Advertisement

Brucellosis

Published:December 20, 2020DOI:https://doi.org/10.1016/j.jns.2020.117280

      Highlights

      • Neurobrucellosis is protean and serious.
      • Combination antibiotic therapy for 3–6 months
      • Neurological involvement is central and peripheral

      Abstract

      Brucellosis is a common Zoonosis affecting half a million people annually. The most common mode of infection is by consuming unpasteurized milk or milk products. The general manifestations are those of fever with generalized symptoms. The nervous system is affected in 4–7% of cases. The manifestations are protean and include meningo-encephalitis as well as peripheral nervous system involvement. The diagnosis relies on culture, which is cumbersome and can be falsely negative. Agglutination tests for the various species of the organism are the mainstay for diagnosis. Treatment is for 3–6 months with combination therapy including Doxycycline, Rifampicin and ceftriaxone. The main issue is prevention and better animal husbandry.

      Keywords

      1. Introduction

      This is an ancient zoonosis described before Hippocrates in human skeletons. It is the most common bacterial zoonosis and remains prevalent across the world. WHO defines zoonotic diseases as infectious diseases that are naturally transmissible from vertebrate animals to humans. Brucellosis (Undulant fever, Malta fever) causes major animal and human morbidity in many parts of the world. The infection is intracellular and in man it causes a myriad of symptoms. The illness is commonly acquired through ingestion of unpasteurized contaminated milk or its products or from direct contact with infected animals. Aerosol transmission is an occupational hazard in those who come in contact with infected material such as placentae resulting in inhalation of aerosol particles.

      2. History

      Although brucellosis is known since antiquities [
      • D’Anastasio R.
      • Staniscia T.
      • Milia M.L.
      • et al.
      Evolution and paleoepidemiology of brucellosis origin.
      ]; its description in humans as a clinical entity “Mediterranean Gastric Remittent Fever” was only made in the nineteenth century by JA Marston in 1860. David Bruce (1865–1931) described the organism as a “micrococcus” in 1887 with the help of a Maltese microbiologist Carruana Scicluna. In 1905, Zammit a Maltese doctor showed that goats transmitted the disease (Fig. 1). Bruce moved to Africa and identified ‘Trypanosoma Brucei” as a cause of Sleeping sickness [
      • Wyatt H.V.
      How Themistocles Zammit found Malta fever (brucellosis) to be transmitted by the milk of goats.
      ].
      Fig. 1
      Fig. 1Malta stamp honoring Bruce and Zammit for the discovery of Brucellosis and its relation to goat's milk.
      Bang was Danish veterinarian who identified an intracellular bacillus as the cause of miscarriage in cattle (Bang's bacillus). For many years no relation was thought to exist between Bruce's micrococcus and Bang's bacillus. Many others contributed to the development of knowledge on brucellosis; however, two have to be specifically mentioned. The first is Mary Elizabeth Steel, the daughter of a Scottish doctor and wife of David Bruce. She was a trained microbiologist and was instrumental in the early work on brucellosis. The second is Alice Evans (1881–1975); an American microbiologist, who was not only the first person to prove that micrococcus melitensis and Bang's bacillus were different species of the same genus but she worked for many years to establish that milk was the source of the infection and her work led to the pasteurization of cow's milk [
      • Colwell R.R.
      • Alice C.
      Evans: breaking barriers.
      ].
      The assistant of David Bruce, Surgeon Captain M Louis Hughes, made the first report on the isolation of M. melitensis from the brain in Malta. His classic monograph in 1897 dedicated to his mentor Lord Lister is the clearest description of brucellosis, which he suffered from himself. Hughes was killed in the second Boer war at the age of 32 years. Brucella melitensis was isolated from the CSF by Lemaire in 1924 [
      • Lemaire G.
      Meningite a melitocoques: alternations importantes du liquide cephlo-rachidien.
      ] and B. Suis was first isolated from a patient with meningo-encephalitis who died of a ruptured cerebral mycotic aneurysm [
      • Sanders W.E.
      Undulant fever meningitis.
      ].

