Abducens nerve palsy and optic neuritis as initial manifestation in brucellosis

Rare Combination of Abducens Nerve Palsy and Optic Neuritis on the Same Side: Case Report and Review of 8 Patients in Literature

The concurrent development of abducens nerve palsy and optic neuritis on the same side is rare. Here we presented an 82-year-old man who developed the combination of abducens nerve palsy and optic neuritis on the left side 2 months after the sixth inoculation of COVID-19 mRNA vaccine. In past history at 45 years old, he experienced subarachnoid hemorrhage and underwent surgery for the clipping of intracranial aneurysm. The patient had no systemic symptoms, such as general fatigue, fever, arthralgia, and skin rashes. Physical and neurological examinations were also unremarkable. Since the aneurysmal metal clip used at that time was not compatible with magnetic resonance imaging, he underwent computed tomographic (CT) scan of the head and showed no space-occupying lesion in the orbit, paranasal sinuses, and brain. As an old lesion, the anterior temporal lobe on the left side had low-density area with metallic artifact on the left side of the skull base, indicative of metal clipping. In 4 weeks of observation from the initial visit, he showed complete recovery of visual acuity and became capable of abducting the left eye in full degrees. We also reviewed 8 patients with the combination of abducens nerve palsy and optic neuritis in the literature to reveal that the combination of signs did occur in mild meningitis with rare infectious diseases and in association with preceding herpes zoster in the first branch of the trigeminal nerve. The course of the present patient suggested that the combination of signs might be vaccine-associated.

Ocular Involvement of Brucellosis: A Pooled Analysis Study

AIM

Brucellosis may affect the eye to varying degrees. The aim of this study was to investigate the ocular involvement of brucellosis and highlight key points.

MATERIAL AND METHODS

Published literature in English language on the ocular involvement of brucellosis within last 30 years was evaluated. The PubMed international database was screened using certain keywords.

RESULTS

The study included 27 publications evaluating a total of 159 cases. The most common types of ocular involvement were uveitis (52.2%) and conjunctivitis (17.6%). Most cases had concomitant systemic brucellosis (27.7%), and the most commonly used diagnostic method was a serological test (92.4%). Of all the patients, 37.1% recovered with sequelae.

CONCLUSION

Brucellosis may cause a wide range of ophthalmic manifestations, and an overlooked or late diagnosis may also lead to the development of sequelae or loss of vision. A routine ophthalmologic examination should be performed in all patients with systemic brucellosis.

Brucellosis presenting with pancytopenia and hearing loss: A case report

BACKGROUND

Brucellosis is one of the most common zoonotic infectious diseases in the world, with approximately 500000 new cases of human brucellosis diagnosed each year. Brucellosis can simulate various multi-system diseases, presenting atypical symptoms. Very few brucellosis cases with pancytopenia accompanied by a severe hearing loss have been reported. In the literature review, we could find only one similar case reported in the past. Moreover, this disease is easily misdiagnosed as a blood system disease leading to delayed treatment. Thus, it is important to improve clinicians' awareness of this disease.

CASE SUMMARY

A 64-year-old woman presented with dizziness and fatigue, accompanied by pancytopenia and severe hearing loss. Brucella melitensis was identified on blood culture. Anti-infective therapy with rifampicin (900 mg/d) and doxycycline (100 mg twice a day) was prescribed for 4 mo along with ceftriaxone 2 g/d for 1 mo. The patient showed a good response to antibiotic therapy. Her blood counts returned to normal followed by significant improvement in hearing.

CONCLUSION

Brucellosis should be considered in the differential diagnosis of patients presenting with pancytopenia and hearing loss.

Ocular Lesions in Brucella Infection: A Review of the Literature

Ocular lesions due to Brucella infection are uncommon and easily overlooked in clinical management, but must be differentiated from non-infectious eye diseases and treated promptly to protect the patient's vision. We reviewed the relevant literature and identified 47 patients with ocular complications of Brucella infection. Among them, 28 showed ocular neuropathy, 15 presented with uveitis, and four patients displayed other ocular symptoms. Ocular symptoms accompanying Brucella infection require prompt diagnosis and treatment. The main methods of diagnosis are intraocular fluid tests and blood tests. Early diagnosis and treatment with suitable antibiotics are central to protecting the patient's vision. Notably, in terms of mechanism of injury, Brucella infection is chronic and cannot be eliminated by phagocytes, and can cause damage to the eye by inducing autoimmune reactions, antigen-antibody complex production, release of endogenous and exogenous toxins, and bacterial production of septic thrombi in the tissues. In this review, we summarize the ocular symptoms, diagnosis, treatment and prognosis of Brucella infection, and discuss the mechanisms of Brucella in ocular lesions, providing a reference for the diagnosis and treatment of Brucella ocular lesions.

