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Case Reports Indian Pediatrics 2003; 40:565-568 |
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Neurobrucellosis |
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P.G. Samdani Shalaaka Patil
Correspondence to: Dr. P.G. Samdani, 217, Mehta House,
2nd Floor, 36 Pandita Ramabai Road, Opp. Bhartiya Vidya Bhawan,
Chowpathy, Mumbai 400 007, India. Manuscript received: February 1, 2002; Initial review completed: August 21, 2002; Revision accepted: January 7, 2003.
Brucellosis is a zoonotic infection having a varied clinical presentation. The diagnosis is often delayed and difficult to make as the signs and symptoms may be overt or subtle. It is transmitted to humans by direct contact with infected animals and their products of conception and discharges or by consuming infected milk, milk products and meat(1). To our knowledge, no case of childhood neurobrucellosis has been reported from India. Case Report A 6-year-old female presented with high grade fever without chills for 15 days duration and one episode of left focal convulsion without residual focal neurological deficit. She was conscious with normal reflexes and no meningeal signs. There was no lymph-adenopathy or skin rash. Liver was palpable 3 cm and spleen 2 cm below costal margins. Rest systemic examination was normal. On investigation, total leucocyte count was 8,600 per cumm with 52% polymorphs, 45% lymphocytes and 3% monocytes. Liver and renal function tests were normal. Widal test was positive with O titer 1:320 and H titer 1:160. 2D-ECHO and CT-brain was normal. Ciprofloxacin was given for 10 days and valproate sodium (20 mg/kg/day) was started for seizures. After 20 days, she again developed right focal convul-sions without focal deficit. Cerebrospinal fluid (CSF) examination showed 6 lympho-cytes/mm3, 2 polymorphs/mm3, proteins of 60 mg/dl, sugar of 44 mg/dl and chlorides of 127 mg/dl, with a positive Pandy’s test. Mantoux test and CSF-PCR for tuberculosis was negative. Chest X-ray was normal and magnetic resonance imaging (MRI) of brain showed thickening of gyri in both hemispheres suggestive of cerebritis. Repeat Widal test showed the same titers as before. As blood level for valproate was subtherapeutic (42.2 µg/ml), dose was increased to 30 mg/kg/day. Ciprofloxacin was repeated for 10 days. However, at the end of treatment she developed high grade fever and unconsciousness along with weakness on right side of body with power of grade III/V, extensor plantars and brisk deep tendon reflexes. There were signs of raised intracranial pressure like hyperventilation and decerebration. Antimitochondrial antibody, serum herpes simplex virus IgG and IgM and antinuclear antibody was negative. CSF viral studies for herpes, Japanese encephalitis-B and West Nile fever were negative. In view of non response to ciprofloxacin, fixed raised widal titers and changing neurological signs, blood titers for antibody against brucella was done by serum agglutination test (SAT). The titers were B. abortus 1:160 and B.melitensis 1:80. Antibody to brucella in CSF could not be done. Therapy was started with intravenous gentamicin (7.5 mg/kg/day in 2 divided doses), oral doxycycline (5 mg/kg/day) and rifampicin (20 mg/kg/day) to which patient started responding. Within 7 days she was conscious, started talking and walking. The repeat antibody titers after 18 days showed rising titers (B. abortus = 1:640, B. melitensis = 1:320). After 21 days gentamicin was replaced with intramuscular streptomycin (20 mg/kg/day). After 2 months of treatment brucella titers were B. abortus = 1:160 and B.melitensis = 1:80. Streptomycin, doxy-cycline, rifampicin and valproate were continued for 6 months. Monitoring of renal, hepatic and auditory function was normal. Child is normal till one year follow up. Discussion Neurobrucellosis is uncommon but a serious complication of brucellosis. It has diverse clinical picture from meningo-encephalitis, myelitis, rediculitis, cranial nerve involvement (acoustic nerve paralysis commonest), brain abscess and subarachnoid hemorrhage to Guillain Barre syndrome(2,3). Dignostic titers of brucella antibody are above 1:160 in non-endemic area and 1:320 in endemic area(3). Widal test may be false positive. Our patient had low titers of Brucella antibodies at time of diagnosis which increased subsequently and finally decreased with treatment. Blood and CSF cultures should be incubated for 6 weeks if brucella is suspected(3). CSF may be acellular or show pleocytosis with normal or slightly elevated protein and normal sugar(2,4). It may be difficult to obtain positive blood and CSF cultures in chronic cases(3,4). CT-Brain findings range from normal, mild brain atrophy and hypodense areas to abscesses in affected lobes which revert back to normal after 3 months of therapy(2,3,5). Table I Chemotherapy of Brucellosis
Netilmicin (dose 2mg/kg/24 hrs in 12 hourly divided dose IV/IM) is preferred over gentamicin or Streptomycin. Netilmicin trough levels in plasma monitored and maintained <2 µg/ml(6). Doxycycline with streptomycin is more effective than doxycycline with Rifampicin as Rifampicin decreases levels of doxycycline in plasma(6). Doxycycline can be given in renal failure instead of amino glycosides(6). PO = Per oral, IV = Intravenous, IM = Intramuscular. According to revised recommendations (1986) of joint FAO/WHO Expert Committee on Brucellosis, doxycycline and rifampicin are recommended over streptomycin and tetracyline in adult brucellosis(4,5). Treat-ment with co-trimoxazole is acceptable alternative to tetracycline and doxycycline for children less than 8 years. However, doxycycline can be used in complicated cases in endemic area where discoloration of teeth is of secondary importance(3). Relapses are inversely related to number of drugs used and duration of therapy. Table I summarizes the treatment guidelines for brucellosis. Contributors: PGS and SP worked up the case and reviewed the literature. Funding: None. Competing Interests: None stated. | ||||||||||||||||||
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