      3. Epidemiology

      Brucellosis is an old disease with minimal mortality. Yet human brucellosis remains the commonest zoonotic Disease worldwide with more than 500,000 new cases annually [
      • Corbel M.J.
      Brucellosis in humans and animals.
      ], The disease is associated with substantial residual disability, and is an important cause of travel-associated morbidity [
      • Pappas G.
      • Papadimitriou P.
      • Akritidis N.
      • et al.
      The new global map of human brucellosis.
      ]. The global epidemiology of the disease has drastically evolved over the past decades. Neurobrucellosis is the most serious form of the disease and affects between 5 and 7% of those involved. Countries affected are many and are widely distributed across the globe. Not only around the Mediterranean basin but extend from China to the Americas. The incidence has remerged in the last decade in spite of enhanced surveillance and the wide reporting of animal cases [
      • Brucellosis Reference Guide
      Exposure, Testing, and Prevention Bacterial Special Pathogens Branch (BSPB) Division of High-Consequence Pathogens and PathologyNational Center for Emerging and Zoonotic Infectious Diseases Centers for Disease Control and Prevention.
      ].
      The genus Brucella is composed of an increasing number of species that infect a wide variety of mammals as primary hosts, such as bovine (B. abortus), caprine (B. melitensis), swine (B. suis), ovine (B. ovis), camels, elk, bison (B. abortus), canine (B. canis), rodents (B. neotomae, B. microti), monkeys (B. papionis), as well as marine mammals such as seals, porpoises, dolphins and whales (B. pinnipidialis and B. ceti), and also amphibians (B. inopinata) [
      • Zheng R.
      • Xie S.
      • Lu X.
      • et al.
      A systematic review and meta-analysis of epidemiology and clinical manifestations of human brucellosis in China.
      ] The only ones that affect humans are abortus, melitensis, suis, and canis.

      4. Transmission

      The commonest infection route is by ingestion of unpasteurized/raw dairy products. The milk of infected sheep, goats, cows, or camels can be contaminated with the bacteria.
      Unpasteurized milk from infected animals will transmit the disease to people who consume the milk and/or cheese products. Moreover brucellosis is an occupational hazard in veterinarians, slaughterhouse workers, meat packers and laboratory workers. Breathing in the bacteria can cause the infection in those exposed in laboratories and slaughterhouses. Hunters of wild animals can get infected when butchering as the bacteria can gain access through skin cuts and abrasions. Trans-Placental, breast feeding and sexual transmission is extremely rare [
      • Pappas G.
      • Papadimitriou P.
      • Akritidis N.
      • et al.
      The new global map of human brucellosis.
      ,
      • Brucellosis Reference Guide
      Exposure, Testing, and Prevention Bacterial Special Pathogens Branch (BSPB) Division of High-Consequence Pathogens and PathologyNational Center for Emerging and Zoonotic Infectious Diseases Centers for Disease Control and Prevention.
      ]. As an intracellular infection there is a complex interaction with the immune system and subsequent effects on the blood brain barrier [
      • Rodríguez A.M.
      • Delpino V.
      • Miragliab M.C.
      • Giambartolomeia G.H.
      Immune mediators of pathology in Neurobrucellosis: from blood to central nervous system.
      ]. Brucella has been reported as a possible type B biological weapon [
      • Pappas G.
      • Panagopoulou P.
      • Christou L.
      • Akritidis N.
      Brucella as a biological weapon.
      ].

