International Journal of Infectious Diseases (2004) 8, 379—381
http://intl.elsevierhealth.com/journals/ijid
LETTER TO THE EDITOR A case of intracranial abscess due to Brucella melitensis Although in developed countries the incidence of brucellosis has declined dramatically in recent years,1 it still remains endemic in Mediterranean and Middle Eastern countries such as Turkey.2 Brucella infection is often not recognized due to its multisystem manifestations and the clinical picture varies from that of an acute febrile illness with non-specific symptoms to one with localized suppurative complications.3 Neurobrucellosis is a rare complication. The most common clinical forms of neurobrucellosis involving the central nervous system are meningitis and myelitis.4 Brain abscess due to neurobrucellosis is exceedingly rare.5 In this report, a case with localized suppurative complications caused by Brucella melitensis is presented, demonstrating unusual involvement of the brain. A 70-year-old man presented with headache, nausea, vomiting and loss of vision. After a cranial magnetic resonance (MR) scan he was admitted after being diagnosed with a mass lesion in the right occipital lobe. His history revealed frequent ingestion of unpasteurized milk and cheese. On admission he was conscious but disorientated. The only pathological sign was a deficiency in the temporal vision of the left eye. Complete blood count and blood chemistry were within normal limits, except for mild leukopenia (leukocyte count: 4.2 109/L) and slightly high erythrocyte sedimentation rate (45 mm/hour). Preoperative MR imaging revealed an arachnoid cyst on the left side and a multiloculated mass lesion in the right occipital lobe, with edema (Figure 1). A right occipital (supratentorial) craniotomy was performed and the intracranial abscess was evacuated. Surgery of the complicated arachnoid cyst was not performed. A small, non-motile, Gram-negative coccobacillus was isolated from the abscess culture (BACTEC, Becton Dickinson, USA). Rods were poorly stained by conventional Gram stain. The organism was aerobic, and catalase and urease positive. The ability to produce H2S; a requirement
for supplementary carbon dioxide for growth; susceptibility to the aniline dyes basic fuchsin, thionine and safranin; growth on agar plate with streptomycin and lysis with tibilisi phage were all negative. Particle agglutination tests with anti-smooth A and M monospecific Brucella sera (Difco Laboratories, Detroit, Michigan, USA) were positive. The strain was identified as Brucella melitensis biotype 3. Cerebrospinal and blood cultures were negative. The patient was treated with doxycyline (100 mg twice daily) and rifampicin (300 mg twice daily) for 24 weeks. A contrast-enhanced MR scan 20 days after surgical evacuation showed complete resolution of the abscess with minimal residue (Figure 2). At follow-up review, the patient’s vision had improved and the patient remained asymptomatic during a seven-month follow-up period. Brucellosis may result in suppurative complications which most frequently involve the bones and joints, but rarely the brain.6,7 Although depression and mental inattention are common complaints, direct invasion of the central nervous system occurs in less than 5% of cases.4,8 Meningitis is the most frequently occurring complication in the central nervous system; reports of Brucella brain abscess are extremely rare.4,8,9 In the English literature, including this report, there have been eight patients to date for whom intracranial abscesses have developed as a complication of brucellosis.10—16 Four of the eight cases were children.10,13,15,16 The male:female patient ratio in the adult group was 2:2. The ages of these patients were 19, 41, 60 and 70 years and all had a history of consuming unpasteurized dairy products. All the adult patients, except this case, had a history of systemic brucellosis with a duration of two weeks to two months. Visual loss has been reported by others.14 Physical examination revealed mild splenomegaly in just one case and only one patient progressed to coma. Blood and CSF fluid cultures were negative in three of four patients. Cultures of CSF yielded B. melitensis in one case.14 Imaging studies revealed the location of abscesses were temporal/parietal, temporo-occipital, and frontal/chiasmatic; the location was not reported in
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Figure 1 Preoperative, contrast-enhanced CT scan of 70-year-old man with a space-occupying lesion in posterior fossa, vermis, and left cerebellar hemisphere. The highest part herniates through tentorial notch and is multiloculated. There is moderate hydrocephalus.
one case. The antibiotic regimens were doxycycline plus rifampicin in three cases, tetracycline plus streptomycin in one case and the duration of therapy varied between six to 24 weeks. There were no deaths or major neurological sequelae. The specific treatment for brucellosis is doxycycline and rifampicin, both of which cross the blood-brain barrier and have synergistic effects.10 Although a fatal prognosis and neurological sequelae are possible, aggressive treatment with evacuation of abscesses does show a good prognosis, as in this case. In conclusion, brucellosis must be considered when diagnosing patients with suspected spaceoccupying lesions and concomitant fever, especially in endemic areas. Conflict of interest: No conflicting interest declared.
