Case presentation
A 41-year-old woman presented to the hospital with chronic headaches,
vertigo, and nausea. Her symptoms had started 8 months earlier with
blurred vision and headache, which was later diagnosed as pseudotumor
cerebri and was controlled with acetazolamide and topiramate. Her vision
acuity further decreased in the past 2 months ago, and myalgia and
intermittent fever were added to the previous complaints. She was
conscious at presentation with no focal neurological deficit. However,
her physical examination revealed bilateral papilledema. The chest test
and cranial nerves examination were all normal. At presentation, routine
laboratory tests were all in the normal range except for an increased
erythrocyte sedimentation rate (ESR) (45 mm/h) and lactate dehydrogenase
(LDH) (540 U/ml). Magnetic resonance imaging and computed tomography of
the brain revealed no occupying lesion or other abnormalities. A lumbar
puncture was performed in order to decrease the intracranial pressure.
The cerebrospinal fluid (CSF) examination revealed an opening pressure
of more than 40 cmH2O, white blood cell (WBC) count of 87 cells/mm (79%
lymphocytes and 21% neutrophils), and protein and glucose
concentrations of 43 and 83 mg/dl, respectively. Due to this
significantly increased ICP, she was a candidate for CSF shunt to
prevent further visual loss. Nevertheless, considering the patient’s
chronic neurologic symptoms and also the lymphocyte dominancy of the CSF
analysis, a serum brucella agglutination test (BAT) was done, which
demonstrated a positive Wright test with a titer of 1:80 and 2ME titer
of 1:40. Interestingly, the CSF wright test was also positive with a
titer of 1:40. Hence, she was started on treatment with gentamycin,
ceftriaxone, doxycycline and rifampin with the diagnosis of
neurobrucellosis. She gradually improved clinically after two weeks
without needing CSF shunting or other neurosurgical intervention.