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| Year : 1999 | Volume
: 47
| Issue : 1 | Page : 58-60 |
Systemic brucellosis with chronic meningitis : A case report.
Ghosh D, Gupta P, Prabhakar S
Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, U.T., 160012, India.
Correspondence Address:
Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, U.T., 160012, India.
A young adult presenting with 11 months history of fever, headache, vomiting was found to have CSF lymphocytic pleocytosis with increased protein. His serum tested strongly positive for Brucella (standard tube agglutination titre 1: 320) whereas CSF was weakly positive. He became asymptomatic on treatment with tetracycline, rifampicin and streptomycin with significant CSF response. This case is reported because of its rarity.
How to cite this article:
Ghosh D, Gupta P, Prabhakar S. Systemic brucellosis with chronic meningitis : A case report. Neurol India 1999;47:58-60 |
Brucellosis caused by various strains of Brucella, is acquired by consuming unpasteurised dairy products or by close contact with cattle.[1],[2] However, history of exposure to cattle may not be available and in that case the route of infection is via aerosol inhalation.[3] Most of the patients with systemic brucellosis present with pyrexia of unknown origin. About 5% have predominant central nervous system (CNS) involvement.[3],[4] We present here a patient with systemic brucellosis complicated by chronic meningitis.
A 22 year old villager from Haryana presented with fever and headache of 11 months duration. Fever was remittent, reaching upto 106OF without any other localisation in the form of cough, dysuria or gastrointestinal disturbances. Headache was global, continuous and mild to start with. It became severe bursting for about a week prior to admission and was associated with projectile vomiting 3-4 times a day. He complained of int rmittent pain in multiple large joints without any swelling. There was no associated anorexia, weight loss, seizures, altered sensorium or focal neurologic deficit. On enquiry, he gave history of milking cows and goats daily and consumption of raw milk. He had been seen by various physicians and treated with antimalarials, antitubercular drugs and for enteric fever without any response. He had been given intravenous inj. cefotaxime l gm twice daily and inj crystalline penicillin 20 lac units 4 hourly, a week before coming to hospital.
On examination, his pulse was 96/min, B.P. 130/80 mm Hg, temperature 101OF. There was no pallor, icterus, clubbing, jaundice, lymphadenopathy, skin rash, joint swelling or tenderness. Cardiovascular and respiratory system were unremarkable. Liver (palpable 2 cms below the right costal margin, spanning 12 cms) was firm and nontender. CNS examination revealed normal higher mental functions and cranial nerves (including fundus). There was no motor or sensory deficit. He had no meningeal signs.
The investigations revealed haemoglobin of 10.5gm, ESR 45 mm in lst hour. Serum albumin was 3.6 and globulin 3.4 gm/dl. Rest of the blood biochemical parameters including renal and liver function tests were within normal limits. Chest X-ray was normal. Mantoux test was negative. Rheumatoid factor, LE cell and antinuclear factor were absent. Blood and urine cultures were sterile. Brucella serology in blood, done by standard tube agglutination (STA) method, was positive (titre 1:320). Plain and contrast enhanced CT scan brain were normal. CSF examination, at admission, showed a 140cells/mm3 with 70% lymphocytes and 30% polymorphs, protein of 100mg and sugar 60mg. Routine Gram staining, India ink preparation and acid fast staining were negative. Fungal, tubercular and bacterial cultures, including that for Brucella, did not grow any organism. CSF Brucella agglutinin titre by STA method was 1:20 (normal <1:20). Repeat CSF examination after 3 weeks of treatment for brucellosis showed reduction of cells to 40/mm3 and proteins to 50 mg%.
The patient was treated with cap. Tetracycline 500mg 6 hourly, cap. Rifampicin 450mg twice daily and inj. Streptomycin 750mg intramuscularly twice daily. Follow up, two months later, revealed an asymptomatic patient.
