Case Presentation: A 24-year-old male with no significant past medical history presented with five days of abdominal pain and lower extremity aching. He also reported subjective fevers, headache, emesis, and decreased appetite with a five-pound weight loss. On initial presentation, he was febrile to 100.9°F and physical exam was notable for diffuse abdominal pain, tender posterior cervical lymphadenopathy and lower extremity myalgias. The patient was newly found to be HIV positive with a CD4 count of 41/µL. During the hospital course, the patient developed neck stiffness but no abnormalities were seen on head computed tomography (CT). A lumbar puncture was performed that revealed lymphocytosis, elevated protein and decreased glucose in the cerebral spinal fluid (CSF) concerning for viral meningitis, however, viral studies were negative. Blood and urine cultures and stool testing were negative. Histoplasma and cryptococcal antigens and antibodies to a variety of microbes including murine typhus and bartonella were negative. However, serology was positive for IgM anti-brucella antibodies. Upon further questioning, the patient revealed he had likely consumed unpasteurized cheese sent to him by a relative from Mexico one month prior to presentation. The patient improved significantly after administration of doxycycline, rifampin and ceftriaxone recommended by the infectious disease service. Brucella specific tests of the CSF are currently pending.
Discussion: More aggressive variants of brucellosis have been described in immunocompromised patients. Co-infection with brucellosis in HIV patients has also been associated with accelerated progression to AIDS. A thorough social history including recent travel to or relatives living in endemic regions should prompt further inquiries regarding ingestion of unpasteurized dairy products or contact with infected sheep and other animals. An integral step in correctly diagnosing brucella infection is testing for murine typhus given the potential cross-reactivity of the brucella IgM and murine typhus IgG antibodies. Our patient’s negative murine typhus IgG antibody, positive brucella IgM antibody, clinical signs and symptoms, and CSF analysis all support the diagnosis of neurobrucellosis.
Conclusions: This case represents a classic presentation of brucella infection in a young patient with newly diagnosed HIV and recent consumption of unpasteurized cheese from Mexico which is a brucella-endemic region. Suspicion should be high in patients with compromised immune systems and whose social history reveals associations with endemic regions. Unexplained neurologic symptoms in these patients should prompt further evaluation for neurobrucellosis.