      5. Symptoms

      Systemic brucellosis may present in a non-specific illness with fever, malaise, anorexia, headaches, muscle aches, arthralgia, fatigue and sweats. Some symptoms may persist for a long time with recurrent fevers, fatigue, depression, arthritis, orchitis, endocarditis, with hepato-splenomegaly. Neurological involvement can be the only presenting feature [
      • Franco M.P.
      • Mulder M.
      • Gilman R.H.
      • Smits H.L.
      Human brucellosis.
      ].
      Neurological involvement is perhaps the most serious complication and it only occurs in a minority of those affected by brucellosis. The rate of involvement varies from 4 to 7% the Centers for Diseases Control and Prevention (CDC) figure of 5%, seems appropriate [
      • Brucellosis Reference Guide
      Exposure, Testing, and Prevention Bacterial Special Pathogens Branch (BSPB) Division of High-Consequence Pathogens and PathologyNational Center for Emerging and Zoonotic Infectious Diseases Centers for Disease Control and Prevention.
      ]. Both the central and peripheral nervous systems can be affected. Attempts to classify neurological involvement are difficult and imprecise. A broad central nervous system category including vascular pathology, a peripheral category or a combination seems the most practical [
      • Khuraibet A.J.
      • Shakir R.A.
      • Trontelj J.V.
      • et al.
      Brainstem auditory evoked potential abnormalities in brucellosis.
      ].
      Meningoencephalitis can present with headache, lethargy and altered consciousness in addition to features of meningism. The presentation can be relatively acute of few days or indeed chronic and brucellosis has to be considered in the differential diagnosis of chronic meningitis. It is of interest to note that as with other conditions affecting the meninges, cranial nerves involvement are well recognized with vestibulocochlear, facial, oculomotor, and sixth nerve palsies. Cerebellar involvement usually with cranial nerve palsies especially nerve deafness has been reported [
      • Shakir R.A.
      • Al-Din A.S.N.
      • Araj G.F.
      • et al.
      Clinical categories of neurobrucellosis.
      ].
      Myelitis leading to spasticity with brisk tendon reflexes, clonus and extensor plantars can present with or without sensory involvement [
      • McLean D.R.
      • Russell N.
      • Khan M.Y.
      Neurobrucellosis: clinical and therapeutic features.
      ]. This can be a process, which can linger for months with eventual bladder and bowel involvement.
      Peripheral nervous system involvement with proximal polyradiculoneuropathy can be the main feature; back pain especially related to sacroiliitis is an important pointer to the diagnosis. Flaccid paraparesis with hypotonia and areflexia can be the main features and can remain for weeks without any further evolution. On the other hand there are reports of patients presenting with an acute meningitic picture with lymphocytic CSF pleocytosis and low CSF sugar is well recognized. Moreover a chronic neurologic involvement may start months or even years later [
      • Awada A.
      • Korri H.
      • Issa Z.
      • et al.
      Progressive paraparesis with sensorineural deafness and leukoencephalopathy revealing neurobrucellosis.
      ]. The level and degree of CSF abnormality depends on the chronicity of the condition.
      It is most interesting to note that neurological presentations can happen without systemic features of brucellosis [
      • GuvenT Ugurlu K.
      • Ergonul O.
      • et al.
      Neurobrucellosis: clinical and diagnostic features.
      ,
      • Shakir R.A.
      Neurobrucellosis.
      ]. However, at times other body organs can be involved such as arthritis or orchitis happening at some stage during the evolution of the neurological syndrome.
      It is important therefore to remember that Brucellosis can present in a protean manner involving the cranial nerves, brain, brainstem, cerebellum, spinal cord and peripheral nerves [
      • Fincham R.W.
      • Sahs A.L.
      • Joynt R.J.
      Protean manifestations of nervous system brucellosis.
      ,
      • Korri H.
      • Awada A.
      • Ali Y.
      • Choucair J.
      Brucellar meningitis complicated by aneurysmal subarachnoid hemorrhage.
      ]. As already stated, it is difficult to come up with an informed classification of symptomatology other than, central, peripheral or a combination [
      • Brucellosis Shakir R.A.
      Tropical Neurology Shakir, Newman and Poser Ed. Pub Saunders.
      ].

