Received 17 November 2008; revised 3 February 2009; accepted 25 February 2009. Available online 9 May 2009.
Summary
Central nervous system involvement is a serious complication of brucellosis; data found in the literature are generally restricted to case reports and case series.
In this study we pooled the data from Turkish medical practice in order to gain a thorough understanding of the subject.
A search of Turkish publications on chronic neurobrucellosis was made using both Turkish and international databases.
A total of 35 publications were analyzed and 187 neurobrucellosis cases were evaluated.
Headache, fever, sweating, weight loss, and back pain were the predominant symptoms, while meningeal irritation, confusion, hepatomegaly, hypoesthesia, and splenomegaly were the most frequent findings.
The major complications in patients were cranial nerve involvement, polyneuropathy/radiculopathy, depression, paraplegia, stroke, and abscess formation. Antibiotics were used in different combinations and over different intervals.
The duration of antibiotic therapy reported ranged from 2 to 15 months (median 5 months).
The mortality was 0.5% with suitable antibiotics. Neurobrucellosis may mimic various pathologies.
For this reason, a thorough evaluation of the patient with probable disease is crucial for an accurate diagnosis and proper management of the disease.
Mohamed N. Seleem, Stephen M. Boyle and Nammalwar Sriranganathan
Received 29 January 2009; revised 4 May 2009; accepted 12 June 2009. Available online 21 June 2009.
Abstract
Brucellosis, especially caused by Brucella melitensis, remains one of the most common zoonotic diseases worldwide with more than 500,000 human cases reported annually.
The bacterial pathogen is classified by the CDC as a category (B) pathogen that has potential for development as a bio-weapon.
Brucella spp. are considered as the most common laboratory-acquired pathogens.
The geographical distribution of brucellosis is constantly changing with new foci emerging or re-emerging.
The disease occurs worldwide in both animals and humans, except in those countries where bovine brucellosis has been eradicated.
The worldwide economic losses due to brucellosis are extensive not only in animal production but also in human health.
Although a number of successful vaccines are being used for immunization of animals, no satisfactory vaccine against human brucellosis is available.
When the incidence of brucellosis is controlled in the animal reservoirs, there is a corresponding and significant decline in the incidence in humans.
Accepted 31 October 2005. Available online 2 May 2006.
Summary
Objective
To determine cognitive and emotional changes among neurobrucellosis patients. Methods
The patients with neurobrucellosis and controls with brucellosis without neurologic involvement were included in the study.
Neurobrucellosis was diagnosed by the following criteria:
(i) symptoms or clinical findings compatible with neurobrucellosis, including headache, confusion, mental and emotional changes;
(ii) isolation of Brucella spp. from CSF and/or demonstration of antibodies to Brucella ≥ 1/4 in the CSF;
(iii) the presence of lymphocytosis, increased protein and decreased glucose levels in the CSF; and
(iv) clinical improvement with appropriate treatment.
Two psychiatrists interviewed the patients, and performed the Hamilton Depression Rating Scale (HDRS) tests and Mini-Mental State Examination (MMSE) tests.
Results
Thirty-four neurobrucellosis cases and 30 patients with brucellosis without neurological involvement were studied.
The mean age was 41 years, 12 (41%) patients were female, 13 (46%) patients were farmers, and 7 (25%) patients were housewives.
Among the neurobrucellosis cases, before the antibiotic therapy, the mean MMSE test score was 21.6, one week after the therapy 22.7, and two weeks after the therapy 24.3 (p = 0.024, and p less than 0.001, respectively).
At the day of admission before therapy, the mean of HDRS test was 9.9, one week after therapy it was 7.8, and two weeks after therapy it was 5 (p = 0.014, and p less than 0.001, respectively). Conclusion
The cognitive and emotional disturbances among neurobrucellosis patients were documented by MMSE and HDRS tests.
These disorders improve by antibiotic therapy, without any anti-depressive or anti-psychotic therapy.
Meltem Arzu Yetkina, Cemal Buluta, Fatma Sebnem Erdinca, Behic Orala and Necla Tulekb
Received 6 February 2006; revised 3 May 2006; accepted 23 May 2006. Available online 17 August 2006.
Summary
Background
Brucellosis is a multisystem disease that may present with a broad spectrum of clinical manifestations and complications. Neurobrucellosis is one of the complications.
Methods
In this study, we describe our experience in the diagnosis, treatment, and the final outcomes of 20 patients with neurobrucellosis out of 305 patients with brucellosis, within a five-year period between January 1999 and June 2004.
Results
The rate of neurobrucellosis was 6.6%. Twelve males and eight females with a mean age of 37.4 years were investigated.
Fever, headache, confusion, and gait disorders were the main complaints.
The duration of their complaints varied between one week and six months.
