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.