      6. Diagnosis

      A high index of suspicion is required. The bacteria is widely spread and even in the absence of history of ingestion of raw/unpasteurized milk or milk products one has to preform the necessary blood and in case of neurological involvement CSF examination.
      Bacterial isolation is the gold standard, however, the sensitivity may not be high depending of the presence of the organism in blood. In acute cases culture results can be quite high with a 10–20% false negative results. But in neurobrucellosis blood culture sensitivity is low at around 20–30%. Bone marrow cultures are more sensitive than blood cultures especially in those with previous antibiotic use [
      • Araj G.F.
      • et al.
      Evaluation of the PANBIO Brucella immunoglobulin G (IgG) and IgM enzyme-linked immunosorbent assays for diagnosis of human brucellosis.
      ,
      • De Glanville W.A.
      • Conde-Alvarez R.
      • Moriyon I.
      • et al.
      Poor performance of the rapid test for human brucellosis in health facilities in Kenya.
      ].
      In the absence of a positive culture the diagnosis relies on serological tests. The agglutination tests such as Rose Bengal test, which is used as a screening test, the serum agglutination tests, and the CDC utilizes a test called the Brucella micro-agglutination test (BMAT), a modified version of the serum (tube) agglutination test (SAT), that can detect antibodies to Brucella species – abortus, melitensis or suis. There is no serological test available to detect antibodies to B. canis [
      • Brucellosis Reference Guide
      Exposure, Testing, and Prevention Bacterial Special Pathogens Branch (BSPB) Division of High-Consequence Pathogens and PathologyNational Center for Emerging and Zoonotic Infectious Diseases Centers for Disease Control and Prevention.
      ]. These agglutination tests are based on the reactivity of antibodies against smooth polysaccharide. The antibodies persist in the patient's serum long after recovery. This off course raises the issue of positivity in endemic areas and the possible misinterpretation when investigating other chronic infective processes. There could be cross reactivity with other gram-negative bacilli such as Yersinia, vibrio cholerae and E coli. The sensitivity and specificity of the confirmatory agglutination tests depends on the cut off value used on the background of the population. A high cut off value will reduce the sensitivity [
      • Baldi P.C.
      • Araj G.F.
      • Racaro G.C.
      • et al.
      Detection of antibodies to Brucella cytoplasmic proteins in the cerebrospinal fluid of patients with neurobrucellosis.
      ]. The use of 2-mercaptoethanol test for measuring specific IgG antibodies can supplement agglutination tests. ELISA is now popular and commercial brands are used in various locations. The use of Brucellacapt showed a high sensitivity and specificity. Serological agglutination and ELISA has been applied to CSF with varying degrees of sensitivity [
      • Orduna A.
      • Almaraz A.
      • Prado A.
      • et al.
      Evaluation of an immunocapture agglutination test (Brucellcapt) for serodiagnosis of human brucellosis.
      ].
      For a diagnosis to be made using serology [
      • Araj G.F.
      • Kattar M.M.
      • Fottouh L.G.
      • et al.
      Evaluation of PANBIO Brucella immunoglobulin G (IgG) and IgM enzyme-linked immunosorbent assays for diagnosis of human brucellosis.
      ], two serum samples are required. The first serum sample should be taken when a person is acutely ill (≤7 days following symptom onset); the second serum sample should be drawn 2–4 weeks later to check for a rise in antibodies (a fourfold or greater rise in antibodies would mean an individual is positive for brucellosis) [
      • Brucellosis Reference Guide
      Exposure, Testing, and Prevention Bacterial Special Pathogens Branch (BSPB) Division of High-Consequence Pathogens and PathologyNational Center for Emerging and Zoonotic Infectious Diseases Centers for Disease Control and Prevention.
      ]. The use of PCR in the diagnosis is now established; it may also be useful in species differentiation and biotyping [
      • Colmenero J.D.
      • Queipo-Ortun M.I.
      • Reguera J.M.
      • et al.
      Real time polymerase chain reaction: a new powerful tool for the diagnosis of neurobrucellosis.
      ,
      • Fan S.
      • Ren H.
      • Weia Y.
      • et al.
      Next-generation sequencing of the cerebrospinal fluid in the diagnosis of neurobrucellosis.
      ].

