Hearing loss in patient with neurobrucellosis.

To the Editor: Brucellosis is a multi-systemic infection that can affect any organ system in the body. Neurobrucellosis is an uncommon, but serious complication of brucellosis. It occurs in less than 5% of patients and usually presents as acute or chronic meningitis in patients with brucellosis. (1-3) Neurologic manifestations of brucellosis include meningitis, encephalitis, myelitis, ra-diculoneuritis, intracerebral abscess, epidural abscess, demyelination and meningovascular syndromes. (4) Cranial nerve involvement is rarely seen in neurobrucellosis. (1-3) Here, we report a case of neurobrucellosis with neuromuscular weakness and hearing loss.

A 19-year-old female patient presented with a history of headache and gradually progressive weakness and pain in the lower limbs of 3 months' duration that caused difficulty with sitting, standing and climbing stairs. She also had hearing loss and lost 20 pounds of body weight. On examination, the patient was afebrile, and vital parameters were normal. Neurologically, she was conscious, alert and orientated. There was no papilledema, neck stiffness was minimal and other meningeal signs were absent. She had impaired sensations in both lower limbs, and deep tendon reflexes were absent in the lower extremities. She was examined by an otolaryngologist and audiogram revealed sensorineural hearing loss with 100% in the left ear and 50% in the right ear. The laboratory results revealed a leukocyte count of 4.10 X [10.sup.9]/L, neutrophil count of 2.40 X [10.sup.9]/L, C-reactive protein (CRP) of 1.1 mg/L, and erythrocyte sedimentation rate (ESR) of 14 mm/h. Lumbar puncture was performed. Cerebrospinal fluid (CSF) examination showed 195 lymphocytes/[mm.sup.3], 6 polymorphonuclear cells/mm3, protein of 4190 mg/L, glucose of 40 mg/dL (serum glucose: 125 mg/dL at the same time). The patient had a positive history of fresh cheese ingestion, so a Wright agglutination test was also performed and the titer was found to be positive at 1:160. This test was also positive at 1:40 for CSF. Contrast enhancement in the spinal root at the lumbosacral level was revealed by magnetic resonance imaging. With these clinical and laboratory findings, the patient was diagnosed with neurobrucellosis. Oral doxycycline 100 mg twice a day, rifampicin 600 mg once a day and trimethoprim/sulfamethoxazole 160/800 mg twice a day treatment was started with gabapentin 800 mg three times a day and tramadol 100 mg twice a day.

Methylprednisolone therapy (48 mg/d) was started as the otolaryngologist offered on the 14th day, and it was gradually tapered off. After 4 weeks, her neurologic status improved. She gradually regained power in both lower limbs and was able to walk without assistance. After discharge, the combination therapy was continued for 12 weeks. On follow-up, all clinical abnormalities were completely resolved except for the hearing loss.

Although uncommon, neurobrucellosis can affect any part of the central or peripheral nervous system, and clinical symptoms are diverse. Brucellosis can cause meningitis, encephalitis, neuritis, brain abscess, demyelination, transient ischemic attacks, occlusive vascular disease, sensorineural hearing loss, vertigo and meningovascular syndromes. (5,6) Hearing loss in brucellosis may develop following involvement of the central auditory pathways. (5) Cranial nerve involvement in neurobrucellosis has been found to be part of the varied neurologic presentation, and there appears to be a predilection for the ves-tibulo-cochlear cranial nerve, leading to sensorineural hearing loss. (7,8)

The diagnosis of neurobrucellosis may be missed, as this infection can imitate various diseases or may present as a subclinical presentation. Patients may be admitted with neurologic, psychiatric or eye disorders. The presence of obscure or unexplained neurologic, psychiatric and eye disorders should alert the clinician to the possibility of neurobrucellosis in endemic regions. We conclude that the diagnosis of neurobrucellosis should be considered in patients presenting with chronic meningitis syndromes with or without cranial nerve involvement and/or myeloradiculopathy from areas endemic for brucellosis.

Atahan Cagatay

Asli Karadeniz

Halit Ozsut

Haluk Eraksoy

Semra Calangu

Department of Infectious Diseases and Clinical Microbiology

Istanbul Faculty of Medicine

Istanbul University

Istanbul, Turkey

References

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3. Sunmez S, Cagatay A, Karadeniz A, et al. A case of acute hepatitis due to brucellosis. South Med J 2006;99:632-633.

4. Young EJ. Brucella species. In: Mandell GL, Bennet JE, Dolin R, eds. Principles and Practice of Infectious Diseases, ed 5. Philadelphia, PA: Churchill Livingstone, 2000, ed 5, pp2386-2393.

5. Bayazit YA, Namiduru M, Bayazit N, et al. Hearing status in brucellosis. Otolaryngol Head Neck Surg 2002;127:97-100.

6. Young EJ. An overview of brucellosis. Clin Infect Dis 1995;21:283-289.

7. Thomas R, Kameswaran M, Murugan V, et al. Sensorineural hearing loss in neurobrucellosis. J Laryngol Otol 1993;107:1034-1036.

8. Shakir RA, al-Din ASN, Araj GF, et al. Clinical categories of neurobrucellosis. Brain 1987;110:213-223.