THINK AGAIN: LISTERIA MONOCYTOGENES MENINGITIS IN …
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© Aurora Health Care, Inc. THINK AGAIN: LISTERIA MONOCYTOGENES MENINGITIS IN A PATIENT WITH SYSTEMIC LUPUS ERYTHEMATOSUS Prakash Nallani MD, Ankoor Biswas MD Aurora Health Care Internal Medicine Residency, Milwaukee WI BACKGROUND Infections are a major cause of morbidity and mortality in patients with systemic lupus erythematosus (SLE) An increased susceptibility to infections exists in SLE patients, either related to immunosuppressive therapies or from disease-related immunological dysfunction Central nervous system (CNS) infections in patients with SLE are rare, affecting approximately 1.4% of patients; however, a death rate of higher than 40% has been reported in this patient group Listeria monocytogenes (LM) is an intracellular gram-positive bacillus which directly spreads fom cell to cell without being exposed to the humoral immune system In the US and France, LM has been reported as the third or fourth most common casue of encephalitis-associated deaths, respectively Those most vulnerable to Listeria infection are healthy adults older than age 65, neonates, pregnant women, immuno-compromised individuals, including those having received immunosuppressive therapy CASE PRESENTATION A 68-year-old female with history of SLE, ischemic cardiomyopathy, and chronic diarrhea presented with acute worsening of diarrhea and rectal pain over 3 days. She had been hospitalized the prior month for new choreiform movements and dysarthria believed to be secondary to CNS involvement of SLE; at the time, she had been taking prednisone 40 mg daily and mycophenolate 750 mg twice daily for immunosuppression. Notable labs on admission included leukocytosis 11.9 K/mcL, sodium 128 mmol/L, bicarbonate 18 mmol/L, glucose 273 mg/dL, BUN 30 mg/dL, and creatinine 1.25 mg/dL. The patient developed altered mentation with high fevers shortly after admission and was emergently intubated, then transferred to ICU; CT head was negative and lumbar puncture (LP) was performed. Empiric IV cefepime, vancomycin, ampicillin, acyclovir and oral vancomycin were started. Cerebrospinal fluid (CSF) culture and rapid meningitis panel grew Listeria monocytogenes, as did initial blood cultures. Repeat blood and CSF cultures were negative, and she completed antibiotic treatment for 3 weeks. Patient clinically improved and was transitioned back to her home from a skilled nursing facility. MRI showed tiny acute embolic infarcts within the right cerebellum without other acute intracranial findings. DISCUSSION Due to their similar manifestations, CNS infections and neuropsychiatric systemic lupus erythematosus (NPSLE) may be difficult to distinguish from one another The most common pathogens involved in CNS infections in SLE patients include M. tuberculosis, C. neoformans, and L. monocytogenes A transient gastroenteritis may precede Listeria meningitis, providing an important clue for accurate diagnosis and therapy SLE patients with CNS infection may present with fever, febrile gastroenteritis, anorexia, and headache; less common features are neck stiffness, coma, and seizures Ampicillin is the recommended first-line agent, and trimethoprim-sulfamethoxazole is the drug of choice for penicillin-allergic patients In order to mitigate high mortality, clinicians must have high suspicion for meningitis and respond with early diagnosis and treatment REFERENCES HortaBaas G, GuerreroSoto O, BarileFabris L (2013) Central nervous system infecBon by Listeria monocytogenes in paBents with systemic erythematosus: analysis of 26 cases, including the report of a new case. Reumatol Clin 9:340347 Hung JJ, et al (2005) Central nervous system infecBons in paBents with systemic lupus erythematosus. J Rheumatol 32:4043 Lee MC, et al (2011) Listeria monocytogenes meningiBs in a young woman with systemic lupus erythematosus. Rheumatol Int 31:555557 Shi TY, et al (2018) A rare case of meningoencephaliBs by Listeria monocytogenes in systemic lupus erythematosus: case report and review. Clin Rheumatol 37: 271275
Transcript of THINK AGAIN: LISTERIA MONOCYTOGENES MENINGITIS IN …
© Aurora Health Care, Inc.
