Blood cultures were negative. Lumbar punction was performed and CSF analy- sis showed mildly opalescent liquor, with pleocytosis 546/mm3 with polimorfonu-.
Listeria Meningoencephalitis in an Immunocompetent Person
Listeria Meningoencephalitis in an Immunocompetent Person Alija Drnda, Nada Koluder, Amir Hadzic, Nermina Bajramovic, Rusmir Baljic, Velida Mulabdic Clinic for Infectious Diseases, University Clinical Center of Sarajevo, BiH Case report Summary
Listeria monocytogenes is a small, aerobic or facultative anaerobic, non-sporulating gram positive bacillus that can be isolated from soil, vegetation or animal reservoirs. There are six species of Listeria, and only L. monocytogenes is pathogenic for humans. Human disease occurs mainly in immunocompromised people, neonates and in pregnancy, while the cases in immunocompetent people are rare. CNS manifestations of the disease can be in form of meningitis, encephalitis, and also cerebritis and abscess since L. monocytogenes shows tropism for brain and brain stem as well for the meninges. In this case we presented 55 year old male patient with etiologically confirmed listerial meningoencephalitis, transferred from regional hospital tothe Clinic for Infectious Diseases with diagnosis of acute meningoencephalitis. Disease started 4 days before the admission. Prior to this the patient was completely healthy. In his history he denied any preexisting disease. At admittance he was febrile, with altered consciousness, disoriented, showing ocular deviation, dystaxia, and with completely positive meningeal signs. Neurologist diagnosis was rhombencephalitis. CSF analysis showed mildly opalescent liquor with pleocytosis 546/mm3 and polymorphonuclear cell predominance >70%. CSF culture showed positive isolate of L. monocytogenes. Initial therapy was: Penicillin G and Chloramphenicol, together with all other supportive and symptomatic therapy. After initial therapy and based on antibiogram, ampicillin was administered for 4 weeks, followed by imipenemum for 10 days. Control CSF analysis showed pleocytosis and increased protein level and the patient was discharged as recovered with diagnosis of acute meningoencephalitis Key words: Listeria, meningoencephalitis, immunocompetent, brain stem
1. Introduction
Listeria monocytogenes is a small, aerobic or facultative anaerobic, nonsporulating gram positive bacillus that can be isolated from soil, vegetation, animal reservoirs (1). In clinical samples organism can be gram variable and look like diphteroids, cocci, or diplococci. There are six species of Listeria, and only L. monocytogenes is pathogenic for humans (1,2). Human disease occurs mainly in immunocompromised people, neonates, and in pregnancy, cases in immunocompetent people are rare (1,3). CNS manifestations of disease can be in form of meningitis, encephalitis, and also cerebritis and abscess since L. monocytogenes has tropism for brain and brain stem as well for the meninges (1, 2). 2. Case study
We presented case of 55-year old male patient who was transferred from regional hospital to Clinic for Infectious Diseases with diagnose of acute meningoencephalitis. His illness begun 4 days before admittance. Prior to this he was completely healthy. In his history he denied any preexisting disease. From second day he received oral antimicrobial treatment. At admittance he was a febrile, with altered consciousness, disoriented, with ocular deviation, and completely positive meningeal signs. He had symmetri112
Encephalitis acuta; ENT specialist: normal finding. Initial therapy was started according to protocol that was used in that period: Penicillin G and Chloramphenicol, together with all other supportive and symptomatic therapy. After initial therapy, based on antibiogram result we used ampicilin for 4 weeks, followed by imipenemum for 10 days. Control CSF analysis showed pleocytosis and increased protein level. Patient was discharged as recovered with diagnose of acute meningoencephalitis. Four months later we arranged his further evaluation, patient had no complaints, physical status was normal, and CSF analysis showed pleocytosis 153 / mm3, with lymphocyte predomination and increased protein level 1,5 g/L. Third sample of serum analyzed with IFT was negative both in IgM and IgG fraction. MRI showed two small areas of changed signal intensity left, paraventricular-probably vascular etiology.EEG showed mild electro cortical dysfunction in both frontotemporal regions of brain. Discharged with normal CSF cytological finding and increased protein level.