      7. Imaging

      Although imaging with MRI and CT can be normal, but could be fairly suggestive, with high signal white matter lesions seen in cases of meningoencephalitis, enhancing lesions, which can be periventricular, are a reported [
      • Soussa M.W.
      • Bohlega S.
      • Alkawi M.Z.
      /akwatban H, Mclean D. Neurobrucellosis: clinical and neuroimaging correlation.
      ,
      • Erdem H.
      • Senbayrak S.
      • Meric K.
      • et al.
      Cranial imaging in neurobrucellosis: results of Istanbul-3 study.
      ). Meningeal enhancement is seen in cases of meningitis and ventriculitis (Fig. 2). Spinal imaging can perhaps be more informative and even be quite typical. Brucella affects the vertebral endplates and then may totally destroy the vertebra (Fig. 3). When the sacro-iliac joints are involved Brucellosis become highly likely [
      • Turgut M.
      • Turgut A.T.
      • Kosar U.
      Spinal brucellosis: Turkish experience based on 452 cases published during the last century.
      ]. The use of scintigraphy as part of imaging is highly rewarding [
      • Aydin M.
      • Yapar A.F.
      • Savas L.
      • et al.
      Scintigraphic findings in osteoarticular brucellosis.
      ].
      Fig. 2
      Fig. 2MRI brain of a 52 year old male farmer with meningoencephlitis, leptomeningitis and active CSF with Positive brucella serology. (Courtesy Prof Faouzi Belahsen, Fes University, Morocco).
      Fig. 3
      Fig. 3(A) Spinal spondylodiscit's MRI at L4 leading to destruction of the vertebrae. (B) CT scan bone windows showing the vertebral involvement as well as the SI joints. (courtesy Dr. Ashish Atre, Star Imaging Centre Pune, Dr. Sudhir Kothari Poona Hospital, Pune India.

      8. Treatment

      The essence of treating complicated brucellosis such as neurobrucellosis is combination therapy to reduce the chances of relapse. The CDC recommendation is to use oral doxycycline in a dose of 2–4 mg/kg a day with a maximum of 200 mg/day in two divided doses OR tetracycline 30–40 mg/kg a day maximum of 2 g daily, in four divided doses AND Rifampicin 15–20 mg/kg per day, maximum 600–900 mg/day in a single dose for six weeks. Combination therapy with trimethoprim-sulfamethoxazole (TMP-SMZ) can be used if tetracyclines are contraindicated [
      • Brucellosis Reference Guide
      Exposure, Testing, and Prevention Bacterial Special Pathogens Branch (BSPB) Division of High-Consequence Pathogens and PathologyNational Center for Emerging and Zoonotic Infectious Diseases Centers for Disease Control and Prevention.
      ],.
      Streptomycin or gentamycin for the first 2 weeks of therapy in addition to tetracycline and rifampicin can be used. It is recommended that in case of meningoencephalitis, the duration of therapy should be for 4–6 months with a case fatality rate of less than 1% [
      • Ariza J.
      • Bosilkovski M.
      • Cascio A.
      Perspectives for the treatment of Brucellosis in the 21st century: the Ioannina recommendations.
      ,
      • Solera J.
      Update on brucellosis: therapeutic challenges.
      ,
      • Al-Tawfiq J.A.
      Therapeutic options for human brucellosis.
      ]. In a systemic review and meta-analysis of randomized controlled trails [
      • Pappas G.
      • et al.
      ], the conclusion was that triple therapy with doxycycline, aminoglycoside and rifampicin is the optimal combination. However, one has to accept that patients prefer using oral combinations rather than additional injectable aminoglycoside either in the form of streptomycin or gentamycin [
      • Skalsky K.
      • Yahav D.
      • Bishara J.
      • Pitlik S.
      • Leibovici L.
      • Paul M.
      Treatment of human brucellosis: systematic review and meta-analysis of randomized controlled trails.
      ]. Moreover, the use of aminoglycosides in neurobrucellosis with the well-recognized complication of hearing loss is not advisable. Ceftriaxone has been found to be effective as the third drug in addition to doxycycline and rifampicin [
      • Erdem H.
      • Ulu-Kilic A.
      • Kilic S.
      • et al.
      Efficacy and tolerability of antibiotic combinations in neurobrucellosis: reults of the Istanbul study.
      ].
      Brucella being an intra-cellular infection creates a vacuole like acidic compartment within the cell and therefore antibiotics have to enter the cell and attack the organism [
      • Gorvel J.P.
      • Moreno E.
      Brucella intracellular life: from invasion to intracellular replication.
      ].
      The duration of antibiotic treatment with triple regime is probably the most likely to lead to satisfactory outcome. The end points of treatment are again unclear, some use repeated lumbar punctures and stop treatment when the CSF is clear. Others rightly feel that this is not practical and opt either for a fixed period ranging from 3 to 6 months depending on the clinical presentation. With no randomized trails on the length of treatment, an arbitrary time limit is what is applicable [
      • Pappas G.
      • et al.
      ]. There is no evidence that the additional use of steroids which is an accepted practice leads to better outcome especially for hearing loss, myelopathy, arachnoiditis and optic nerve involvement [
      • Pappas G.
      • Akritidis N.
      • Chrisou L.
      Treament of neurobrucellosis: what is known and what remains to be answered.
      ]. One has to remember that the two most likely persisting disabilities following the eradication of Brucella from the nervous system is hearing loss and paraparesis.

