Neurologic Manifestations of Brucellosis Follow-up

  • Author: Robert Stanley Rust Jr, MD, MA; Chief Editor: Karen L Roos, MD   more...
 
Updated: Jan 11, 2010
 

Further Inpatient Care

Follow-up sampling of CSF in order to ensure clearance of evidence for inflammation or the presence of organisms is important in determining the efficacy and duration of antibiotic treatment.

Next

Further Outpatient Care

Follow-up care is needed to ensure compliance for a full 6-week course of antibiotics and to determine whether a relapse has occurred. In some instances, a relapsing and remitting course similar to MS develops. In such instances, treatment with triple therapy (as noted in Medical Care) may be undertaken for periods as long as 6 months or more.

The prognosis for meningoencephalitis is generally good. Chronic forms tend to have a less favorable prognosis. The granulomatous and arachnoiditic changes tend to respond to antibiotic therapy, but the chronic meningoencephalitic and polyradiculopathic processes are less responsive. Residual deficits, including deafness and weakness, may be found in a fair number of patients.

Relapsing brucellosis must be distinguished from instances in which patients experience reinfection. The degree of immunity induced by an initial attack of brucellosis may be inadequate to prevent reinfection. Second, third, or even more instances of reinfection may occur, especially in veterinarians and others individuals with continual exposure to animals. Some individuals acquire infection-induced hypersensitivity to Brucella antigens. This may result in a severe local reaction due to accidental self-inoculation with Brucella vaccines. Reactions of this sort are especially likely to be experienced by veterinarians and others who are responsible for inoculating animal herds.

Previous
Next

Deterrence/Prevention

Avoid consumption of unpasteurized milk and milk products, as well as raw or undercooked meats. Education may be provided to the patient and family concerning risks and should emphasize avoiding anything identified as a specific cause in the case at hand. Should the identified source be a live animal, the herd or flock from which it came should be investigated.

Scrupulous hygiene may prevent infection, especially when practiced by individuals likely to have close contact with goats, sheep, cows, camels, pigs, reindeer, rabbits, or hares. Obviously, this contact is of greatest importance in areas of endemic disease.

Considerable concern has been harbored by authorities concerning the utilization of Brucella species in biological weapons. Airborne transmission of these bacteria is readily achieved via the mucous membranes of the conjunctivae, nasal passages, oropharynx, and respiratory tract. Infection may occur as the result of lodging of organisms in cuts or abrasions. As few as 10-100 organisms may produce infection via aerosol exposure. The resulting disease may have any of the many various manifestations of which Brucella species are capable.

Bichat guidelines have been established for the management of individuals at risk for or manifesting evidence of brucellosis after bioterroristic exposure. Treatment regimens combining doxycycline with either streptomycin or rifampin are thought adequate in such situations and the combination of ofloxacin with rifampin is also cited. However, currently no evidence exists concerning efficacy of postexposure prophylaxis as a method of preventing brucellosis.[20]

Previous
Next

Complications

Initiation of antibiotic treatment may provoke the Jarisch-Herxheimer reaction with clinical worsening and CSF changes from lymphocytic to polymorphonuclear predominance.

Previous
Next

Prognosis

In uncomplicated cases of acute brucellosis, fever, malaise, and many other manifestations improve rapidly with bed rest, while sustained physical activity may prolong or worsen the degree of illness.

  • Considerable improvement from the symptoms of the acute "toxic" phase of illness occurs in most cases within a few weeks, with or without treatment. In many cases this is followed by complete remission within 2-6 months.
  • Recovery tends to be more rapid in individuals infected with B abortus than in those infected with B melitensis or B suis.

Death seldom occurs as the consequence of acute brucellosis, although it has been reported. Postmortem analysis of such cases confirms that the burden of acute brucellotic infection is borne by tissues of the lymphoreticular system.

Recurrence of symptoms of acute brucellosis is not uncommon. The recurrent disease may be systemic or localized. In some of these patients, the condition evolves into chronic brucellosis, which if untreated may be progressive.

