A 20-year-old woman presented with left arm and leg numbness and weakness for 1 month. One week before admission, the symptoms had become particularly severe; they had been accompanied by a mild headache. The patient had a history of previous brucellosis. The diagnosis of brucellosis was first made 4 months previously. At that time, she was treated with rifampicin 600 mg/day and doxycycline 200 mg/day for 45 days. She had remained free of symptoms until 1 month previously.
Upon examination, the patient was afebrile, and neurological examination showed left hemiparesis. Routine laboratory analyses indicated only leukocytosis (19,500/mm3). The differential blood count indicated 85.6% neutrophils and 4.8% lymphocytes. The C-reactive protein (CRP) value (40 mg/dl) and sedimentation rate (38 mm/h) were elevated. An initial serological titer for Brucella was positive at 1:640 via Wright's agglutination test. Then, blood cultures were sent for Brucella. Magnetic resonance imaging (MRI) showed a 1.5 x 1.5 cm enhancing nodular lesion with moderate surrounding edema in the right parietal lobe (Fig. 1). These findings suggested a cerebral tumor. The patient underwent a right parietal craniotomy with the total excision of the neoplasm. The final examination of the pathological specimens showed a nongranulomatous encephalitis that consisted of diffuse lymphocytic infiltrates and perivascular lymphocytic cuffing (Fig. 2). The stains for mycobacteria, bacteria, fungi, and spirochetes were negative. These observations led us to investigate the etiology of encephalitis. Then, a lumbar puncture was performed. Examination of the CSF showed no pleocytosis, a protein concentration of 48 mg/dl, and a glucose level of 52 mg/dl. CSF samples were sent for Gram and Ziehl-Neelsen staining and bacterial, mycobacterial, and fungal cultures. Polymerase chain reaction (PCR) testing for Mycobacterium tuberculosis was performed as well. All results, as well as those of the CSF serologies for cytomegalovirus (CMV), Epstein-Barr virus (EBV), herpes simplex virus type 1 and 2 (HSV-1 and HSV-2), rubella, and toxoplasmosis, were negative. Serum serologies for human immunodeficiency virus, serum hepatitis C, CMV, EBV, HSV-1 and HSV-2, rubella, Borrelia burgdorferi, toxoplasmosis, and syphilis, except for serum hepatitis B, were negative. Wright's agglutination test in the CSF was positive at 1:320 titers. Eventually, Brucella melitensis was isolated in the blood culture. Based on these findings, the patient was diagnosed with neurobrucellosis, presenting as nongranulomatous encephalitis. Therapy with rifampin (600 mg/day), trimethoprim-sulfamethoxazole (640-3,200 mg/day), and ceftriaxone (2 g/day) was started and continued for 3 weeks. Thereafter, therapy with rifampin (600 mg/day) and trimethoprim-sulfamethoxazole (640-3,200 mg/day) was maintained, but ceftriaxone was replaced with doxycycline (200 mg/day), and the new antimicrobial combination was planned to be continued for 6 months. On hospital day 14, the patient's symptoms had apparently subsided. During the next 6 months, the patient will be followed up closely with serological, microbiological, and MRI imaging assays until complete recovery.