although , the disease has been reported around the world , it has a higher prevalence in countries where the health care problems and animal health are not standardized . in asian countries and turkey , clinical manifestation of brucellosis includes weakness , fever , headache , pain involving muscles and joints ( low back pain in 60% of cases ) , rash , splenomegaly and hepatomegaly , diarrhea , nausea , vomiting , constipation , and lack of appetite ( 3 , 4 ) . neurobrucellosis ( nb ) is an uncommon complication , which occurs in 3%5% of brucellosis and could present in any stage of the disease . although , this side effect is not so common , it is a significant problem in mediterranean regions ( 1 , 5 ) . there is a controversy about diagnostic criteria for nb in different papers . diagnosis based on the detection of neurological symptoms in a patient with brucellosis and in others on the microbiological results of cerebrospinal fluid analysis . microbiological evaluation and culture of the cerebrospinal fluid is the gold standard for diagnosis of nb , however , because growth rate of microorganism is low this method is time consuming . thus , performing serological tests and cerebrospinal fluid ( csf ) analysis in suspected patients is necessary and could be more helpful ( 5 , 6 ) . the clinical course of the disease is relatively insidious and the most common pattern of presentation is subacute or chronic ( 4 ) . here , we reported a case of an apparent healthy young woman presented with hyperacute onset of headache and abnormal behavior and diagnosed nb . in endemic areas , nb should be considered for each patient referred with unexplained neurological problems . the patient is a 25 yr - old afghani woman presented with severe acute headache , agitation and abnormal behavior since one day prior to her admission in nemazee hospital ; an academic center affiliated to shiraz university of medical sciences , shiraz , south of iran in 2105 . she was an animal husbandry and had no any significant disease in the past medical and drug histories . the patient lived in rural areas of shiraz ( south of iran ) and used to consume unsterilized milk products . on arrival in the hospital , the patient was confused , restless and agitated without verbal communication . there was nuchal rigidity ; however , the rest of general and neurological examinations were normal . laboratory tests including complete blood counts ( cbc ) , blood urea nitrogen ( bun ) , serum creatinine , electrolytes and liver function tests proved to be normal . brain mri with and without contrast was consistent with diffuse dural and leptomeningeal enhancement ( fig . lumbar puncture was performed 2 times in a 72-h period and checked for analysis , gram staining and culture ( table 1 ) . coronal ( a ) and axial ( b ) views of brain mri with and without contrast show diffuse dural and leptomeningeal enhancement ( original ) pattern of first and second csf analysis further csf evaluations were requested for herpes simplex virus ( hsv - pcr ) , igg- and igm- antibody for nb , ada and pcr for mycobacterium tuberculosis ( tb ) . igg - antibody for nb was 121.3 mg / dl , ( normal range lower than 0.5 mg / dl ) . serum igg for brucella demonstrated 108 mg / dl ( normal range less than 8 mg / dl ) and for igm 3.2 mg / dl(less than 8 mg / dl ) ; 2-me titer also was 1:20 and wright test 1:80 which were positive for this endemic area . with suspicion to brucellosis , treatment was initiated with rifampin , doxycycline , and co - trimoxazol . few days later , she was discharged from the hospital in a good situation with oral medications . consumption of unpasteurized milk products , as well as contact with infected animals , is a common route of transmission ( 7 , 8) . neurologic complications of brucellosis are not so common , but very important . diagnosis of nb was difficult and there was not a definite diagnostic test for this disease ( 9 ) . since this condition can be very dangerous and problematic for patients , it is very important to consider it in every patient with un - diagnosed neurological manifestations . indeed , it has a long - term treatment period and its response to treatment is slow . in one study in turkey this finding has also been confirmed in other studies ( 11 , 12 ) . our patient presented with hyperacute onset of symptoms ( which started and reached its peak among hours ) , such as headache , abnormal behavior , and impaired level of consciousness . clinical symptoms and the course of the disease were also consistent with nb ; however , that was contrary to the usual cases , and her symptoms appeared suddenly ( 13 ) . initial symptoms of this patient in our study were started by sudden headache and behavioral changes . the aim of this case study was to alert physicians on the unusual manifestations and presentations of nb , which could be missed if there is no suspicion about it . ethical issues ( including plagiarism , informed consent , misconduct , data fabrication and/or falsification , double publication and/or submission , redundancy , etc . ) have been completely observed by the authors .
neurobrucellosis is uncommon ; however , it is an important complication of brucellosis , which could be seen in any stage of the disease . 
 it presents with different kinds of neurology manifestations and diagnosis is mainly made on history , physical examination and laboratory tests . 
 the clinical course of the disease is relatively insidious and the most common pattern of presentation is subacute or chronic . 
 it has a long - term treatment period and its response to treatment is slow . here 
 , we report a case of an apparent healthy 25 yr - old afghani woman from fars province ( south of iran ) that presented at first with hyperacute onset of headache and abnormal behavior and diagnosed neurobrucellosis in nov 2015 . in endemic areas , neurobrucellosis should be considered for each patient referred with unexplained neurological problems .