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the patient was a 46-year - old saudi woman who had chronic hepatitis c , end - stage renal disease of undetermined etiology , and a renal transplant in 1993 .
seizures were usually preceded by epigastric pain and a sensation of nausea for few seconds , followed by left arm posturing and loss of consciousness .
she lived in a rural area , was involved in animal husbandry , and consumed unpasteurized milk products .
her medications included mycophenolate mofetil ( 500 mg 2/d since 1993 ) , prednisone ( 5 mg 1/d since 1993 ) , levetiracetam ( 500 mg 2/d for 5 mo ) , and phenytoin ( 200 mg every night for 1 mo ) .
neurologic examination showed left homonymous hemianopia , increased deep tendon reflexes in the left hemibody , and the babinski sign on the left hallux .
initial laboratory test results , including those for complete blood count , erythrocyte sedimentation rate , c - reactive protein , and liver and renal profiles , were within references ranges . results of serologic analysis for hiv and hepatitis b virus were negative . a standard agglutination tube ( sat ) test result for brucella spp .
was positive ( titer 1:320 ) , and a 2-mercaptoethanol test result for brucella spp .
cerebrospinal fluid ( csf ) had a leukocyte count of 21 ( 90% lymphocytes ) .
levels of protein , glucose , and lactate dehydrogenase in csf were within references ranges .
gram staining of a csf sample and cultures for bacteria , virus , fungi , and acid - fast bacilli ( afb ) showed negative results .
serologic analysis of csf showed brucella igg ( titer < 1:20 ) and antibodies against brucella ( titer 1:320 ) .
test results were negative for antibodies against aspergillus , aspergillus galactomannan , blastomyces , borrelia , coccidia , cryptococcus , histoplasma , and toxoplasma .
an electroencephalogram showed sharp waves over the right temporal region and continuous slow activity over the right temporooccipital region .
magnetic resonance imaging ( mri ) of the brain showed diffuse t2/fluid - attenuated inversion recovery hyperintense white matter lesions involving the right frontal , parietal and temporal lobes ( figure 1 ) . no appreciable mass effect or enhancement after administration of gadolinium was observed . positive emission tomography of the brain showed hypometabolic cerebral activity involving a large area of right cerebral hemisphere .
magnetic resonance spectroscopy shows a low peak of n - acetyl aspartate ( 2.2 ppm ) .
magnetic resonance imaging of the brain of a 46-year - old immunocompromised woman with central nervous system brucellosis granuloma and white matter disease , saudi arabia .
a ) axial t2 images showing hyperintensity in the right frontoparietal lobe and right temporal lobe .
b ) axial fluid - attenuated inversion recovery ( flair ) and c ) coronal flair images showing that hypersensitivity extends to u - fibers without involvement of the cortex .
d ) gadolinium - enhanced image showing that no appreciable mass effect and no central or peripheral enhancement after administration of gadolinium were observed .
each image within each panel shows involvement in different levels of frontal , parietal , and temporal lobes .
a brain biopsy specimen of cerebral cortex and superficial white matter showed a moderate lymphoplasmacytic and focally histiocytic infiltrate that involved deep cortex , white matter , and leptomeninges .
the inflammatory reaction , including granulomas , was mainly perivascular with some angiocentric patterns and focal parenchymal involvement .
there were no morphologic signs of a specific etiology : no viral inclusions , and staining results microorganisms ( afb , fungi , epstein - barr virus , and jc polyomavirus ) were negative ( figure 2 ) .
histologic analysis of a brain biopsy specimen from a 46-year - old immunocompromised woman with central nervous system brucellosis granuloma and white matter disease , saudi arabia .
a ) low magnification view of cerebral cortex showing infiltration by perivascular lymphocytes and histiocytes .
b ) high magnification view showing an angiocentric epithelioid granuloma cuffed by mature lymphocytes ( original magnification 200 ) .
was sensitive to gentamicin , streptomycin , tetracycline , trimethoprim / sulfamethoxazole , and rifampin .