References 1. Wise RI. Brucellosis in the United States:past, present, and future. JAMA 1980;244:2318—22. 2. C ¸eviker N, Baykaner K, Go ¨ksel M, Sener L, Alp H. Spinal cord compression due to brucella granuloma. Infection 1989; 17:304—5. 3. Abramson O, Rosenvasser Z, Block C, Dagan R. Detection and treatment of brucellosis by screening a population at risk. Pediatr Infect Dis J 1991;10:434—8.
Letter to the Editor
Figure 2 CT scan 10 day after operation shows nearly complete disappearance of the lesion, with minimal residue.
4. Shakir RA, Al-Din ASN, Araj GF, Lulu AR, Mause AR, Saadah MA. Clinical categories of neurobrucellosis. A rare report on 19 cases. Brain 1987;110:213—23. 5. Bahemuka M, Rahman AS, Panayiotopoulos CP, Al-Aska AK, Obeid T, Daif AK. Neurological syndromes of brucellosis. J Neurol Neurosurg Psychiatry 1988;51:1017—21. 6. Young EJ. Brucella species. In: Mandell GL, Bennett JE, Dolin R, editors. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases. 5th Edition. Philadelphia: Churchill Livingstone; 2000. pp. 2386—91. 7. Shoshan Y, Maayan S, Gomori JM, et al. Chronic subdural empyema: a new presentation of neurobrucellosis. Clin Infect Dis 1996;23:400—1. 8. Young EJ. Overview of brucellosis. Clin Infect Dis 1995; 21:283—9. 9. MacLean DR, Russel N, Khan MY. Neurobrucellosis: Clinical and therapeutic features. Clin Infect Dis 1992;15:582—90. ˘lu M, Ceylan S, Ko 10. Kaleliog ¨rk F. Brain ¨ksal I, Kuzeyli K, Aktu abscess caused by Brucella abortus and Staphylococcus aureus in a child. Infection 1990;6:386—7. 11. Ayala-Gaytan J, Ortego ¨n-Baquero H, De la Maza M. Brucella melitensis cerebellar abscess. J Infect Dis 1980;160: 730—2. 12. Stranjalis G, Singounas E, Boutsikakis I, Saroglou G. Chronic intracerebral Brucella abscess. J Neurosurg 2000; 92:189. ¨ kten A, Bektas¸ S. Brucellosis in a 13. Gu ¨venc¸ H, Kocabay K, O child complicated with multiple brain abscess. Scand J Infect Dis 1989;21:333—6. 14. Santini C, Baiocchi P, Berardelli A, Venditti M, Serra P. A case of brain abscess due to Brucella melitensis. Clin Infect Dis 1994;19:977—8. 15. Al-Eissa YA. Unusual suppurative complications of brucellosis in children. Acta Pediatr 1993;82:987—92.
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16. Galanakis E, Bourantas KL, Leveidiotou S, Lapatsanis PD. Childhood brucellosis in north-western Greece: a retrospective analysis. Eur J Pediatr 1996;155:1—6.
Sibel Gu ¨ndes¸* Meliha Meric ¸ Ays¸e Willke Department of Infectious Diseases University of Kocaeli, Faculty of Medicine 41900-Kocaeli, Turkey ˘ Sevil Erdenlig Veterinary Control and Research Institute Pendik-Istanbul, University of Kocaeli Faculty of Medicine 41900-Kocaeli, Turkey
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Kenan Koc¸ Department of Neurosurgery University of Kocaeli, Faculty of Medicine 41900-Kocaeli, Turkey *
Corresponding author. Tel.: +262 2335980 fax: +262 2335488 E-mail address:
[email protected] 6 May 2004 Corresponding Editor: Michael Whitby, Brisbane, Australia
