Background
A 34-year-old male patient presented with persistent diplopia, dizziness, and headache lasting for more than 4 months, followed by recurrent headache, vomiting, and low-grade fever for 4 days. He was admitted to our hospital on November 12, 2022. The flowchart for the case presentation is detailed in Figure 1.
Clinical Course
Starting 4 months prior to admission, the patient experienced continuous diplopia, blurred vision, dizziness, headache, and fatigue without any evident cause. The patient did not work in livestock farming and had not traveled to high-risk areas. The only potential exposure identified was consumption of grilled mutton shashlik. CSF mNGS confirmed the presence of Brucella and human herpesvirus 4 (EBV) (Table 1). CSF analysis revealed elevated protein levels and an elevated white blood cell count (Table 3, column 1), consistent with meningitis. Various neuroimaging studies, including computed tomography (CT) and MRI, indicated bilateral optic neuritis, meningitis, and cerebral vascular changes. Blood tests indicated normal to slightly altered liver and renal function, with normal blood counts and inflammatory markers. The T-SPOT-TB results and multiple pulmonary nodules on CT imaging suggested healed asymptomatic pulmonary tuberculosis.
The patient was initially treated in Lingnan Hospital’s Department of Infectious Diseases on September 20, 2022, with oral rifampicin 0.6g qd, oral doxycycline 0.1g q12h, and intravenous ceftriaxone 2.0 q12, along with antiviral, antihypertensive, and dehydration therapies. Upon improvement, he was transferred to Nanchang’s Ninth Hospital for continued treatment with oral doxycycline 100mg bid, rifampicin 600mg qd, compound sulfamethoxazole, ceftriaxone sodium, levofloxacin, and antiviral therapy against EBV, along with liver protection and enzyme reduction treatments.
Recent Developments
On November 8th, 2022, the patient experienced recurrent headaches, vomiting, and a low-grade fever, with his body temperature fluctuating between 37.1°C and 37.4°C, indicating a potential exacerbation of his condition. He was then admitted to our hospital. Upon admission, the patient was alert with normal muscle strength and tone in all limbs. Superficial reflexes, including abdominal reflexes, and deep reflexes, such as biceps, triceps, knees, and Achilles reflexes, were normal. No pathological reflexes were elicited, and the meningeal irritation sign was negative. CSF NGS indicated the presence of Brucella and EBV (Table 2).
Therapeutic Approach
During the patient’s hospital stay, the treatment regimen included doxycycline 0.1g twice daily, rifampin 0.6g once daily, and ceftriaxone 2g every 12 hours as combined anti-infection therapy. Additional supportive treatments included mannitol for dehydration, mecobalamin for neural nutrition, and filgrastim to increase the white blood cell count. The patient received both intravenous and oral therapies tailored to the clinical situation, resulting in gradual improvement characterized by decreased CSF pressure and reduced meningitis symptoms (Table 3, columns 4-6). Follow-up laboratory tests showed resolution of the infection’s acute phase, leading to the discontinuation of ceftriaxone in favor of ciprofloxacin for continued anti-infection treatment, given the patient’s stabilized condition. Ongoing monitoring was advised due to residual concerns and the risk of chronic complications. Subsequent telephone follow-ups confirmed the patient’s symptoms did not recur and his condition remained stable.