the patient received intravenous ceftriaxone ( 2 g every 12 h ) , oral doxycycline ( 100 mg every 12 h ) , oral rifampin ( 600 mg 1/d ) , and trimethoprim / sulfamethoxazole ( 1 tablet [ 160 mg/800 mg ] every 12 h ) for 2 wk .
after discharge , she was receiving oral doxycycline ( 100 mg every 12 h ) , rifampin ( 600 mg , 1/d ) , trimethoprim / sulfamethoxazole ( 1 tablet every 12 h ) , and ciprofloxacin ( 500 mg every 12 h ) for 6 mo : she was also receiving levitiracetam ( 750 mg 2/d ) , carbamazepine ( 200 mg 2/d ) , mycophenolate mofetil ( 500 mg 2/d ) , and prednisone ( 5 mg 1/d ) .
three months later , repeat mri of the brain showed decreased t2 hyperintensity associated with volume loss and ex vacuo dilatation of the subjacent right lateral ventricle .
neurobrucellosis can affect the central or peripheral nervous systems and lead to diverse clinical syndromes ( 4 ) .
diagnosis of neurobrucellosis depends on clinical manifestations , csf findings suggestive of pinocytosis , high protein levels , low or standard glucose levels , and a positive antibody titer for brucella spp .
although the patient had mild pleocytosis with a predominance of lymphocytes and high antibody titers against brucella spp . in csf ,
however , low levels of antibodies might not be detected by sat . in suspicious cases in which the sat result is negative , sat and a coombs test , elisa , and pcr are helpful in making a diagnosis .
77the clinicalradiologic correlation for neurobrucellosis ranges from uneventful results for imaging studies , despite positive clinical findings , to imaging abnormalities ( 3 ) .
neurobrucellosis with a focal brain mass has been rarely observed in imaging studies ( 7,8 ) .
radiologic results in this case suggested an infectious disease , autoimmune disease , or malignancy in an immunocompromised patient . because we deemed it necessary to exclude other conditions , such as progressive multifocal leukoencephalopathy or lymphoma
the diagnosis was established by detecting antibodies against a brucella sp . in serum and csf and confirmed by isolation of a brucella sp . from brain tissue .
we found that the patient had epilepsy and extensive white matter changes secondary to brucellosis .
mri of the brain showed abnormal results ( prominent white matter disease and focal encephalomalacia ) .
inflammation can cause permanent cellular biochemical dysfunction , which can lead to electrically irritable tissue and parenchymal damage despite successful treatment .
longitudinal studies of white matter hyperintensities caused by vascular , noninfectious , infectious , and inflammatory conditions showed white matter hyperintensities over time despite effective treatment .
reported that white matter changes in neurobrucellosis were sequelae of demyelination , as confirmed by the pathologic analysis ( 9 ) .
we believe that unresolved white matter hyperintensities in this patient were a sequela of the inflammatory process . a case report documented similar clinical features in a patient with seizures caused by chronic neurobrucellosis for 2.5 years ( 10 ) .
solitary cysticercus granuloma and calcified lesion are 2 common neuroimaging abnormalities in patients with epilepsy .
treatment for underlying cysticercosis does not cure epilepsy ( 12 ) . seizures associated with central nervous system tuberculomas
the underlying pathogenesis for relapsing epilepsy in neurocysticercosis is probably related to abnormal neurons and their arrangement within calcified nodules ( 13 ) .
the epilepsy prognosis for neurobrucellosis is probably similar to that for central nervous system neurocysticercosis ( 13 ) .
our findings indicate the need for suspecting neurobrucellosis as a cause of epilepsy and white matter disease in immunocompromised patients in disease - endemic areas .
brucellosis is a multisystem zoonotic disease . 
 we report an unusual case of neurobrucellosis with seizures in an immunocompromised patient in saudi arabia who underwent renal transplantation . 
 magnetic resonance imaging of the brain showed diffuse white matter lesions . 
 serum and cerebrospinal fluid were positive for brucella sp . granuloma was detected in a brain biopsy specimen .