Chronic brucellosis is variously classified, but includes systemic and specific localized forms (including various types of neurobrucellosis), the characteristics of which are discussed in the Clinical section.

  • The various forms of chronic brucellosis, including neurobrucellosis, are due to continued infectious disease, for which additional treatment is indicated and effective.
  • Objective clinical and laboratory evidence for ongoing disease is demonstrable. Patients who do not have such evidence and who complain of occasional mild symptoms similar to those found in acute brucellosis are likely to have psychoneurosis. This complication of acute brucellosis does not usually resolve with anti-brucellosis treatments, although such treatments may exert placebo effects for individual bouts. Psychiatric treatment may be indicated.
  • The likelihood of recurrence is greater in individuals who are not treated or who are inadequately treated for acute brucellosis.
  • Recurrence is possible even in properly treated patients who have had acute brucellosis. Addition of oral rifampicin to oral tetracycline may reduce the recurrence risk for patients who are treated with that combined therapy for acute brucellosis.
  • Chronic brucellosis may continue to trouble patients for as long as 25 years, but such cases are quite rare.

Neurobrucellosis, a specific subtype of localized chronic brucellosis, has a variable outcome.

  • Recovery of patients with acute brucellotic meningitis, meningoencephalitis, or disseminated encephalomyelitis is typically excellent.
  • The likelihood of an excellent outcome from neurobrucellosis is thought to be increased when effective antimicrobial therapy is started early in the course of illness.
  • There is as yet, however, no agreement on the criterion standard for treatment of neurobrucellosis. The issues involved are considered in the Treatment section.
  • The Herxheimer reaction is either extremely uncommon or unknown in the treatment of neurobrucellosis.
  • The scrupulousness with which seizures and cardiovascular complications are treated and supportive care is undertaken to manage incontinence and to prevent of bedsores is likely also to influence outcome.
  • Some patients with neurobrucellosis manifest permanent deficits. The risk for permanent deficits is higher in certain subgroups of primary or secondary neurobrucellosis.
  • Outcome is worse in cases in which neurobrucellosis is complicated by critical elevations of intracranial pressure. Prompt recognition and effective treatment of raised intracranial pressure usually results in rapid and complete recovery, however. In cases of malignant intracranial hypertension, surgical decompression has been advocated by some authorities as improving outcome and as a method of preventing death due to herniation.
  • Permanent deficits may occur in individuals who have cerebrovascular occlusive strokes secondary to brucellar endocarditis, producing emboli that cause occlusions or prompt the development of intracerebral mycotic aneurysms. Outcome may be poor in cases of intracranial mycotic aneurysm rupture with intracerebral or subarachnoid hemorrhage.
  • The risk for permanent deficits is higher in individuals who develop osteoarthritic forms of brucellosis that compromise spinal cord or spinal roots due to spondylitic compressive myelopathy and radiculopathy. The outcome for peripheral neuritis of the lower spinal nerves, which may be difficult to distinguish from spondylitic myelopathy, may be better than the outcome for disease secondary to musculoskeletal abnormalities.
Previous
Next

Patient Education

  • Education with regard to vectors, consumption of pasteurized or appropriately cooked foods, and hygiene may reduce the risk of contracting brucellosis for family members living in areas of endemic disease.
  • Reassurance concerning recurrent symptoms that are not associated with clinical or laboratory evidence of acute brucellotic disease is important in some instances.
  • For excellent patient education resources, visit eMedicine's Brain and Nervous System Center and Public Health Center. Also, see eMedicine's patient education articles Brain Infection and Foreign Travel.
Previous
 
Contributor Information and Disclosures
Author

Robert Stanley Rust Jr, MD, MA  Thomas E Worrell Jr Professor of Epileptology and Neurology, Co-Director of FE Dreifuss Child Neurology and Epilepsy Clinics, Director, Child Neurology, University of Virginia; Chair-Elect, Child Neurology Section, American Academy of Neurology

