How is neurobrucellosis with spinal involvement treated?

Treatment of Neurobrucellosis with Spinal Involvement

Neurobrucellosis with spinal involvement should be treated with a combination of doxycycline plus rifampicin for 3-6 months, with the addition of an aminoglycoside (preferably streptomycin) for the first 2-3 weeks. 1

Diagnosis

Before initiating treatment, proper diagnosis is essential:

• Clinical suspicion: Consider neurobrucellosis in patients with new or worsening back pain and fever, especially in endemic regions 2
• Laboratory confirmation:
  • Blood cultures (sensitivity 15-70%)
  • Serological tests: Standard agglutination test (SAT) with titers ≥1:160 considered significant in endemic areas 1
  • In non-endemic areas: ELISA screening followed by confirmatory agglutination test 2
• Imaging:
  • MRI of the spine is mandatory when spinal involvement is suspected, regardless of the spinal level affected 2
  • Image-guided aspiration biopsy may not be necessary if blood cultures are positive for Brucella or if serology is strongly positive in endemic areas 2, 1

Treatment Algorithm

First-line Treatment Regimen:

1. Doxycycline: 100 mg twice daily orally for 3-6 months
2. Rifampicin: 600-900 mg daily orally for 3-6 months
3. Streptomycin: 15 mg/kg daily intramuscularly for the first 2-3 weeks 1

Alternative Regimens:

• If streptomycin is unavailable or contraindicated:

  • Gentamicin: 5 mg/kg daily parenterally for 7 days can replace streptomycin 1

• For cases with severe CNS involvement:

  • Ceftriaxone: Consider adding ceftriaxone due to its high concentration in the cerebrospinal fluid 3

Duration of Treatment:

• Uncomplicated neurobrucellosis: Minimum 3 months
• Complicated spinal brucellosis (with abscesses): 6 months or longer 4

Surgical Management

Surgical intervention is indicated in the following scenarios:

• Spinal cord compression
• Spinal instability
• Presence of abscesses requiring drainage
• Failure of medical treatment 1, 5

The spine (especially if there is cervical involvement) should be immobilized to avoid devastating neurological complications 2.

Monitoring and Follow-up

• Clinical response should be monitored regularly
• Follow-up for at least 2 years after treatment completion 1
• Monitor for relapse, particularly in patients treated with regimens other than doxycycline-streptomycin 1
• Repeat imaging may be necessary to evaluate treatment response

Special Considerations

• Complicated vs. Uncomplicated Cases: Complicated spinal brucellosis (with paravertebral, prevertebral, epidural, or psoas abscesses) requires longer treatment duration 4
• Aminoglycoside-containing regimens may be superior to rifampicin-containing ones for spinal involvement 2
• Early recognition of complicated cases is critical in preventing devastating complications 4

Potential Pitfalls

• Inadequate treatment duration is a common cause of relapse
• Streptomycin's questionable ability to penetrate into the cerebrospinal fluid and its potential neurotoxicity may complicate the clinical presentation 3
• Thoracic spine involvement is more frequently associated with complications 4
• Delayed diagnosis can lead to permanent neurological sequelae

By following this treatment approach, most patients with neurobrucellosis with spinal involvement can achieve good outcomes, though some may experience residual neurological deficits despite appropriate therapy.