Neurologic Manifestations of Brucellosis Treatment & Management

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

Medical Care

Initial treatment of patients presenting with acute meningoencephalitis usually entails treatment for herpes encephalitis, until that entity has been excluded. In some instances, treatment under the presumption that partially treated meningitis is the cause of illness may entail the use of appropriate antibiotics, until that possibility also is excluded. In some instances where various other zoonoses are considered, broader initial coverage to include ciprofloxacin may be considered. This is especially true of the case of suspected infection from the use of a biological warfare weapon.

Once acute brucellar infection has been presumed or established as the cause of acute illness, treatment for 2 weeks with the combination of tetracycline and rifampicin (Rifampin) is the standard therapy. Whether this treatment influences recovery from meningoencephalitis, which usually occurs over several days with or without such treatment, is not clear. However, this treatment is aimed at preventing the development of chronic manifestations. Streptomycin has been combined with tetracycline in the treatment of some serious cases of brucellosis.

A standard treatment for adults with acute spinal brucellosis is the combination of doxycycline (100 mg bid) for at least 12 weeks, combined during the first 2-3 weeks with streptomycin (1 g qd). Alternative therapies include combinations of drugs including rifampin, co-trimoxazole, and fluoroquinolones.[8]

The standard treatment for chronic neurobrucellosis entails triple therapy. The 3 agents may be selected from a group of agents that includes rifampicin, doxycycline, gentamicin, streptomycin, and ciprofloxacin.

  • One common combination used in adolescents or adults includes oral rifampicin (600-900 mg/d) and doxycycline (100-200 mg/d) for 3 months, combined for the first 6 weeks of therapy with 0.5-1 g of streptomycin administered intramuscularly.
  • Emphasis has been placed on the importance of including an aminoglycoside in the combined therapy for chronic neurobrucellosis; gentamicin may be substituted for streptomycin. However, these agents probably should not be employed in patients with acute brucellosis-induced deafness or in patients who have impaired renal function. Doses of all selected medications must be adjusted in children weighing less than 40 kg, in elderly patients, or in patients with renal or hepatic abnormalities.

Duration and effectiveness of therapy should be judged on clinical and radiological grounds rather than on the basis of changes in antibody titer.

Patients have been treated with antibiotic courses lasting for only 8 weeks.

The addition of methylprednisolone may be beneficial in patients with severe or diffuse CNS involvement, cranial neuropathies, optic neuritis or other MS-like presentations, or arachnoiditis.

Next

Surgical Care

Although antibiotic treatment is usually sufficient for the management of brucellosis, spinal disease with severe neurological impairment may require surgery. Whether or not extensive surgery is planned, surgery also affords the opportunity to obtain tissue for diagnosis. Epidural abscesses approached surgically also afford the opportunity to improve the likelihood of response to antibiotic therapy. Surgery with discectomy or transpedicle drainage may be of importance in the alleviation of pain due to radiculopathy as well via transpedicle drainage.

Among the presentations of spinal brucellosis to which surgical techniques have been applied are spondylitis, spondylodiscitis, discitis, epidural abscess, paraspinal abscess, and vertebral collapse.[19] In selected instances, the response rate to the combination of surgery and antibiotics may be excellent.

Previous
Next

Consultations

Infectious diseases consultation may be warranted, especially with regard to diagnosis and antibiotic treatment.

  • Orthopedic or neurosurgical consultation may be required for management of inflammatory disturbances of vertebrae and spinal disks.
  • Other consultations may be required when other nonneurological organ systems are involved.
Previous
Next

Diet

Discuss with patients the importance of consuming pasteurized milk and milk products and on the avoidance of other possible sources of infection. Obviously, the impact of such education will have the greatest effect on family and friends who may be at risk for infection.

Previous
Next

Activity

Restriction of activity with bed rest appears to confer benefit in the acute phase of brucellosis, increasing the rate of recovery.

Previous
Proceed to Medication
 
 
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.