Case presentation
A 41-year-old woman presented to the hospital with chronic headaches, vertigo, and nausea. Her symptoms had started 8 months earlier with blurred vision and headache, which was later diagnosed as pseudotumor cerebri and was controlled with acetazolamide and topiramate. Her vision acuity further decreased in the past 2 months ago, and myalgia and intermittent fever were added to the previous complaints. She was conscious at presentation with no focal neurological deficit. However, her physical examination revealed bilateral papilledema. The chest test and cranial nerves examination were all normal. At presentation, routine laboratory tests were all in the normal range except for an increased erythrocyte sedimentation rate (ESR) (45 mm/h) and lactate dehydrogenase (LDH) (540 U/ml). Magnetic resonance imaging and computed tomography of the brain revealed no occupying lesion or other abnormalities. A lumbar puncture was performed in order to decrease the intracranial pressure. The cerebrospinal fluid (CSF) examination revealed an opening pressure of more than 40 cmH2O, white blood cell (WBC) count of 87 cells/mm (79% lymphocytes and 21% neutrophils), and protein and glucose concentrations of 43 and 83 mg/dl, respectively. Due to this significantly increased ICP, she was a candidate for CSF shunt to prevent further visual loss. Nevertheless, considering the patient’s chronic neurologic symptoms and also the lymphocyte dominancy of the CSF analysis, a serum brucella agglutination test (BAT) was done, which demonstrated a positive Wright test with a titer of 1:80 and 2ME titer of 1:40. Interestingly, the CSF wright test was also positive with a titer of 1:40. Hence, she was started on treatment with gentamycin, ceftriaxone, doxycycline and rifampin with the diagnosis of neurobrucellosis. She gradually improved clinically after two weeks without needing CSF shunting or other neurosurgical intervention.