Brucellosis should be common in India because of improper methods of animal husbandry, poor standards of hygiene and food habits.[4] All species of Brucella are abundant in Indian cattle. It is quite surprising that there is scanty literature available on human brucellosis[2] in general and neurobrucellosis, in particular, from our country. It may be possible that many cases remain undiagnosed because of lack of high index of suspicion and, above all, the investigative facilities. Neurobrucellosis may present with meningo-encephalitis, meningomyelitis, papilloedema without localisation, meningovascular involvement (TIA or stroke), peripheral and cranial neuritis, central or peripheral demyelination and spondylitis.[2],[5],[6], Meningeal involvement with CSF abnormality is seen in all cases of neurobrucellosis irrespective of the mode of presentation.[7],[8],[9] The criteria necessary for definite diagnosis of neurobrucellosis are 1) neurological dysfunction not explained by other neurologic diseases, 2) abnormal CSF indicating lymphocytic pleocytosis and increased protein, 3) positive CSF culture for Brucella organisms or positive Brucella IgG agglutination titre in the blood and 4) CSF, response to specific chemotherapy with a significant drop in the CSF lymphocyte count and protein concentration. Our patient fulfilled all the above mentioned criteria for the diagnosis of neurobrucellosis except that the CSF IgG agglutination titre was not significantly high. Demonstration of Brucella organism from CSF in culture media is the confirmatory test for diagnosis of neurobrucellosis. However, this is uncommon in most of the series and yield does not exceed 30%. STA test may give false negative titre because of the blocking antibodies.[9] This can be the reason for low CSF Brucella titre which was not significantly higher in the present case though serum was strongly positive. False positive Brucella agglutination tests may also occur because of Brucella skin tests, cholera vaccination, acute infection with Vibrio cholerae, Francisella tularensis, Yersinia enterocolitica. Our patient was neither vaccinated nor had he undergone skin test. He had no gastrointestinal symptom and none of those infections causes of chronic meningitis presenting as headache and fever for almost a year , with associated high CSF protein and lymphocytic pleocytosis. Improvement of clinical and CSF parameters only on antibrucella treatment gives further credence to the aetiology. The patient was given 3 month treatment with triple drug regime (tetracycline, rifampicin and streptomycin) as recommended by Al-Deeb et al.[2] Response, as expected, was good.
We suggest every clinician to have a high index of suspicion to rule out Brucella in any case of chronic meningitis of apparent unproven aetiology. It may be possible that many cases of tuberculous meningitis are basically cases of neurobrucellosis receiving unnecessary prolonged therapy. It is to be noted that both share someommon drugs for treatment.
To conclude, the case reported should alert clinicians to investigate for Brucella in any case of pyrexia of unknown origin and also to look for this condition in chronic meningitis. [1],[10],[11],[12] This becomes significant if we realise that there is an abundance of cattle population harboring all Brucella serotypes in rural India and people have very poor milk hygiene, thus providing an ideal stage for developing brucellosis.
| 1. | Young EJ : Human Brucellosis. Review of Infectious Diseases 1983; 5 : 821-842.  |
| 2. | Al-Deeb SM, Yakub BA, Sharif HS, : Neurobrucellosis. In: A.A. Harris (Editor), Handbook of Clinical Neurology, Vol. 8(52) - Elsevier Science Publishers, Amsterdam 1988; 581-601. |
| 3. | Al-Deeb SM, Phadeke J, Yaqub BA : Neurobrucellosis. Neurology 1988; 38 : 354. |
| 4. | Young EJ : Serologic diagnosis of human brucellosis : analysis of 214 cases by agglutination tests and review of the literature. Review of Infectious Diseases 1991; 13 : 359-372. |
| 5. | Nichols E : Meningoencephalitis due to brucellosis with the report of a case in which B. abortus was recovered from the cerebrospinal fluid and review of literature. Ann Intern Med 1951; 35 : 673-693. |
| 6. | Fincham RW, Sahs AL, Jeyut RJ : Protean manifestation of nervous system Brucellosis. J AMA 1963; 184 : 269-276. |
| 7. | Paston MA, Thomason RH : Meningitis due to Brucella in a child. Arch Dis Child 1936; 52 : 904-906. |
| 8. | Mugerwa RD, D'Arbela PG : Brucella meningitis - a case report and review of the literature. East Afr Med J 1976; 53 : 266- 269. |
| 9. | Al-Orainey I, Laajam MA, AL-Aska AK et al : Brucella meningitis. J Infect 1987; 14 : 141-145. |
| 10. | Bouza E, Garcia de la Torre M, Parras F et al : Brucella Meningitis Review of Infections Disease 1987; 9 : 810-822. |
| 11. | 11. Pasinal J, Combarios O, Palo JM, : Localised CNS brucellosis: report of 7 cases. Acta Neurol Scand 1988; 78 : 282-289. |
| 12. | 12. Guvene H, Korabay K, Okten A : Brucellosis in a child complicated with multiple brain abscesses. Scand J Infect Dis 1989; 21 : 333-336. |
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