Robert Stanley Rust Jr, MD, MA is a member of the following medical societies: American Academy of Neurology, American Epilepsy Society, American Headache Society, American Neurological Association, Child Neurology Society, International Child Neurology Association, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Specialty Editor Board

Aashit K Shah, MD  Associate Professor of Neurology, Wayne State University; Program Director, Clinical Neurophysiology Fellowship, Department of Neurology, Detroit Medical Center

Aashit K Shah, MD is a member of the following medical societies: American Academy of Neurology, American Clinical Neurophysiology Society, and American Epilepsy Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Florian P Thomas, MD, MA, PhD, Drmed  Director, Spinal Cord Injury Unit, St Louis Veterans Affairs Medical Center; Director, National MS Society Multiple Sclerosis Center; Director, Neuropathy Association Center of Excellence, Professor, Department of Neurology and Psychiatry, Associate Professor, Institute for Molecular Virology, and Department of Molecular Microbiology and Immunology, St Louis University School of Medicine

Florian P Thomas, MD, MA, PhD, Drmed is a member of the following medical societies: American Academy of Neurology, American Neurological Association, American Paraplegia Society, Consortium of Multiple Sclerosis Centers, and National Multiple Sclerosis Society

Disclosure: Nothing to disclose.

Selim R Benbadis, MD  Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital

Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association

Disclosure: UCB Pharma Honoraria Speaking, consulting; Lundbeck Honoraria Speaking, consulting; Cyberonics Honoraria Speaking, consulting; Glaxo Smith Kline Honoraria Speaking, consulting; Pfizer Honoraria Speaking, consulting; Sleepmed/DigiTrace Honoraria Speaking, consulting

Chief Editor

Karen L Roos, MD  John and Nancy Nelson Professor of Neurology, Professor of Neurological Surgery, Department of Neurology, Indiana University School of Medicine

Karen L Roos, MD is a member of the following medical societies: American Academy of Neurology and American Neurological Association

Disclosure: Nothing to disclose.

References

  1. Pappas G, Papadimitriou P, Akritidis N. The new global map of human brucellosis. Lancet Infect Dis. Feb 2006;6(2):91-9. [Medline].

  2. Al Dahouk S, Nockler K, Tomaso H. Seroprevalence of brucellosis, tularemia, and yersiniosis in wild boars (Sus scrofa) from north-eastern Germany. J Vet Med B Infect Dis Vet Public Health. Dec 2005;52(10):444-55. [Medline].

  3. Al-Majali AM, Hussain NO, Amarin NM, Majok AA. Seroprevalence of, and risk factors for, peste des petits ruminants in sheep and goats in Northern Jordan. Prev Vet Med. Jun 15 2008;85(1-2):1-8. [Medline].

  4. Edwards C, Jawad AS. History of brucellosis. J R Soc Med. Feb 2006;99(2):54. [Medline].

  5. Al Dahouk S, Jubier-Maurin V, Scholz HC, Tomaso H, Karges W, Neubauer H, et al. Quantitative analysis of the intramacrophagic Brucella suis proteome reveals metabolic adaptation to late stage of cellular infection. Proteomics. Sep 2008;8(18):3862-70. [Medline].

  6. Badiaga S, Imbert G, La Scola B. Imported Brucellosis associated with Plasmodium falciparum malaria in a traveler returning from the tropics. J Travel Med. Sep-Oct 2005;12(5):282-4. [Medline].

  7. Fallatah SM, Oduloju AJ, Al-Dusari SN. Human brucellosis in Northern Saudi Arabia. Saudi Med J. Oct 2005;26(10):1562-6. [Medline].

  8. Alp E, Doganay M. Current therapeutic strategy in spinal brucellosis. Int J Infect Dis. Nov 2008;12(6):573-7. [Medline].

