Uncontrolled seizures resulting from cerebral venous sinus thrombosis complicating neurobrucellosis
The case was a 33-year-old woman who was referred to the Neurology Clinic of Vali-e-Asr Hospital, Arak, Iran, with headache, asthenia, decreased appetite, fever, sweating, and increased number of seizures up to 3-4 times a day. Night sweats and fever; suspicious myalgia description, and residence in rural area and being in contact with farm animals; counseling for infectious diseases; and medical assessments for brucellosis and hepatitis C and B were in the patient's history. The patient's history indicated that she was diagnosed with a complex partial seizure persisting for 10 years. A month before referral to the hospital, her seizure had gone out of control and, despite the patient's frequent visits and increased drug dose, the treatment had not been successful. Prior to admission, the patient was prescribed 50 mg lamotrigine and 400 mg carbamazepine three times a day and 1 mg folic acid once a day.\nThe patient's body temperature was 37.8 °C, which did not pose any significant problems. A nervous system examination also indicated that the patient was in a complete state of awareness and did not demonstrate neck stiffness.\nRoutine lab tests reported increased liver enzymes and normal CBC. The results of Wright's agglutination test (1/640), Coombs-Wright test (1/640), and 2ME (1/320) were positive and confirmed brucellosis, while hepatitis C and B were not verified. Concurrently, an evaluation was carried out to discover the cause of abrupt increase in the frequency of seizures in spite of treatment with antiepileptic drugs. A brain CT scan revealed hyper-dense areas in the left posterior parietal and temporal lobe together with peripheral hypo-density, hemorrhagic focus, and edema around it []. An MRI indicated a suspicious lesion similar to those in hemorrhagic infarction or hematoma in the left temporal lobe and an abnormal signal in the left transverse sinus []. Hence, on suspicion of venous sinus thrombosis, an MRV was prescribed for the patient [].\nWith the verification of brucellosis, treatment was performed by administration of Rifampin (600 mg/d), Doxycycline (100 mg two times a day), and Streptomycin 1 g/day. Streptomycin was stopped after 10 days while Rifampin and Doxycycline continued for eight weeks. In addition, Warfarin and Heparin were administered, eventually leading to the control of seizures. Three days after admission and the initiation of treating brucellosis and CVST, seizure was finally under control and the fever and other symptoms disappeared. Therefore, the patient was discharged with anti-brucellosis drugs Carbamazepine 200 mg three times per day, and Warfarin, in good general health conditions without fever and signs of infection.\nIn the third month after treatment, Wright's agglutination and 2ME tests showed 1/40 and 1/20 respectively. These values of Wright's agglutination and 2ME tests are negative in Iran based on guidelines for tuberculosis control program. The prescribed Warfarin continued for one year and during the first year an MRI and MRV showed a decline in venous sinus thrombosis symptoms and brain bleeding.