On physical examination, 13 patients had fever, six had neck stiffness and confusion, three had motor deficit on either their upper or lower extremities, and four of them had diplopia.
The Rose-Bengal test and standard tube agglutination tests were positive in all of the patients.
Brucella melitensis was isolated from the blood of six of the 20 (30%) patients.
Cerebrospinal fluid (CSF) was analyzed in 18 patients.
Pleocytosis with a mean value of 244 � 106 cells/L, and high protein levels were detected in all.
A low glucose level in the CSF was detected in ten patients.
Patients were treated medically and a complete resolution was achieved in all. Conclusion
Patients with a Brucella infection occasionally manifest central nervous system involvement.
Clinicians, especially serving in endemic areas or serving patients coming from endemic areas should consider the likelihood of neurobrucellosis in the patients with unexplained neurological and psychiatric symptoms, and should perform the necessary tests on blood and CSF.
Rosario R. Trifiletti, Domenico A. Restivo, Piero Pavone, Salvatore Giuffrida and Enrico Parano
Received 29 February 2000; revised 17 May 2000; accepted 17 May 2000. Available online 15 September 2000.
Abstract
Brucellosis is an infection due to Brucella species and is characterized by acute febrile illness, chilly sensations, sweats, weakness, generalized malaise, body aches and headache.
The involvement of the nervous system is rare. A few cases have been reported with symptoms and sign of optic neuritis, meningoencephalitis, meningomyelitis and cranial nerve palsy.
We report a case with culture proven neurobrucellosis who presented with diabetes insipidus along with systemic signs.
Neuroimaging revealed multiple lesions in brain parenchyma, including the suprasellar region.
Both diabetes and suprasellar lesions improved markedly with specific antibiotic therapy.
Kadir Ceylana, Mustafa Kasm Karahocagil Yasemin Soyoral, Hayriye Sayarlolud, Hasan Karsen, Ekrem Dogan, Hayrettin Akdeniz, İrfan Bayram, Mustafa K�sem and Reha Erkoc
Received 20 December 2007; accepted 29 January 2008. Available online 18 April 2009.
Objectives
To examine our patients with brucellosis and renal involvement. Although brucellae have been recovered from the urine of patients with brucellosis, renal involvement is uncommon. Methods
The data from 15 patients (8 males and 7 females, mean age 43 � 18.9 years, range 16 to 80), who had been admitted to our hospital with the diagnosis of brucellosis with renal involvement from 1998 to 2006, were retrospectively evaluated.
Results
In almost all cases, urinalysis revealed hematuria and variable amounts of proteinuria; some of the patients had pyuria. Of the 15 patients, 14 had renal failure.
The etiology of renal failure was prerenal azotemia in 1, acute tubular necrosis because of nonsteroidal anti-inflammatory drug use in 1, anuric tubulointerstitial nephritis due to rifampin use in 1, nephritis accompanied by brucellar endocarditis in 3, brucellar endocarditis and tubulointerstitial nephritis-associated vasculitis in 1, brucellar membranoproliferative glomerulonephritis in 1, and brucellar tubulointerstitial nephritis clinically in 6 patients.
Hemodialysis was required in 5 patients.
Chronic renal failure developed in 1 patient, 2 patients were lost to follow-up, and renal function completely recovered in 11 patients.
Two patients underwent renal biopsy and membranoproliferative glomerulonephritis with intraglomerular infiltration of histiocytes was identified in 1 patient and chronic tubulointerstitial nephritis associated with vasculitis and immune complex nephritis features was identified in the other.
Conclusions
In areas endemic for brucellosis, this infection can be associated with hematuria, proteinuria, and renal failure. In addition, many diverse etiologies can play a role in the renal involvement associated with Brucella infection.
-------------------- Note: I'm NOT a medical professional. The information I share is from my own personal research and experience. Please do not construe anything I share as medical advice, which should only be obtained from a licensed medical practitioner. Posts: 4881 | From Middlesex County, NJ | Registered: Jul 2006
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bettyg
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caat
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Posts: 1436 | From Humboldt county ca usa | Registered: Mar 2002
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AliG
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Thanks for the bumps. I saw this & decided to read further.
I'm breaking this one up for Betty & others because I think it's worth reading.
Author: Robert Rust Jr, MD, Thomas E Worrell Jr Professor of Epileptology and Neurology, Co-Director of FE Dreifuss Child Neurology and Epilepsy Clinics, University of Virginia School; Clinical and Residency Training, Child Neurology, University of Virginia Hospital and Clinics
Updated: Jun 8, 2006
Follow-up
Further Inpatient Care
* Follow-up sampling of CSF in order to ensure clearance of evidence for inflammation or the presence of organisms is important in determining the efficacy and duration of antibiotic treatment.