  9. Bouza E, Sánchez-Carrillo C, Hernangómez S, González MJ,. Laboratory-acquired brucellosis: a Spanish national survey. J Hosp Infect. Sep 2005;61(1):80-83. [Medline].

  10. Gerberding JL, Romero JM, Ferraro MJ. Case records of the Massachusetts General Hospital. Case 34-2008. A 58-year-old woman with neck pain and fever. N Engl J Med. Oct 30 2008;359(18):1942-9. [Medline].

  11. Solera J, Lozano E, Martínez-Alfaro E, Espinosa A, Castillejos ML, Abad L. Brucellar spondylitis: review of 35 cases and literature survey. Clin Infect Dis. Dec 1999;29(6):1440-9. [Medline].

  12. Ugarriza LF, Porras LF, Lorenzana LM, Rodríguez-Sánchez JA, García-Yagüe LM, Cabezudo JM. Brucellar spinal epidural abscesses. Analysis of eleven cases. Br J Neurosurg. Jun 2005;19(3):235-40. [Medline].

  13. James DG. A mimic of sarcoidosis: brucellosis [editorial]. Sarcoidosis. Sep 1990;7(2):87-8. [Medline].

  14. Sharif HS, Clark DC, Aabed MY, Haddad MC, al Deeb SM, Yaqub B. Granulomatous spinal infections: MR imaging. Radiology. Oct 1990;177(1):101-7. [Medline].

  15. Laboratory-acquired brucellosis--Indiana and Minnesota, 2006. MMWR Morb Mortal Wkly Rep. Jan 18 2008;57(2):39-42. [Medline].

  16. Araj GF, Kattar MM, Fattouh LG, Bajakian KO, Kobeissi SA. Evaluation of the PANBIO Brucella immunoglobulin G (IgG) and IgM enzyme-linked immunosorbent assays for diagnosis of human brucellosis. Clin Diagn Lab Immunol. Nov 2005;12(11):1334-5. [Medline].

  17. Darouiche RO. Spinal epidural abscess. N Engl J Med. Nov 9 2006;355(19):2012-20. [Medline].

  18. Kayani I, Kamani I, Syed I, Saifuddin A, Green R, MacSweeney F. Vertebral osteomyelitis without disc involvement. Clin Radiol. Oct 2004;59(10):881-91. [Medline].

  19. Katonis P, Tzermiadianos M, Gikas A, Papagelopoulos P, Hadjipavlou A. Surgical treatment of spinal brucellosis. Clin Orthop Relat Res. Mar 2006;444:66-72. [Medline].

  20. Bossi P, Tegnell A, Baka A. Bichat guidelines for the clinical management of brucellosis and bioterrorism-related brucellosis. Euro Surveill. Dec 2004;9(12):E15-6. [Medline].

  21. Abramsky O. Neurological features as presenting manifestations of brucellosis. Eur Neurol. 1977;15(5):281-4. [Medline].

  22. Abu Shaqra QM. Epidemiological aspects of brucellosis in Jordan [In Process Citation]. Eur J Epidemiol. Jun 2000;16(6):581-4. [Medline].

  23. Akdeniz H, Irmak H, Anlar O. Central nervous system brucellosis: presentation, diagnosis and treatment. J Infect. May 1998;36(3):297-301. [Medline].

  24. al Deeb SM, Yaqub BA, Sharif HS. Neurobrucellosis: clinical characteristics, diagnosis, and outcome. Neurology. Apr 1989;39(4):498-501. [Medline].

  25. al-Eissa YA. Clinical and therapeutic features of childhood neurobrucellosis. Scand J Infect Dis. 1995;27(4):339-43. [Medline].

  26. Araj GF, Brown GM, Haj MM. Assessment of Brucellosis Card test in screening patients for brucellosis. Epidemiol Infect. Jun 1988;100(3):389-98. [Medline].

  27. Araj GF, Lulu AR, Khateeb MI. ELISA versus routine tests in the diagnosis of patients with systemic and neurobrucellosis. APMIS. Feb 1988;96(2):171-6. [Medline].