cally decreased miotatic reflexes on his lower extremities, also in neurological examination dystaxia was noted. Laboratory findings were: ESR 18/49; CRP 92, 6 ng/ml; WBC 12,3 x10e9; (neutrophilia >70%), Fibrinogen 25,6 mmol/L; 3. Discussion while RBC, HGB, blood glucose, urea, In this case study we showed a pacreatinin, bilirubin, AST, ALT, CK, tient with etiologically confirmed ListeLDH, ABS, serum minerals were normal. rial meningoencephalitis, and organism Blood cultures were negative. Lumbar was cultured from CSF. Patient was sucpunction was performed and CSF analy- cessfully treated and recovered. Imporsis showed mildly opalescent liquor, with tance of this case is in the fact that we pleocytosis 546/mm3 with polimorfonu- had an immunocompetent person, while clear cell predominance >70%. listerial brain infection is usually disease CSF culture showed positive isolate of newborns and immunocompromised of L. monocytogenes. Results of IFT se- people. Also this patient was examined rology, series of 2 samples taken in 15 by neurologist, and the finding of ocuday were negative. EEG finding showed lar deviation, together with changes in nonspecific changes in brain activity, mental status and dystaxia were enough laterally on both sides. Radiological examination: X-ray findings of head (pyramidal, mastoid, sinuses) were normal, CT showed no pathological findings. MRI showed area sized 5 mm, located right, in back, in brain stem region, at border of pons and mesenchepalon, without opacification with used contrast. Neurologist diagnose was: Rhombencephalitis per acuta, Figure 1. Electron micrograph of a rod-shaped Listeria monocytogenes
Med Arh 2009;63(2) • Prikazi slučaja | Case reports
Listeria Meningoencephalitis in an Immunocompetent Person
lands(4). Competent data for our country still do not exist but we can expect similar changes due to immunization programs.
potential listeriosis, must be used as initiating therapy for meningitis and meningoencephalitis in elderly patient. References
Lorber B. Listeria monocytogenes. In: Mandell GL, Bennet JL, Dolin R, eds. Mandell, Douglas, and Bennet’s princi4. Conclusion ples and practice of infectious disease. Listeria should be kept 5th ed. New York: Churchill Livingstone, in mind as possible patho2000; 2208-15. gen not only in elderly and 2. Shuchat A, Broome V. CNS infection. Listeriosis. In: Braunwald E, et al, editors. immunocompromited paHarrison’s Principles of Internal Meditient with meningitis and cine, 14th edition. New York: McGraw meningoencephalitis, but Hill; 2003: 900. also in immunocompe- 3. Antal E, Dietrichs E, Loberg E, Melby K, tent people. Maehlen J. Brain stem encephalitis in listeriosis. Scandinavian Journal Of InfecLi ster ia rhombentious Diseases [serial on the Internet]. cephalitis is rare condi(2005), [cited November 2, 2008]; 37(3): tion with brain stem af190-194. Available from: MEDLINE Figure 2. MRI showed two small areas of changed signal intensity fection, it is considered 4. Brouwer M, van de Beek D, Heckenberg S, left, paraventricular probably vascular etiology that many of cases goes Spanjaard L, de Gans J. Community-acquired Listeria monocytogenes meningiundetected, therefore we for him to diagnose rhombencephalitis. tis in adults. Clinical Infectious Diseases: should keep in mind possibility of Listerial rhombencephalitis is rare conAn Official Publication Of The Infectious rhombencephalitis in adult patient with dition where brain stem involvement Diseases Society Of America [serial on the meningitis and symptoms of brain stem Internet]. (2006, Nov 15), [cited Novemwith progressive dysfunction occurs. In involvement. ber 2, 2008]; 43(10): 1233-1238. Available clinical picture combined motor, senIn this paper we presented Listeria from: MEDLINE sory and cerebellar deficits together with meningoencephalitis with three impor- 5. Alstadhaug K, Antal E, Nielsen E, Rualterations of consciousness and circulasic Z, Mortensen L, Salvesen R. Listeria tant clinical concepts: tion and respiration failure can be found rhombencephalitis - a case report. Euro•• we presented Listeria meningoenpean Journal Of Neurology: The Official (3). Untreated disease is fatal. According cephalitis in adult patient younger Journal Of The European Federation Of to literature clinical diagnosis of rhombthan 65 without preexistent disNeurological Societies [serial on the Interencephalitis can be established when paease and without immunocompronet]. (2006, Jan), [cited November 2, 2008]; tient have combination of 2 or more of 13(1): 93. Available from: MEDLINE mised state signs and symptoms of brain stem lesion •• etiological diagnosis is confirmed 6. Wing E, Gregory S. Listeria monocytoincluding cranial nerve deficits, cerebelgenes: clinical and experimental update. (liquor culture: L. monocytogenes The Journal Of Infectious Diseases [selar dysfunction, motor deficit, respiraisolated) rial on the Internet]. (2002, Feb 15), [cited tion, altered consciousness. •• af ter second hospital course, November 2, 2008]; 185 Suppl 1: S18-24. It is important to state that due to definit diagnosis was chronical lisAvailable from: MEDLINE.
changes in epidemiological patterns and introduction of immunization for other pathogens Listeria is listed as third causative organism responsible for meningitis among adults in USA and Nether-
teria meningoencephalitis, without obviuos concenquences in neurological and psychical status. Empirical therapy directed against
1.
Corresponding author: Alija Drnda, MD. Clinic for Infectious Diseases, University Clinical Center of Sarajevo, BiH. Tel.: 033 297 000.
Med Arh 2009;63(2) • Prikazi slučaja | Case reports
113