Metagenomic Next-Generation Sequencing to Investigate Infectious Endophthalmitis of Brucella: A Case Report

Introduction

Brucellosis is a systemic disease that exists prevalently in clinical manifestations. The symptoms present in organs such as the eyes (in ocular brucellosis) can lead to misdiagnosis or even failure to diagnose. Metagenomic Next-Generation Sequencing (mNGS), a high-throughput sequencing approach, could be applied for the detection of microorganisms.

Case Presentation

A 57-year-old female with acute right-eye vision loss, treated with clindamycin and dexamethasone sodium phosphate for 1.5 months, was difficult to diagnose using regular methods. mNGS was utilized for the aqueous fluid from the patient, and Brucella melitensis was identified. The inflammation was treated with 3 months of antibiotherapy. However, even with specific medicine and surgery, the vision remained poor because severe ocular conditions last for a long time.

Conclusion

It suggests that brucella should still be a probable pathogen in endophthalmitis despite its low incidence in non-epidemic areas. Moreover, mNGS can achieve early diagnosis and timely treatment for difficult-to-diagnose ocular infections.

An unusual presentation of sixth nerve palsy: neurobrucellosis

Abducens nerve palsy is generally seen in older patients with diabetes and hypertension. It is relatively rare in young and otherwise healthy patients. An extensive differential diagnosis is considered in patients younger than 50 years of age who develop a sixth nerve palsy. We report here a 25-year-old patient from Turkey who was admitted with sixth nerve palsy as a component of neurobrucellosis. She was referred to our clinic because she had double vision and restricted right eye abduction. During the ophthalmic examination, both pupils were round and reactive to light and accommodation. Extraocular movements were intact with the exception that the right eye was unable to abduct. Magnetic resonance imaging revealed no pathology. She also had a diagnosis of brucellosis and her abducens nerve palsy was a form of clinical manifestation of neurobrucellosis. We conclude that neurobrucellosis should be considered in patients with sixth cranial nerve palsy especially in areas where brucellosis is endemic.

An Interesting Case of Neurobrucellosis Mimicking Neuropsychiatric Lupus

This case describes a patient presenting with acute onset papilledema, subacute strokes resulting in upper extremity weakness and numbness, arthritis, maculopapular rash, depressed C4 and CH50, and a high titer anti-double-stranded DNA antibody. The patient was given the diagnosis of probable systemic lupus erythematosus, which was supported by the Systemic Lupus International Collaborating Clinics (SLICC) criteria. He was aggressively treated for neuropsychiatric lupus (NPSLE) with pulse dose steroids and a dose of intravenous cyclophosphamide. Blood cultures drawn on admission later grew out 2/4 bottles of Gram-variable bacteria, speciated as Brucella melitensis by PCR. Serum Brucella serologies were also positive. On further evaluation, the patient noted a history of eating unpasteurized cheese in Mexico. Given these additional findings, the patient's presentation was most consistent with a diagnosis of neurobrucellosis. Steroids were tapered off, no further doses of cyclophosphamide were given, and a prolonged course of intravenous and oral antibiotic therapy was administered, resulting in complete resolution of the patient's presenting symptoms.

Infectious optic neuropathies: a clinical update

Different forms of optic neuropathy causing visual impairment of varying severity have been reported in association with a wide variety of infectious agents. Proper clinical diagnosis of any of these infectious conditions is based on epidemiological data, history, systemic symptoms and signs, and the pattern of ocular findings. Diagnosis is confirmed by serologic testing and polymerase chain reaction in selected cases. Treatment of infectious optic neuropathies involves the use of specific anti-infectious drugs and corticosteroids to suppress the associated inflammatory reaction. The visual prognosis is generally good, but persistent severe vision loss with optic atrophy can occur. This review presents optic neuropathies caused by specific viral, bacterial, parasitic, and fungal diseases.

Ocular involvement of brucellosis

A 29-year-old male diagnosed with brucellosis a week earlier was referred to the ophthalmology clinic with visual complaints. On examination, visual acuity was 20/25, he had conjunctival injection on slit lamp examination. There was also bilateral optic disk swelling plus retinal hyperemia (optic disc hyperemia and vascular tortuosity) and intraretinal hemorrhage on funduscopy. The patient was admitted and treated with cotrimoxazole, rifampin, doxycycline and prednisolone for 2 months. Ocular manifestations subsided gradually within 6 months after treatment. Brucellosis can affect the eye and lead to serious ocular complications. Early diagnosis and prompt treatment should be considered in endemic areas.