  28. Bahemuka M, Shemena AR, Panayiotopoulos CP. Neurological syndromes of brucellosis. J Neurol Neurosurg Psychiatry. Aug 1988;51(8):1017-21. [Medline].

  29. Basaranoglu M, Mert A, Tabak F. A case of cervical Brucella spondylitis with paravertebral abscess and neurological deficits. Scand J Infect Dis. 1999;31(2):214-5. [Medline].

  30. Bashir R, Al-Kawi MZ, Harder EJ. Nervous system brucellosis: diagnosis and treatment. Neurology. Nov 1985;35(11):1576-81. [Medline].

  31. Bouza E, Garcia de la Torre M, Parras F. Brucellar meningitis. Rev Infect Dis. Jul-Aug 1987;9(4):810-22. [Medline].

  32. Brouillard JE, Terriff CM, Tofan A. Antibiotic selection and resistance issues with fluoroquinolones and doxycycline against bioterrorism agents. Pharmacotherapy. Jan 2006;26(1):3-14. [Medline].

  33. Bucher A, Gaustad P, Pape E. Chronic neurobrucellosis due to Brucella melitensis. Scand J Infect Dis. 1990;22(2):223-6. [Medline].

  34. Cerri D, Ebani VV, Pedrini A. Evaluation of tests employed in serological diagnosis of brucellosis caused by Brucella ovis [In Process Citation]. New Microbiol. Jul 2000;23(3):281-8. [Medline].

  35. Comerci DJ, Altabe S, de Mendoza D. Brucella abortus synthesizes phosphatidylcholine from choline provided by the host. J Bacteriol. Mar 2006;188(5):1929-34. [Medline].

  36. DeJong RN. Central nervous system involvement in undulant fever, with the report of a case and survey of the literature. Lancet. 1936;430-442.

  37. Dockal M, Carter DC, Ruker F. The three recombinant domains of human serum albumin. Structural characterization and ligand binding properties. J Biol Chem. Oct 8 1999;274(41):29303-10. [Medline].

  38. Estevao MH, Barosa LM, Matos LM. Neurobrucellosis in children. Eur J Pediatr. Feb 1995;154(2):120-2. [Medline].

  39. Fiori PL, Mastrandrea S, Rappelli P. Brucella abortus infection acquired in microbiology laboratories. J Clin Microbiol. May 2000;38(5):2005-6. [Medline].

  40. Fleming DO, Byers KB. Biological safety: Principles and Practices. 2000.

  41. Gokhle YA, Bichile LS, Gogate A. Brucella spondylitis: an important treatable cause of low backache. J Assoc Physicians India. Apr 1999;47(4):384-8. [Medline].

  42. Gomez MC, Rosa C, Geijo P. [Comparative study of the Brucellacapt test versus the Coombs test for Brucella]. Enferm Infecc Microbiol Clin. Jun-Jul 1999;17(6):283-5. [Medline].

  43. Hernandez MA, Anciones B, Frank A. [Neurobrucellosis and cerebral vasculitis]. Neurologia. Nov-Dec 1988;3(6):241-3. [Medline].

  44. Hong PC, Tsolis RM, Ficht TA. Identification of genes required for chronic persistence of Brucella abortus in mice. Infect Immun. Jul 2000;68(7):4102-7. [Medline].

  45. Jacobs F, Abramowicz D, Vereerstraeten P. Brucella endocarditis: the role of combined medical and surgical treatment. Rev Infect Dis. Sep-Oct 1990;12(5):740-4. [Medline].

  46. Khuraibet AJ, Shakir RA, Trontelj JV. Brainstem auditory evoked potential (BAEP) abnormalities in brucellosis. J Neurol Sci. Nov 1988;87(2-3):307-13. [Medline].

