A forty-year-old housewife, from a very low socio-economic status group, presented with history of gradually progressive weakness of left lower limb of 6 months duration, rapidly progressive weakness of right lower limb of 8 days duration and urinary incontinence of 6 months duration. She had been living near a very unhygienic abattoir and admitted to drinking unpasteurised goat's milk. There was history of fever on and off with night sweats. There was no history trauma or past history of tuberculosis. On examination, she was moderately built and nourished. General physical examination was normal. She was febrile with a temperature of 99 F (37.2 C). Vital parameters were normal. Neurologically she was conscious, alert and orientated. Cranial nerve examination was normal. There was no papilledema and meningeal signs were absent. She had flaccid areflexic paraplegia with power 0/5 (MRC grade). She had impaired sensations in both lower limbs with a level at T10. Perianal sensations were impaired and she had poor anal tone. Routine haematological parameters revealed a total white blood cell (WBC) count of 13,980/cu mm with neutrophil predominance. Erythrocyte sedimentation rate ESR (Westergreen) was 50 mm in 1 hour. Standard agglutination test (tube) titer was 1:320 and 2-mercaptoethanol agglutination test titer was 1:80. Plain radiograph of lumbosacral spine was normal. MRI scan of the spine showed a lesion in the spinal cord extending from lower part of T12 to L2. It was hyper-intense on T1WI and iso-intense on T2WI There was cord edema extending cranially up to T10 (figure 1).
She underwent T11 to L3 laminectomy. The lower end of the cord and the conus medullaris were swollen and the cauda equina nerve roots were pushed to the right side. Myelotomy was done at the conus level. At a depth of about 0.5 cm, purulent fluid was encountered, which was sent immediately for microbiological analysis. Under operating microscope the abscess cavity was visualized through the limited myelotomy (fig 2). The abscess was completely evacuated, after which the cord and conus had become lax and pulsating well. Dura was closed completely.
Pus revealed gram-negative bacilli. It was inoculated aerobically [Brucella agar, chocolate and MacConkey media], and anaerobically [Kanamycin-vancomycin laked sheep blood agar (KVLB) and Bacteroides bile esculin agar (BBE)]. Brucella agar and CA were incubated in CO2 jar and after 2 days minute translucent colonies were seen. Gram stain from culture showed gram-negative bacilli. Oxidase, catalase, and urease test were positive. There was no H2S production and it was resistant to dye inhibition. The organism was confirmed as Brucella melitensis . The organism isolated in blood culture taken preoperatively, also was identified as Brucella melitensis.
Postoperatively she had fever, headaches and vomiting lasting for about 1 week. It subsided once antibiotics were instituted. She was started on injection streptomycin 1 gm once a day for 1 month with oral doxycycline 100 mgm twice a day for 1 month. After one month she received oral rifampicin 450 mgm once a day with oral doxycycline 100 mgm twice a day for 1 month. Dexamethasone was given only perioperatively and was rapidly tapered and stopped in the post-operative period. Post operatively she gradually improved in neurological status. At 2-year follow up she had grade 3/5 power in both lower limbs and was mobilising on a wheel chair. The urinary symptoms did not resolve and she continues to be on Foley catheter. She refused a repeat MRI scan, as she could not afford it.