A brucellosis-associated vasculopathy presenting with focal neurological deficit: a case report in a pediatric patient with unique imaging

Abstract

Brucellosis is the most prevalent bacterial zoonosis worldwide. While neurobrucellosis occurs in 5–7% of the affected adults, it is a rare pediatric complication, with an estimated incidence of 0.8%. Limited knowledge of its presentations, diagnosis, and management leads to a significant delay in accurate diagnosis. Although rare, cerebrovascular accident is a leading cause of childhood mortality, 30–50% of which occurs in the context of cerebral vasculopathy. Infection is the most common etiology of secondary cerebral vasculopathies. A 10-year-old girl presented to the emergency department with a throbbing left-sided parietal headache, nausea, vomiting, photophobia, phonophobia, nuchal rigidity, and bilateral papilledema. Her initial symptoms began five months ago, including polyarthritis, limping, and conjunctivitis, accompanied by a progressively worsening headache and fever, which led to two prior hospitalizations at our institution. Past medical and familial history were unremarkable, except for a diagnosis of familial hypercholesterolemia. The clinical course was further complicated by a sudden onset of right-sided hemiparesis one day after admission. Brain MRI upon the focal neurologic deficit demonstrated an enhancing parasellar-suprasellar lesion that encased and significantly narrowed the left internal carotid artery along the cavernous to supraclinoid segments. The only remarkable laboratory findings were positive CSF inflammatory markers, elevated CSF 2-ME and serum anti-Brucella antibodies, and a positive CSF culture for Brucella species. The constellation of clinical, laboratory, and imaging findings led to a final diagnosis of left internal carotid perivascular granuloma in the context of neurobrucellosis. Treatment was initiated with anti-Brucella antibiotics and corticosteroids, resulting in complete resolution of the perivascular granuloma and clinical symptoms, with no residual sequelae. This case demonstrates that cerebral vascular involvement can occur in pediatric neurobrucellosis. With prompt diagnosis and targeted therapy, this complication can yield a favorable outcome. Clinicians should include neurobrucellosis-associated cerebral vascular involvement in the differential diagnosis when evaluating pediatric patients who present with focal neurologic deficits in the setting of meningoencephalitis.