  47. Kochar DK, Kumawat BL, Agarwal N. Meningoencephalitis in brucellosis. Neurol India. Jun 2000;48(2):170-3. [Medline].

  48. Leggiadro RJ. The threat of biological terrorism: a public health and infection control reality. Infect Control Hosp Epidemiol. Jan 2000;21(1):53-6. [Medline].

  49. Lopes C, Oliveira J, Malcata L. [Spinal brucellosis. 4 years of experience]. Acta Med Port. Sep 1992;5(8):419-23. [Medline].

  50. Lopez-Urrutia L, Alonso A, Nieto ML. Lipopolysaccharides of Brucella abortus and Brucella melitensis induce nitric oxide synthesis in rat peritoneal macrophages. Infect Immun. Mar 2000;68(3):1740-5. [Medline].

  51. Lubani MM, Dudin KI, Araj GF. Neurobrucellosis in children. Pediatr Infect Dis J. Feb 1989;8(2):79-82. [Medline].

  52. Lulu AR, Araj GF, Khateeb MI. Human brucellosis in Kuwait: a prospective study of 400 cases. Q J Med. Jan 1988;66(249):39-54. [Medline].

  53. Madkour MM, Sharif HS, Abed MY. Osteoarticular brucellosis: results of bone scintigraphy in 140 patients. AJR Am J Roentgenol. May 1988;150(5):1101-5. [Medline].

  54. Mainar-Jaime RC, Vazquez-Boland JA. Associations of veterinary services and farmer characteristics with the prevalences of brucellosis and border disease in small ruminants in Spain. Prev Vet Med. Jun 11 1999;40(3-4):193-205. [Medline].

  55. Mantur BG, Akki AS, Mangalgi SS. Childhood brucellosis--a microbiological, epidemiological and clinical study. J Trop Pediatr. Jun 2004;50(3):153-7. [Medline].

  56. McLean DR, Russell N, Khan MY. Neurobrucellosis: clinical and therapeutic features. Clin Infect Dis. Oct 1992;15(4):582-90. [Medline].

  57. Milionis H, Christou L, Elisaf M. Cutaneous manifestations in brucellosis: case report and review of the literature. Infection. Mar-Apr 2000;28(2):124-6. [Medline].

  58. Mousa AM, Bahar RH, Araj GF. Neurological complications of brucella spondylitis. Acta Neurol Scand. Jan 1990;81(1):16-23. [Medline].

  59. Mousa AR, Koshy TS, Araj GF. Brucella meningitis: presentation, diagnosis and treatment--a prospective study of ten cases. Q J Med. Sep 1986;60(233):873-85. [Medline].

  60. Murrell TG, Matthews BJ. Multiple sclerosis--one manifestation of neurobrucellosis?. Med Hypotheses. Sep 1990;33(1):43-8. [Medline].

  61. Nimri LF. Diagnosis of recent and relapsed cases of human brucellosis by PCR assay. BMC Infect Dis. Apr 28 2003;3(1):5. [Medline].

  62. Oliveri Rl, Matera G, Foca A. Polyradiculoneuropathy with cerebrospinal fluid albuminocytological dissociation due to neurobrucellosis [see comments]. Clin Infect Dis. Oct 1996;23(4):833-4. [Medline].

  63. Omar FZ, Zuberi S, Minns RA. Neurobrucellosis in childhood: six new cases and a review of the literature. Dev Med Child Neurol. Nov 1997;39(11):762-5. [Medline].

  64. Pedro-Pons A, Foz M, Codina A. [Neurobrucellosis: a study of 41 cases]. Munch Med Wochenschr. Mar 30 1973;115(13):531-6. [Medline].

  65. Piampiano P, McLeary M, Young LW. Brucellosis: unusual presentations in two adolescent boys. Pediatr Radiol. May 2000;30(5):355-7. [Medline].

  66. Public health consequences of a false-positive laboratory test result for Brucella--Florida, Georgia, and Michigan, 2005. MMWR Morb Mortal Wkly Rep. Jun 6 2008;57(22):603-5. [Medline].

