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LETTER TO EDITOR
Year : 2014  |  Volume : 62  |  Issue : 3  |  Page : 320-321

Cervical spine Brucellosis presenting as fever with neck stiffness and cervical compressive myelopathy: A case report


Department of Medicine, Byramjii-Jeejeebhoy Government Medical College, Pune, Maharashtra, India

Date of Submission15-Mar-2014
Date of Decision30-Mar-2014
Date of Acceptance02-Jun-2014
Date of Web Publication18-Jul-2014

Correspondence Address:
Rahul S Kulkarni
Department of Medicine, Byramjii-Jeejeebhoy Government Medical College, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.137005

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How to cite this article:
Basavaraj A, Kulkarni RS. Cervical spine Brucellosis presenting as fever with neck stiffness and cervical compressive myelopathy: A case report. Neurol India 2014;62:320-1

How to cite this URL:
Basavaraj A, Kulkarni RS. Cervical spine Brucellosis presenting as fever with neck stiffness and cervical compressive myelopathy: A case report. Neurol India [serial online] 2014 [cited 2021 Jan 16];62:320-1. Available from: https://www.neurologyindia.com/text.asp?2014/62/3/320/137005


Sir,

Osteoarticular brucellosis is the most common presentation of systemic brucellosis and most commonly affects lumbar spine, but isolated involvement of cervical region is very rare, 1.2-2.1%. [1] Cervical spine involvement can pose diagnostic difficulties due to its similarities with other conditions such as tuberculous spondylitis, metastases, and myeloma, [2] causing delay in diagnosis and treatment.

A 60-year-old male farmer presented with moderate-grade intermittent fever and restricted neck movements of one month and 9 days duration, respectively. There was no history of chronic cough, hemoptysis, altered sensorium, neck trauma, weight loss, or any medical illness. General examination was normal except for pallor. Neck stiffness and neck muscle spasm was present. Neurological examination was normal. Blood investigations revealed normocytic normochromic anemia, elevated erythrocyte sedimentation rate of 70 mm at 1 hour, and hyperglobulinemia (globulins - 7.2 gm%). Cerebrospinal fluid examination was normal . Sputum for acid fast bacilli and Mantoux test was negative. Magnetic resonance imaging (MRI) of cervical spine showed altered marrow signal intensities in cervical vertebrae C3-C5 indicating diffuse marrow infiltrative disorder [Figure 1]a. Bone marrow biopsy revealed normocellular marrow with plasmacytosis (plasma cells <10%). Urine Bence Jones protein and X-ray of skull in lateral view was normal. Serum electrophoresis was ordered. However, due to personal reasons, the patient took discharge against medical advice. One and half month later, the patient presented with non-resolving fever, neck stiffness, and spastic weakness in all four limbs, with bladder and bowel incontinence. Motor power was grade 3/5 in all four limbs, with brisk deep tendon and plantar response was bilaterally extensor. Serum electrophoresis ordered during last admission was negative for M band, ruling out multiple myeloma. This time patient had single enlarged cervical lymph node. Biopsy showed chronic non-specific reactive lymphadenitis with no evidence of tuberculosis. Repeat MRI cervical spine showed significant increase in the extent of previous lesions, altered marrow signal in C1-C3, C6-C7, and D1 vertebral bodies with partial collapse of D1. [Figure 1]b. Bone scan also revealed increased uptake in cervical vertebrae consistent with infective etiology like tuberculosis [Figure 1]c. Hence, we again reviewed the history to rule out other causes of marrow infiltrative disorder. On enquiry, patient gave history of ingestion of unpasteurized goat milk four months back during his visit to his native place in Mhada village, (Solapur, Maharashtra). Brucella IgM antibody was negative but Brucella IgG antibody was strongly positive (6.04) by enzyme-linked immunosorbent assay (ELISA, definite positive >1.1). For definitive diagnosis, CT-guided biopsy was done from vertebral lesion, which showed chronic inflammatory lesion with moderate infiltration by plasma cells, with no features suggestive of tuberculosis. [Figure 1]d. In view of patient's history, raised IgG for brucellosis and no evidence of tuberculosis on cervical lymphnode, bone marrow biopsy and local vertebral lesion biopsy, this chronic inflammatory lesion was reported as brucella infection. Thus, the final diagnosis was brucellosis of cervical spine (spondylitis) with cervical compressive myelopathy. The patient was not willing for operative intervention and was discharged on doxycycine 200 mg/day and streptomycin 1 gm/day. Three months after discharge, the patient was afebrile with symptomatic improvement, however, with persistent residual neurologic deficit.
Figure 1: (a) MRI on 1st visit showing altered marrow signal intensities in cervical vertebrae C3-C5 s/o diffuse marrow infiltrative disorder, diffuse disc bulges and osteophytes (b) MRI cervical spine on subsequent admission showing progression of lesion with altered marrow signal C1, C2, C3, C6, C7, D1 vertebral body, discs, tip of clivus with partial collapse (c) Bone scan showing increased radionucleotide uptake in cervical region (d) Vertebral biopsy showing chronic non specific inflammation with plasma cells and russel bodies

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In this patient, the diagnosis of osteoarticular brucellosis is established based on the presence of criteria laid by Turgut et al.[3] Our case fulfilled 4 out of 5 criteria. Blood culture is the diagnostic test, but it is positive only in 20-30% of cases. ELISA IgG and IgM antibodies is now considered the most sensitive, specific, and rapid test for diagnosis of osteoarticular brucellosis. [4] Management of spinal brucellosis is mainly medical with doxycyclin along with streptomycin for 12 weeks. [5] Surgical treatment is reserved for biopsy purpose, advanced cases not responding to medical treatment, or severe neurological compromise. Difficulties in the diagnosis of cervical brucellosis spondylitis may cause a delay in treatment and may lead to devastating neurological consequences. Hence, brucellosis should be included in the differential diagnosis of fever with neck stiffness and spondylitis, particularly in countries like India, where brucellosis is still endemic.

 
  References Top

1.Zormpala A, Skopelitis E, Thanos L, Artinopoulos C, Kordossis T, Sipsas NV. An unusual case of brucellar spondylitis involving both the cervical and lumbar spine. Clin Imaging 2000;24:273-5.  Back to cited text no. 1
    
2.Ozaksoy D, Yucesoy K, Yucesoy M, Kovanlikaya I, Yuce A, Naderi S. Brucellar spondylitis: MRI findings. Eur Spine J 2001;10:529-33.  Back to cited text no. 2
    
3.Turgut M, Turgut AT, Kosar U. Spinal brucellosis: Turkish experience based on 452 case published during the last century. Acta Neurochir (Wien) 2006;148:1033-44.  Back to cited text no. 3
    
4.Sathyanarayan MS, Suresh DR, Sonth SB, Krishna S, Mariraj J, Surekha YA, et al. A comparative study of agglutination tests, blood culture and ELISA in the laboratory diagnosis of human brucellosis. Int J Biol Med Res 2011;2:569-72.  Back to cited text no. 4
    
5.Vajramani GV, Nagmoti MB, Patil CS. Neurobrucellosis presenting as an intra-medullary spinal cord abscess. Ann Clin Microbiol Antimicrob 2005;4:14-8.  Back to cited text no. 5
    


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