      9. Prevention

      There are two issues here; the first is concerned with immediate contacts in those working in laboratory facilities, farms, slaughterhouses and the milk industry who are considered at risk. Using Doxycycline 100 mg twice daily and Rifampicin 600 mg daily for three weeks is recommended [
      • Brucellosis Reference Guide
      Exposure, Testing, and Prevention Bacterial Special Pathogens Branch (BSPB) Division of High-Consequence Pathogens and PathologyNational Center for Emerging and Zoonotic Infectious Diseases Centers for Disease Control and Prevention.
      ].
      The disease is wide spread in animals and it is notifiable in various countries. There are animal vaccines for some strains, however human vaccines are not available [
      • Huanhuan Hou A.
      • Xiaofeng Liu B.
      • Qisheng Peng A.
      The advances in brucellosis vaccines.
      ,
      • Traxler R.M.
      • Guerra M.A.
      • Morrow M.G.
      • et al.
      Review of brucellosis cases from laboratory exposures in the United States in 2008 to 2011 and improved strategies fro disease prevention.
      ]. This is by and large a result of the peculiar way that Brucella behaves as an intracellular organism. Various measures to control zoonotic brucellosis [
      • Pappas G.
      The peculiar ways of Brucella survival: looking through the keyhole.
      ] are the only way to eradicate the disease as man is a dead end host.