Neurobrucellosis developing unilateral oculomotor nerve paralysis

Brucellosis is a zoonotic infectious disease that is common around the world. Its clinical course demonstrates great diversity as it can affect all organs and systems. However, the central nervous system is rarely affected in the pediatric population. Neurobrucellosis is most frequently observed with meningitis and has numerous complications, including meningocephalitis, myelitis, cranial nerve paralyses, radiculopathy, and neuropathy. Neurobrucellosis affects the second, third, sixth, seventh, and eighth cranial nerves. Involvement of the oculomotor nerves is a very rare complication in neurobrucellosis although several adult cases have been reported. In this article, we present the case of a 9-year-old girl who developed unilateral nerve paralysis as a secondary complication of neurobrucellosis and recovered without sequel after treatment. This case is notable because it is a very rare, the first within the pediatric population. Our article emphasizes that neurobrucellosis should be considered among the distinguishing diagnoses in every case that is admitted for nerve paralysis in regions where Brucella infection is endemic.

The visual impairment and inscrutable disease of Samuel Johnson

Samuel Johnson, the acclaimed author of the Dictionary of the English Language, survived childhood scrofula with impaired sight and hearing. The cause of his scrofula has been attributed to bovine tuberculosis, but mycobacterial infection does not satisfactorily account for the peculiar features of Johnson's eye disorder or his hearing loss. The subject of numerous biographies, Johnson may have the most scrutinized medical history of all time. Medical detectives, hampered by the vagueness of 18(th)-century diagnosis, suspect that phlyctenular eye disease related to tuberculosis was the reason for his visual impairment. Pediatric brucellosis can also explain childhood scrofula associated with visual and auditory disabilities, but it may be difficult to reconcile any single diagnosis given the uncertainties surrounding Johnson's medical and ocular histories.

Infranuclear ocular motor disorders

This chapter covers the very large number of possible disorders that can affect the three ocular motor nerves, the neuromuscular junction, or the extraocular muscles. Conditions affecting the nerves are discussed under two major headings: those in which the site of damage can be anatomically localized (e.g., fascicular lesions and lesions occurring in the subarachnoid space, the cavernous sinus, the superior orbital fissure, or the orbit) and those in which the site of the lesion is either nonspecific or variable (e.g., vascular lesions, tumors, "ophthalmoplegic migraine," and congenital disorders). Specific comments on the diagnosis and management of disorders of each of the three nerves follow. Ocular motor synkineses (including Duane's retraction syndrome and aberrant regeneration) and disorders resulting in paroxysms of excess activity (e.g., neuromyotonia) are then covered, followed by myasthenia gravis and other disorders that affect the neuromuscular junction. A final section discusses disorders of the extraocular muscles themselves, including thyroid disease, orbital myositis, mitochondrial disease, and the muscular dystrophies.

Ophthalmoparesis, papillitis and premacular hemorrhage in a case with endocarditis: a rare presentation of Brucellosis

We report a rare presentation of brucellosis as bilateral optic nerve and right abducent nerve involvement, and endocarditis complicated by right premacular hemorrhage in a 28-year-old white female. The patient showed improvement with both medical and surgical therapy. Brucellosis should be considered in the differential diagnosis of papillitis, gaze palsy and endocarditis complicated with premacular hemorrhage in endemic regions.

Multiple cranial nerve involvement caused by Brucella melitensis

A case of neurobrucellosis complicated by optic, abducens and vestibulocochlear nerve palsies is reported. Brucella melitensis was isolated in the cerebrospinal fluid, and the patient was diagnosed with retrobulbar neuritis. Despite medical treatment, the patient developed optic atrophy. Multiple cranial nerve involvement should be kept in mind in patients presenting with blurred vision and double vision, especially in regions where brucellosis is endemic.

Irreversible papillitis and ophthalmoparesis as a presenting manifestation of neurobrucellosis

A 35-year-old man presented with a meningeal syndrome and acute onset of visual blurring. Clinical investigations revealed bacterial meningitis with bilateral papillitis and ophthalmoparesis. Serum and cerebrospinal fluid serology confirmed the diagnosis of chronic active neurobrucellosis. Following therapy there was no improvement and he developed optic atrophy. Extensive literature review revealed, one case of bilateral irreversible papillitis resulting from neurobrucellosis. However no cases of neurobrucellosis have been reported with meningitis, irreversible papillitis and ophthalmoparesis. This case demonstrates that in endemic areas, acute meningitis is a potential manifestation of neurobrucellosis and that bilateral irreversible papillitis with ophthalmoparesis can be a potential serious complication.