67 year old Caucasian woman with history of depression, dyslipidemia, hypothyroidism, and irritable bowel syndrome presented with fatigue, 25 lbs weight loss, subjective fevers, neck stiffness, and headaches.  3 month later, she developed CN6 palsy which prompted a negative workup(myasthenia panel, CPK, EMG-NCS, mestinon trial, brain MRI without/with contrast, MRA head).  CT chest, abdomen and pelvis and mammogram were unremarkable.  CSF showed a normal opening pressure and 128 white cells (98% lymphocytes), 9 RBCs, glucose 58 and protein 212.  Bacterial, fungal, AFB  cultures, ACE, VDRL, VZV,HSV PCRs, coccidiomycosis, Cryptococcus, MTB, Fungitell 1-3 B-D glucan, cytology(3 times), and toxoplasmosis antibodies were negative. 5 CNS-specific oligoclonal bands were seen.  Metagenomic next-generation sequencing was negative for DNA/RNA viruses, bacteria, fungi, and parasites.  Notable negative serum studies included ANCA, dsANA, SS-AB,ESR, anti Smith, eosinophilia, Hep C, Lyme, LCMV, serum toxoplasmosis, cysticercus, HTLV, and West Nile.

Brucella IGG was positive(1.44), IGM negative, repeat testing showed similar results.  The patient does not consume dairy except rare string cheese.  No exposure to farm animals, travel history, or undercooked beef.

She completed ceftriaxone as well as oral doxycycline and rifampin therapy.  Despite resolution of diplopia, her neck pain and malaise recurred.

Over 5 month, four spinal taps showed no consistent improvement of her lyphocytic pleocytosis, high CSF protein and low-normal glucose.