Case presentation
A 21-year-old Iranian man from rural area of Ardebil was admitted to our hospital with bilateral frontal headache, binocular horizontal diplopia, bilateral non-pulsatile tinnitus, and occasional vomiting for three months. There was no history of drug use and weight gain or loss. His past medical and familial history were negative. He took non-pasteurized diary regularly. Physical examination did not reveal any pathology such as lymphadenopathy or organomegaly. Neurological examination was normal except ophthalmological examination that revealed bilateral stage III papilledema. There was no fever, meningeal irritation, and change of mental status. An intracranial hypertension was suspected and the patient was hospitalized. Brain magnetic resonance imaging (MRI) and magnetic resonance venography (MRV) were normal (Figure 1). In first lumbar puncture (LP), the opening cerebrospinal fluid (CSF) pressure was 60cmH2O and microscopic examination of the CSF revealed 30 cells/ml white blood cells (WBC) with lymphocytic prominence, elevated protein level (80mg/dl, normal 15-45 mg/dl) and glucose level was 51 mg/dl. Other laboratory data including vasculitis were normal and mentioned with detail in Table 1. CSF culture was checked for chronic meningitis including fungal, Tuberculosis, and brucellosis, Brucellosis PCR in CSF was positive while wright, coombs wright and 2 ME tests in serum all were negative. The patient was diagnosed with chronic neurobrucellosis meningitis complicated intracranial hypertension and was treated with Rifampin (600mg/daily) and Doxycycline (100mg/BD) for 24 weeks, intravenous ceftriaxone (2g/daily) for 6 weeks, and Streptomycin (2gr/daily) for two weeks. Because, CSF pressure was 31 cmH2O in the last LP, acetazolamide was continued (250mg/QID). The patient’s clinical condition gradually improved. CSF pressure decreased with medical treatment (20cmH2O) and visual loss improved within four weeks, and he discharged after 6 weeks with on follow up after 8 weeks, he reported lower bilateral radicular pain and weakness. Electromyography was suggestive of bilateral mild subacute L5-S1 radiculopathy, and prednisolone 50 mg was added to his regime for 2 weeks. In follow up, there was significant clinical improvement, and CSF PCR for brucellosis became negative on 1-year follow-up.