Further Outpatient Care
* Follow-up care is needed to ensure compliance for a full 6-week course of antibiotics and to determine whether a relapse has occurred.
In some instances, a relapsing and remitting course similar to MS develops.
In such instances, treatment with triple therapy (as noted in Medical Care) may be undertaken for periods as long as 6 months or more.
* The prognosis for meningoencephalitis is generally good.
Chronic forms tend to have a less favorable prognosis.
The granulomatous and arachnoiditic changes tend to respond to antibiotic therapy, but the chronic meningoencephalitic and polyradiculopathic processes are less responsive.
Residual deficits, including deafness and weakness, may be found in a fair number of patients.
* Relapsing brucellosis must be distinguished from instances in which patients experience reinfection.
The degree of immunity induced by an initial attack of brucellosis may be inadequate to prevent reinfection.
Second, third, or even more instances of reinfection may occur, especially in veterinarians and others individuals with continual exposure to animals.
Some individuals acquire infection-induced hypersensitivity to Brucella antigens.
This may result in a severe local reaction due to accidental self-inoculation with Brucella vaccines.
Reactions of this sort are especially likely to be experienced by veterinarians and others who are responsible for inoculating animal herds.
Deterrence/Prevention
* Avoid consumption of unpasteurized milk and milk products, as well as raw or undercooked meats.
Education may be provided to the patient and family concerning risks and should emphasize avoiding anything identified as a specific cause in the case at hand.
Should the identified source be a live animal, the herd or flock from which it came should be investigated.
* Scrupulous hygiene may prevent infection, especially when practiced by individuals likely to have close contact with goats, sheep, cows, camels, pigs, reindeer, rabbits, or hares. Obviously, this contact is of greatest importance in areas of endemic disease.
* Considerable concern has been harbored by authorities concerning the utilization of Brucella species in biological weapons.
Airborne transmission of these bacteria is readily achieved via the mucous membranes of the conjunctivae, nasal passages, oropharynx, and respiratory tract.
Infection may occur as the result of lodging of organisms in cuts or abrasions.
As few as 10-100 organisms may produce infection via aerosol exposure.
The resulting disease may have any of the many various manifestations of which Brucella species are capable.
* Bichat guidelines have been established for the management of individuals at risk for or manifesting evidence of brucellosis after bioterroristic exposure.
Treatment regimens combining doxycycline with either streptomycin or rifampin are thought adequate in such situations and the combination of ofloxacin with rifampin is also cited.
However, currently no evidence exists concerning efficacy of postexposure prophylaxis as a method of preventing brucellosis (Bossi, 2004).
Complications
* Initiation of antibiotic treatment may provoke the Jarisch-Herxheimer reaction with clinical worsening and CSF changes from lymphocytic to polymorphonuclear predominance.
Prognosis
* In uncomplicated cases of acute brucellosis, fever, malaise, and many other manifestations improve rapidly with bed rest, while sustained physical activity may prolong or worsen the degree of illness.
o Considerable improvement from the symptoms of the acute "toxic" phase of illness occurs in most cases within a few weeks, with or without treatment.
In many cases this is followed by complete remission within 2-6 months.
o Recovery tends to be more rapid in individuals infected with B abortus than in those infected with B melitensis or B suis.
* Death seldom occurs as the consequence of acute brucellosis, although it has been reported.
Postmortem analysis of such cases confirms that the burden of acute brucellotic infection is borne by tissues of the lymphoreticular system.
* Recurrence of symptoms of acute brucellosis is not uncommon. The recurrent disease may be systemic or localized.
In some of these patients, the condition evolves into chronic brucellosis, which if untreated may be progressive.
* Chronic brucellosis is variously classified, but includes systemic and specific localized forms (including various types of neurobrucellosis), the characteristics of which are discussed in the Clinical section.
o The various forms of chronic brucellosis, including neurobrucellosis, are due to continued infectious disease, for which additional treatment is indicated and effective.
o Objective clinical and laboratory evidence for ongoing disease is demonstrable.
Patients who do not have such evidence and who complain of occasional mild symptoms similar to those found in acute brucellosis are likely to have psychoneurosis.
This complication of acute brucellosis does not usually resolve with anti-brucellosis treatments, although such treatments may exert placebo effects for individual bouts.
Psychiatric treatment may be indicated.
o The likelihood of recurrence is greater in individuals who are not treated or who are inadequately treated for acute brucellosis.
o Recurrence is possible even in properly treated patients who have had acute brucellosis.
Addition of oral rifampicin to oral tetracycline may reduce the recurrence risk for patients who are treated with that combined therapy for acute brucellosis.
o Chronic brucellosis may continue to trouble patients for as long as 25 years, but such cases are quite rare.
