Case Presentation: A previously healthy 48 year-old Guatemalan male presented with malaise, anorexia, 20-pound weight loss. Three weeks prior, he had fever, chills, emesis and diarrhea. A thorough history revealed that the patient was having intermittent confusion with labile, tearful mood swings. Lab-work confirmed pancytopenia, hyponatremia and mild transaminitis. Abdominal ultrasound showed hepatosplenomegaly. MRI brain showed “Interval development of diffuse pachymeningeal thickening and enhancement”. Patient had similar presentation two weeks prior and at that time MRI was unremarkable. Son disclosed that the patient had consumed unpasteurized goat cheese three months prior to the onset of symptoms and coworkers had similar symptoms. Patient was started on empirical treatment for Brucellosis with Doxycyline and Rifampicin. His depressed mood and neurologic changes were suspicious for Neurobrucellosis, so Ceftriaxone was added to the above regimen. Blood Cultures were positive for Brucella melitensis. Brucella Antibody was positive. RPR was negative. CSF showed 11 RBC, 3 nucleated cells, no organisms on culture. His neurological symptoms resolved rapidly after initiation of antibiotics and patient was back to baseline prior to discharge. The patient’s associated diarrhea, transaminitis and pancytopenia also improved during his hospital stay. Infectious Disease recommended completing a 6 week course of Ceftriaxone, Doxycycline and Rifampicin.
Discussion: Brucellosis is a zoonosis that presents with non-specific symptoms of fever, sweats, fatigue, anorexia, and weight loss. It occurs due to consumption of unpasteurized milk and milk products or by direct contact with infected animals. It is most commonly seen in the Mediterranean countries, Middle East, India, Mexico, South and Central America but is now also being seen in developed countries as a travel related illness. Neurobrucellosis is rare and occurs in <7% of the cases. Signs and symptoms are non-specific ranging from fever, malaise, headache to behavioral changes, depression, confusion, meningeal signs, and pseudotumor cerebri. The yield for a positive CSF culture is very low (5–30 %) but serological tests like enzyme-linked immunosorbent assay (ELISA) on CSF are helpful in diagnosis. Antibiotics are the mainstay of brucellosis treatment. Monotherapy is no longer recommended due to the high relapse rates. Combination therapy for prolonged duration is crucial in preventing relapses. Rifampicin (600-900 mg/day orally) plus Doxycycline (200 mg/day orally) for 6 weeks is the preferred regimen for uncomplicated brucellosis due to lower costs and higher adherence rates. It is recommended that Ceftriaxone (2g Q 12 hrs intravenously) should be added to the above regimen in Neurobrucellosis as Ceftriaxone achieves high concentrations in the cerebrospinal fluid, much higher than the MICs against Brucella.
Conclusions: Hospitalists commonly admit patients with systemic symptoms and confusion. The above patient could have been easily misdiagnosed as his presentation could have been attributed to a psychiatric illness, substance abuse or a nonspecific viral illness. A high index of suspicion and a history of consumption of unpasteurized milk or milk products are crucial to diagnose neurobrucellosis. CSF and imaging findings can be normal. It is important to start empiric treatment of neurobrucellosis early to decrease morbidity and prevent neurologic sequelae.