Fulminant listerial infection of the central nervous system in an otherwise healthy patient: a case report
Fulminant listerial infection of the central nervous system in an otherwise healthy patient: a case report
Introduction: The mortality of listerial rhombo-encephalitis exceeds 26% and may involve otherwise healthy patients. A case is presented of a man with fatal listerial infection of the central nervous system that was monitored in an intensive care unit.
Case presentation: A 42-year-old, previously healthy man was admitted with fever of 39°C, blurred vision, confusion and headache. He had right-sided central facial paresis, bilateral absent gag reflex and bilateral cerebellar ataxia. After a few hours, he became septic and developed bilateral vocal cord paralysis and airway obstruction. He was intubated and put on mechanical ventilation. Computed tomography brain scans revealed multiple frontal hypodense areas and slight hydrocephalus. Cerebrospinal fluid findings included pleocytosis of 4200 cells/μL (77% neutrophils), protein of 114 mg/dL and normal glucose levels. Listerial infection was suspected; therefore ampicillin was added to his initial therapeutic regimen, already including ceftriaxone and gentamicin. All cultures were negative, and no immunologic abnormality could be documented, but the patient’s clinical condition deteriorated rapidly. Continuous neuromonitoring by means of transcranial Doppler and optic nerve sonography along with follow-up computed tomography brain scans confirmed the severity of the brain damage; hence, dexamethasone and mannitol were also administered. The patient was clinically documented as ‘brain dead’ 7 days after his admission to the intensive care unit; thereafter, blood- and post-mortem brain tissue cultures grew Listeria monocytogenes.
Conclusion: This case report illustrates the importance of neuromonitoring in patients with severe brain damage. We also show that, despite prompt antibiotic treatment and dexamethasone administration, listerial infection of the central nervous system can be lethal.
Introduction
Listeria monocytogenes is an anaerobic, Gram-positive bacillus causing infections of the central nervous system (CNS) primarily observed in immunocompromised hosts. A specific form of listerial CNS infection, listerial rhomboencephalitis, usually occurs in otherwise healthy adults. Typically, it is a biphasic illness with neurologic signs appearing 4 to 5 days after the onset of fever. Mortality exceeds 26%, and serious sequelae are common in survivors [1]. We present a case of listerial CNS infection in a previously healthy person in whom diagnosis was based on the clinical findings of blood- and post-mortem tissue cultures, cerebrospinal fluid (CSF) results and computed tomography (CT). The patient was admitted to the intensive care unit (ICU) and underwent continuous neuromonitoring. Despite early administration of antibiotic and dexamethasone treatment, the listerial infection proved lethal. Previous studies did not focus on the neuromonitoring in cases of CNS infection. In our report, we performed non-invasive methods such as transcranial Doppler sonography (TCD) and optic nerve sonography, which may be used in the ICU for neuromonitoring purposes.
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