  67. Reviriego FJ, Moreno MA, Dominguez L. Risk factors for brucellosis seroprevalence of sheep and goat flocks in Spain. Prev Vet Med. Apr 28 2000;44(3-4):167-73. [Medline].

  68. Roldan-Montaud A, Jimenez-Jimenez FJ, Zancada F. Neurobrucellosis mimicking migraine. Eur Neurol. 1991;31(1):30-2. [Medline].

  69. Ruben B, Band JD, Wong P. Person-to-person transmission of Brucella melitensis. Lancet. Jan 5 1991;337(8732):14-5. [Medline].

  70. Samartino L, Gregoret R, Gall D. Fluorescence polarization assay: application to the diagnosis of bovine brucellosis in Argentina. J Immunoassay. Aug 1999;20(3):115-26. [Medline].

  71. Sanchez Chaparro MA, Merida de la Torre FJ, Gonzalez Alegre P. [Transverse myelitis caused by Brucella (letter)]. Rev Clin Esp. Nov 1999;199(11):778. [Medline].

  72. Sanchez-Sousa A, Torres C, Campello MG. Serological diagnosis of neurobrucellosis. J Clin Pathol. Jan 1990;43(1):79-81. [Medline].

  73. Sathiyaseelan J, Jiang X, Baldwin CL. Growth of Brucella abortus in macrophages from resistant and susceptible mouse strains. Clin Exp Immunol. Aug 2000;121(2):289-94. [Medline].

  74. Savell VH, Parham DM, Jacobs RF. Pathological case of the month. Disseminated brucellosis. Arch Pediatr Adolesc Med. Mar 2000;154(3):311-2. [Medline].

  75. Shaalan MA, Memish ZA, Mahmoud SA. Brucellosis in children: clinical observations in 115 cases. Int J Infect Dis. Sep 2002;6(3):182. [Medline].

  76. Shakir RA. Neurobrucellosis. Postgrad Med J. Dec 1986;62(734):1077-9. [Medline].

  77. Shakir RA, Al-Din AS, Araj GF. Clinical categories of neurobrucellosis. A report on 19 cases. Brain. Feb 1987;110 ( Pt 1):213-23. [Medline].

  78. Shamelian SO. Diagnosis and treatment of brucellosis [letter; comment]. Neth J Med. May 2000;56(5):198-200. [Medline].

  79. Silva CA, Rio ME, Maia-Goncalves A. Oligoclonal gamma-globulin of cerebrospinal fluid in neurobrucellosis. Acta Neurol Scand. Jan 1980;61(1):42-8. [Medline].

  80. Spink WW. The Nature of Brucellosis. Minneapolis, Minn: University of Minnesota Press;1956.

  81. Spink WW. What is chronic brucellosis?. Ann Int Med. 1951;35:358-374.

  82. Thomas R, Kameswaran M, Murugan V. Sensorineural hearing loss in neurobrucellosis. J Laryngol Otol. Nov 1993;107(11):1034-6. [Medline].

  83. Tur BS, Suldur N, Ataman S. Brucellar spondylitis: a rare cause of spinal cord compression. Spinal Cord. May 2004;42(5):321-4. [Medline].

  84. Verghese S, Padmaja P, Elizabeth SJ. Bacterial endocarditis caused by Brucella melitensis biotype I. Indian Heart J. Mar-Apr 2000;52(2):203-4. [Medline].

  85. Young EJ. Human brucellosis. Rev Infect Dis. Sep-Oct 1983;5(5):821-42. [Medline].

  86. Young EJ. Serologic diagnosis of human brucellosis: analysis of 214 cases by agglutination tests and review of the literature. Rev Infect Dis. May-Jun 1991;13(3):359-72. [Medline].

  87. Young EJ, Tarry A, Genta RM. Thrombocytopenic purpura associated with brucellosis: report of 2 cases and literature review. Clin Infect Dis. Oct 2000;31(4):904-9. [Medline].

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.