Discussion
Brucellosis is one of the most common zoonosis infection caused by the bacteria of genus Brucella, and involving multisystem including liver, nervous and musculoskeletal (5). It is transmitted by eating or drinking contaminated animal products or with a direct contact with infected animals(1). The neurobrucellosis is detected in 3-5% of the patients that has been categorized as acute meningoencephalitis, chronic meningitis with intracranial hypertension, meningovascular involvement, neuropathy, radiculopathy, and myelitis (2,6). Sometimes neurological findings may be the only symptoms of brucellosis and neurobrucellosis should always be considered in the differential diagnosis of neurological, rheumatologically, and neuropsychiatric presentation in endemic regions for brucellosis(7,8). Chronic meningitis with increased intracranial pressure has been rarely encountered as an initial manifestation of neurobrucellosis and studies on this complications are scarce and limited to case reports and series (9,10). Papilledema, headache, vomiting, and blurred vision are the main presenting features of intracranial hypertension due to chronic neurobrusellosis meningitis. meningeal irritation, and focal neurological deficit are not seen in these patients(2,11). Lumbar radiculopathy is detected in 9.1% of the patients that often affects the lumbar (especially at the L4-L5 level) and low thoracic vertebrae than the cervical spine. Back pain and sciatica radiculopathy are the most common complaints about patients(12,13). While it is endemic in many countries, it is frequently misdiagnosed due to its nonspecific presentations, and it requires a high index of suspicion and special care to be cured(14). Because neuroberocellosis does not present a typical clinical picture, it is suspected in patients with chronic neurological symptoms accompanied by CSF lymphocytosis or compatible neuroimaging findings. It is confirmed by positive serum brucella agglutination test, positive serological tests (increased brucella antibody in the CSF), positive CSF wright test, and isolation of brucella species or detection of brucella DNA in the CSF with PCR test(5,15). The detection of high antibody titers(>=1/160) is considered diagnostic together with a compatible clinical presentation(16). In a study by Al-Sous et al. four types of imaging have been reported: normal, inflammation, white matter involvement, and vascular insult(17). There is no consensus on the choice of antibiotic, dose and duration of antimicrobial treatment for neurobrucellosis, and there are no randomized controlled trials. A combination of four antibiotics including Rifampin, Doxycycline, Streptomycin, and ceftriaxone for 3-6 months is commonly used until the clinical manifestations vanish and the CSF returns to normal(5,18). One –fifth of patients treated for neurobrucellosis experience lower limb weakness. Conversation management is the most adopted method of treatment across various studies for radiculopathy. The main reason for the success of conservative management is early diagnosis, strict adherence to the antibiotic protocol, and regular follow up(10,13). The disease generally has a good prognosis if treated appropriately and is curable within a few months with minimal risk of relapse and chronicity, but severe neurological outcomes have been reported(14). Here, we have presented a rare case of neurobrucellosis with concomitant intracranial hypertension and L5-S1 radiculopathy without evidence of another systemic symptoms of brucellosis while only two patients with concomitant of these two complications have been reported (table 2). This case and simultaneous cases highlight that in endemic areas of Brucellosis, the possibility of neurobrucellosis must be considered in patient with chronic headache or other common symptoms of intracranial hypertension with or without radiculopathy.
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