Psychotic attacks due to toxic neurobrucellosis in two adolescent patients

Immunopathologic mechanisms like T-cell mediated cytotoxicity and microglia activation are suggested to play a role in neurobrucellosis. The diagnosis of toxic neurobrucellosis is confirmed by isolation of Brucella organism from blood cultures and/or positive Coombs Wright test and the Standard agglutination test (SAT) in serum, when there are no cerebrospinal şuid (CSF) findings. The magnetic resonance imaging (MRI) of brain in patients with neurobrucellosis may show abnormalities such as inşammation, white matter changes and vascular pathologies and these can mimic other neurologic diseases. In this study, we present two adolescents who presented with psychotic symptoms due to toxic neurobrucellosis.

Case 1: A is a 15-year-old student living in a village within the municipal boundaries of Van Province. Such complaints as talking nonsense, hallucinations, laughing to oneself, detrimental behavior towards people and things around him, insomnia and lack of appetite were reported to have started a month before the patient’s application to the psychiatry outpatient service. In his physical examination, it was revealed that he had pain and sensitivity in his left hip joint aggravating upon movement and causing a limp in his walk. In laboratory analyses, Wright’s Brucella tube agglutination test result was positive in the titration of 1/60. Leukoencephalytic changes in peri-supraventricular white matter were monitored in both cerebral hemispheres through Magnetic Resonance Imaging (MR).

Case 2: B is a 14-year-old female applying for treatment from district of Patnos, a province of Agri. The patient, not having applied for psychiatric help so far, was brought to our psychiatry outpatient service by her relatives with complaints of such behavior as talking nonsense, talking to herself, insomnia, nervousness, hearing voices calling her name, leaving home, breaking things, punching people around her, attempting at setting the house on fire, tearing her clothes off, seeing non-existent things such as a man in white, two girls and two dogs and saying that she was talking with them and an increase in movements and amount of speech. As for organic etiology, increased white matter signals were recorded and monitored at the level of right corona radiata and in the vicinity of left lateral ventricle atrium in brain MR. In her clinical follow-up visit, she was consulted to the department of infectious diseases since she had fever at sub-febrile levels, and a blood culture sample collected at the time of her fever was sent thereto. Brucella reproduced in the blood culture.

These data suggest that white matter involvement may be an immune-mediated reaction in central nervous system to brucellosis infection. Persistence of residual symptoms in follow-up visits of the two cases demonstrates that the bacteria might give rise to longer and chronic processes due to toxic effect since bacteria can trigger immune mechanisms.