      References

        • D’Anastasio R.
        • Staniscia T.
        • Milia M.L.
        • et al.
        Evolution and paleoepidemiology of brucellosis origin.
        Epidemiol. Infect. 2011; 139: 149-156
        • Wyatt H.V.
        How Themistocles Zammit found Malta fever (brucellosis) to be transmitted by the milk of goats.
        J. R. Soc. Med. 2005; 98: 451-454
        • Colwell R.R.
        • Alice C.
        Evans: breaking barriers.
        Yale J. Bio. Med. 1999; 72: 349-356
        • Lemaire G.
        Meningite a melitocoques: alternations importantes du liquide cephlo-rachidien.
        Bull. Soc. Med. Paris. 1924; 48: 1636-1644
        • Sanders W.E.
        Undulant fever meningitis.
        J. Iowa Med. Soc. 1931; 21: 510-511
        • Corbel M.J.
        Brucellosis in humans and animals.
        in: World Health Organization in collaboration with the Food and Agriculture Organization of the United Nations and World Organization for Animal Health. 2006
        • Pappas G.
        • Papadimitriou P.
        • Akritidis N.
        • et al.
        The new global map of human brucellosis.
        Lancet Infect. Dis. 2006; 6: 91-99
        • Brucellosis Reference Guide
        Exposure, Testing, and Prevention Bacterial Special Pathogens Branch (BSPB) Division of High-Consequence Pathogens and PathologyNational Center for Emerging and Zoonotic Infectious Diseases Centers for Disease Control and Prevention.
        2017
        • Zheng R.
        • Xie S.
        • Lu X.
        • et al.
        A systematic review and meta-analysis of epidemiology and clinical manifestations of human brucellosis in China.
        Biomed. Res. Int. 2018; 5712920https://doi.org/10.1155/2018/5712920
        • Rodríguez A.M.
        • Delpino V.
        • Miragliab M.C.
        • Giambartolomeia G.H.
        Immune mediators of pathology in Neurobrucellosis: from blood to central nervous system.
        Neuroscience. 2019; 410: 264-273
        • Pappas G.
        • Panagopoulou P.
        • Christou L.
        • Akritidis N.
        Brucella as a biological weapon.
        Cell. Mol. Life Sci. 2006; 62: 2229-2236
        • Franco M.P.
        • Mulder M.
        • Gilman R.H.
        • Smits H.L.
        Human brucellosis.
        Lancet Infect. Dis. 2007; 7: 775-786
        • Khuraibet A.J.
        • Shakir R.A.
        • Trontelj J.V.
        • et al.
        Brainstem auditory evoked potential abnormalities in brucellosis.
        J. Neurol. Sci. 1998; 87: 307-313
        • Shakir R.A.
        • Al-Din A.S.N.
        • Araj G.F.
        • et al.
        Clinical categories of neurobrucellosis.
        Brain. 1987; 110: 213-223
        • McLean D.R.
        • Russell N.
        • Khan M.Y.
        Neurobrucellosis: clinical and therapeutic features.
        Clin. Infect. Dis. 1992; 15: 582-590
        • Awada A.
        • Korri H.
        • Issa Z.
        • et al.
        Progressive paraparesis with sensorineural deafness and leukoencephalopathy revealing neurobrucellosis.
        Rev. Neurol. (Paris). 2011; 167: 181-184
        • GuvenT Ugurlu K.
        • Ergonul O.
        • et al.
        Neurobrucellosis: clinical and diagnostic features.
        Clin. Infect. Dis. 2013; 56: 1407-1412
        • Shakir R.A.
        Neurobrucellosis.
        Postgrduate Med. J. 1986; 62: 1077-1079
        • Fincham R.W.
        • Sahs A.L.
        • Joynt R.J.
        Protean manifestations of nervous system brucellosis.
        JAMA. 1963; 184: 269-276
        • Korri H.
        • Awada A.
        • Ali Y.
        • Choucair J.
        Brucellar meningitis complicated by aneurysmal subarachnoid hemorrhage.
        Rev. Neurol. (Paris). 2008; 64: 1052-1055
        • Brucellosis Shakir R.A.
        Tropical Neurology Shakir, Newman and Poser Ed. Pub Saunders.
        1995: 167-181
        • Araj G.F.
        • et al.
        Evaluation of the PANBIO Brucella immunoglobulin G (IgG) and IgM enzyme-linked immunosorbent assays for diagnosis of human brucellosis.
        Clin. Diagn. Lab. Immunol. 2005; 12: 1334-1335
        • De Glanville W.A.
        • Conde-Alvarez R.
        • Moriyon I.