* Neurobrucellosis, a specific subtype of localized chronic brucellosis, has a variable outcome.
o Recovery of patients with acute brucellotic meningitis, meningoencephalitis, or disseminated encephalomyelitis is typically excellent.
o The likelihood of an excellent outcome from neurobrucellosis is thought to be increased when effective antimicrobial therapy is started early in the course of illness.
o There is as yet, however, no agreement on the criterion standard for treatment of neurobrucellosis. The issues involved are considered in the Treatment section.
o The Herxheimer reaction is either extremely uncommon or unknown in the treatment of neurobrucellosis.
o The scrupulousness with which seizures and cardiovascular complications are treated and supportive care is undertaken to manage incontinence and to prevent of bedsores is likely also to influence outcome.
o Some patients with neurobrucellosis manifest permanent deficits. The risk for permanent deficits is higher in certain subgroups of primary or secondary neurobrucellosis.
o Outcome is worse in cases in which neurobrucellosis is complicated by critical elevations of intracranial pressure.
Prompt recognition and effective treatment of raised intracranial pressure usually results in rapid and complete recovery, however.
In cases of malignant intracranial hypertension, surgical decompression has been advocated by some authorities as improving outcome and as a method of preventing death due to herniation.
o Permanent deficits may occur in individuals who have cerebrovascular occlusive strokes secondary to brucellar endocarditis, producing emboli that cause occlusions or prompt the development of intracerebral mycotic aneurysms.
Outcome may be poor in cases of intracranial mycotic aneurysm rupture with intracerebral or subarachnoid hemorrhage.
o The risk for permanent deficits is higher in individuals who develop osteoarthritic forms of brucellosis that compromise spinal cord or spinal roots due to spondylitic compressive myelopathy and radiculopathy.
The outcome for peripheral neuritis of the lower spinal nerves, which may be difficult to distinguish from spondylitic myelopathy, may be better than the outcome for disease secondary to musculoskeletal abnormalities.
Patient Education
* Education with regard to vectors, consumption of pasteurized or appropriately cooked foods, and hygiene may reduce the risk of contracting brucellosis for family members living in areas of endemic disease.
* Reassurance concerning recurrent symptoms that are not associated with clinical or laboratory evidence of acute brucellotic disease is important in some instances.
* For excellent patient education resources, visit eMedicine's Brain and Nervous System Center and Public Health Center. Also, see eMedicine's patient education articles Brain Infection and Foreign Travel.
Miscellaneous
Medicolegal Pitfalls
* Standard medicolegal risks for an infectious disease are applicable to brucellosis. Misdiagnosis, delayed diagnosis, and medication reactions/allergies are also medicolegal risks.
Special Concerns
* The zoonotic issues have been discussed. Vectors for human infection include goats, sheep, cows, pigs, camels, reindeer, rabbits, and hares. Brucella species pose a medical threat to herd animals.
This threat is of particular importance with regard to the induction of abortion by B suis infection. Herds can be protected by vaccination.
-------------------- Note: I'm NOT a medical professional. The information I share is from my own personal research and experience. Please do not construe anything I share as medical advice, which should only be obtained from a licensed medical practitioner. Posts: 4881 | From Middlesex County, NJ | Registered: Jul 2006
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AliG
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-------------------- Note: I'm NOT a medical professional. The information I share is from my own personal research and experience. Please do not construe anything I share as medical advice, which should only be obtained from a licensed medical practitioner. Posts: 4881 | From Middlesex County, NJ | Registered: Jul 2006
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AliG
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from the link above titled,'Differential Diagnoses & Workup - Brucellosis' (my bolding):
quote:The organisms are gram negative. It is important to note that the penetration of counterstain may be slow and limited; 3 minutes of immersion may be necessary to identify the gram negativity.
The organisms are small, nonmotile coccobacilli or short rods (0.5-1.5 �m in length, 0.5-0.8 �m in width).
They are devoid of flagella or endospores, and if any capsule is found, it may be quite small.
They occur singly or in small groups.
They are usually slow-growing, strict anaerobes, although in some instances minimal facultative aerobic growth may occur.
Could Brucella canis be the "Fry - Mystery bug"?!!!!
-------------------- Note: I'm NOT a medical professional. The information I share is from my own personal research and experience. Please do not construe anything I share as medical advice, which should only be obtained from a licensed medical practitioner. Posts: 4881 | From Middlesex County, NJ | Registered: Jul 2006
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AliG
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-------------------- Note: I'm NOT a medical professional. The information I share is from my own personal research and experience. Please do not construe anything I share as medical advice, which should only be obtained from a licensed medical practitioner. Posts: 4881 | From Middlesex County, NJ | Registered: Jul 2006
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