THINK AGAIN: LISTERIA MONOCYTOGENES MENINGITIS IN A PATIENT WITH SYSTEMIC LUPUS ERYTHEMATOSUS
Prakash Nallani MD, Ankoor Biswas MD Aurora Health Care Internal Medicine Residency, Milwaukee WI
BACKGROUND § Infections are a major cause of morbidity and
mortality in patients with systemic lupus erythematosus (SLE)
§ An increased susceptibility to infections exists in SLE patients, either related to immunosuppressive therapies or from disease-related immunological dysfunction
§ Central nervous system (CNS) infections in patients with SLE are rare, affecting approximately 1.4% of patients; however, a death rate of higher than 40% has been reported in this patient group
§ Listeria monocytogenes (LM) is an intracellular gram-positive bacillus which directly spreads fom cell to cell without being exposed to the humoral immune system
§ In the US and France, LM has been reported as the third or fourth most common casue of encephalitis-associated deaths, respectively
§ Those most vulnerable to Listeria infection are healthy adults older than age 65, neonates, pregnant women, immuno-compromised individuals, including those having received immunosuppressive therapy
CASE PRESENTATION A 68-year-old female with history of SLE, ischemic cardiomyopathy, and chronic diarrhea presented with acute worsening of diarrhea and rectal pain over 3 days. She had been hospitalized the prior month for new choreiform movements and dysarthria believed to be secondary to CNS involvement of SLE; at the time, she had been taking prednisone 40 mg daily and mycophenolate 750 mg twice daily for immunosuppression. Notable labs on admission included leukocytosis 11.9 K/mcL, sodium 128 mmol/L, bicarbonate 18 mmol/L, glucose 273 mg/dL, BUN 30 mg/dL, and creatinine 1.25 mg/dL.
The patient developed altered mentation with high fevers shortly after admission and was emergently intubated, then transferred to ICU; CT head was negative and lumbar puncture (LP) was performed. Empiric IV cefepime, vancomycin, ampicillin, acyclovir and oral vancomycin were started. Cerebrospinal fluid (CSF) culture and rapid meningitis panel grew Listeria monocytogenes, as did initial blood cultures. Repeat blood and CSF cultures were negative, and she completed antibiotic treatment for 3 weeks. Patient clinically improved and was transitioned back to her home from a skilled nursing facility.
MRI showed tiny acute embolic infarcts within the right cerebellum without other acute intracranial findings.
DISCUSSION § Due to their similar manifestations, CNS infections
and neuropsychiatric systemic lupus erythematosus (NPSLE) may be difficult to distinguish from one another
§ The most common pathogens involved in CNS infections in SLE patients include M. tuberculosis, C. neoformans, and L. monocytogenes
§ A transient gastroenteritis may precede Listeria meningitis, providing an important clue for accurate diagnosis and therapy
§ SLE patients with CNS infection may present with fever, febrile gastroenteritis, anorexia, and headache; less common features are neck stiffness, coma, and seizures
§ Ampicillin is the recommended first-line agent, and trimethoprim-sulfamethoxazole is the drug of choice for penicillin-allergic patients
§ In order to mitigate high mortality, clinicians must have high suspicion for meningitis and respond with early diagnosis and treatment
REFERENCES Horta-‐Baas G, Guerrero-‐Soto O, Barile-‐Fabris L (2013) Central nervous system infecBon by Listeria monocytogenes in paBents with systemic erythematosus: analysis of 26 cases, including the report of a new case. Reumatol Clin 9:340-‐347 Hung JJ, et al (2005) Central nervous system infecBons in paBents with systemic lupus erythematosus. J Rheumatol 32:40-‐43 Lee MC, et al (2011) Listeria monocytogenes meningiBs in a young woman with systemic lupus erythematosus. Rheumatol Int 31:555-‐557 Shi TY, et al (2018) A rare case of meningoencephaliBs by Listeria monocytogenes in systemic lupus erythematosus: case report and review. Clin Rheumatol 37: 271-‐275
