, the neurological presentation is varied and may include meningitis, encephalitis, cranial neuropathies, radiculitis, and peripheral neuropathy. The clinical presentation can be very similar to tuberculous meningitis. The main route of transmission is through the consumption of unpasteurized or contaminated dairy products. The diagnosis of neurobrucellosis is based on suggestive symptoms, positive cultures of cerebrospinal fluid for Brucella spp., or positive IgG agglutination titers for Brucella in the blood or CSF, presence of lymphocytic pleocytosis and increased protein levels in cerebrospinal fluid, and positive response to specific antibiotics. Radiological aspects and cerebrospinal characteristics can aid in diagnosis, but should be differentiated from other conditions causing similar symptoms, presentations of neurobrucellosis can also be diverse, with 45% of cases showing meningeal inflammation with post-contrast enhancement. The treatment of neurobrucellosis typically involves prolonged antibiotic therapy with Ceftriaxone, rifampicin and doxycycline. The duration of therapy may be extended to 4 to 6 months, and other regimens are available. Final comments: Given the atypical clinical presentation of neurobrucellosis, diagnosis can be challenging, and clinical suspicion is essential in patients presenting with chronic meningitis and a history of exposure in endemic regions.