        • et al.
        Poor performance of the rapid test for human brucellosis in health facilities in Kenya.
        PLoS Negl. Trop. Dis. 2017; 11e0005508
        • Baldi P.C.
        • Araj G.F.
        • Racaro G.C.
        • et al.
        Detection of antibodies to Brucella cytoplasmic proteins in the cerebrospinal fluid of patients with neurobrucellosis.
        Clin. Daign Lab Immunol. 1999; 6: 756-759
        • Orduna A.
        • Almaraz A.
        • Prado A.
        • et al.
        Evaluation of an immunocapture agglutination test (Brucellcapt) for serodiagnosis of human brucellosis.
        J. Clin. Microbiol. 2000; 38: 4000-4005
        • Araj G.F.
        • Kattar M.M.
        • Fottouh L.G.
        • et al.
        Evaluation of PANBIO Brucella immunoglobulin G (IgG) and IgM enzyme-linked immunosorbent assays for diagnosis of human brucellosis.
        J. Clin. Immunol. 2005; 12: 1334-1335
        • Colmenero J.D.
        • Queipo-Ortun M.I.
        • Reguera J.M.
        • et al.
        Real time polymerase chain reaction: a new powerful tool for the diagnosis of neurobrucellosis.
        J. Neurol. Neurosurg. Psychiatry. 2005; 76: 1025-1027
        • Fan S.
        • Ren H.
        • Weia Y.
        • et al.
        Next-generation sequencing of the cerebrospinal fluid in the diagnosis of neurobrucellosis.
        Int. J. Infect. Dis. 2018; 67: 20-24
        • Soussa M.W.
        • Bohlega S.
        • Alkawi M.Z.
        /akwatban H, Mclean D. Neurobrucellosis: clinical and neuroimaging correlation.
        Am. J. Neuroradiol. 2004; 25: 395-401
        • Erdem H.
        • Senbayrak S.
        • Meric K.
        • et al.
        Cranial imaging in neurobrucellosis: results of Istanbul-3 study.
        Infection. 2016; 44: 623-631
        • Turgut M.
        • Turgut A.T.
        • Kosar U.
        Spinal brucellosis: Turkish experience based on 452 cases published during the last century.
        Acta Neurochir. 2006; 148: 1033-1044
        • Aydin M.
        • Yapar A.F.
        • Savas L.
        • et al.
        Scintigraphic findings in osteoarticular brucellosis.
        Nucl. Med. Commun. 2005; 26: 639-647
        • Ariza J.
        • Bosilkovski M.
        • Cascio A.
        Perspectives for the treatment of Brucellosis in the 21st century: the Ioannina recommendations.
        PLoS Med. December 2007; 4 (1872): e317
        • Solera J.
        Update on brucellosis: therapeutic challenges.
        Int. J. Antimicrob. Agents. 2010; 36S: S18-S20
        • Al-Tawfiq J.A.
        Therapeutic options for human brucellosis.
        Expert Rev. Anti-Infect. Ther. 2008; 6: 109-120
        • Pappas G.
        • et al.
        BMJ. 2008; 336: 678-679
        • Skalsky K.
        • Yahav D.
        • Bishara J.
        • Pitlik S.
        • Leibovici L.
        • Paul M.
        Treatment of human brucellosis: systematic review and meta-analysis of randomized controlled trails.
        BMJ. 2008; 336: 701-704
        • Erdem H.
        • Ulu-Kilic A.
        • Kilic S.
        • et al.
        Efficacy and tolerability of antibiotic combinations in neurobrucellosis: reults of the Istanbul study.
        Antimicrob. Agnets Chemother. 2012; 56: 1523-1528
        • Gorvel J.P.
        • Moreno E.
        Brucella intracellular life: from invasion to intracellular replication.
        Vet Micorbiol. 2002; 90: 281-297
        • Pappas G.
        • Akritidis N.
        • Chrisou L.
        Treament of neurobrucellosis: what is known and what remains to be answered.
        Exp. Rev. Infect. Ther. 2007; 5: 983-990
        • Huanhuan Hou A.
        • Xiaofeng Liu B.
        • Qisheng Peng A.
        The advances in brucellosis vaccines.
        Vaccine. 2019; 37: 3981-3988
        • Traxler R.M.
        • Guerra M.A.
        • Morrow M.G.
        • et al.
        Review of brucellosis cases from laboratory exposures in the United States in 2008 to 2011 and improved strategies fro disease prevention.
        J. Clin. Microbiol. 2013; 51: 132-136
        • Pappas G.
        The peculiar ways of Brucella survival: looking through the keyhole.
        Virulence. 2010; 1: 473-474