AN UNCOMMON PRESENTATION, AN UNUSUAL ASSOCIATION: A STROKE, DEMYELINATING DISORDER, OR AN INFECTION?

Abstract

SESSION TITLE: Critical Care 1 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Rhombencephalitis, a rare manifestation of listeria is seen in immunocompetent young adults. Reverse takotsubo(r-TTC) is an unusual association described with listeria rhombencephalitis (LRE). CASE PRESENTATION: A 42-year-old Brazilian female with medical history of migraine presented with headache, nausea, vomiting, photophobia, left facial numbness and fevers for four days. Physical findings remarkable for bilateral horizontal nystagmus, left facial numbness and left upper extremity dysdiadochokinesia. Multiple lower cranial nerves were involved subsequently leading to compromised airway, hypoxia, orotracheal intubation and mechanical ventilation. She was treated with ceftriaxone, vancomycin and acyclovir initially. Later ampicillin and double strength trimethoprim/sulfamethoxazole (DS-TMP/SMZ) were added based on the magnetic resonance imaging (MRI) brain results. MRI revealed a ring-enhancing central T1 hypointense lesion in the left cerebral peduncle with extension to posterolateral pons and medulla suspicious for LRE. Chest computerized tomography (CT) was suggestive of pulmonary edema. Echocardiography revealed left ventricular global hypokinesis sparing the apex suggestive of r-TTC. Given her worsening hemiparesis and altered mentation, dexamethasone was initiated on day 4 and continued for seven days. Blood and cerebrospinal fluid culture (CSF) were negative. However, CSF polymerase chain reaction (PCR) confirmed the diagnosis of listeria. Subsequently all antimicrobials were discontinued except ampicillin and DS-TMP/SMZ. A gradual recovery of mentation and hemiparesis was evident. Echocardiography on day 9 showed improvement in the ejection fraction (50-55%). She underwent tracheostomy and subsequently weaned from mechanical ventilation. She was then discharged to acute rehabilitation where she completed 6 weeks of DS-TMP/SMZ and ampicillin. DISCUSSION: Mortality with LRE is high and approaches 51%. CSF culture is the gold standard for diagnosis. Real time PCR, a reliable diagnostic modality is relatively new but not widely available. MRI brain is the preferred radiological investigation. Prognosis depends on timely diagnosis and therapy. rTTC, a form of stress-induced myocardial injury is reversible with recovery from the inciting illness. The role of dexamethasone is controversial and lacks supporting evidence except as reported in case series. In retrospect, corticosteroid was probably beneficial in our patient. Increased penetration into the meninges and bactericidal properties of the ampicillin plus DS-TMP/SMZ combination is an effective therapy for LRE. CONCLUSIONS: LRE is a life-threatening illness and warrants early diagnosis and management in order prevent adverse outcomes and minimize morbidity. Stress related cardiomyopathy, a well-known entity needs prompt identification and supportive therapy. Reference #1: Armstrong RW, Fung PC. Brainstem encephalitis (rhombencephalitis) due to Listeria monocytogenes: case report and review. Clinical Infectious Diseases. The University of Chicago Press; 1993;16(5):689–702. Reference #2: Ruggieri F, Cerri M, Beretta L. Infective rhomboencephalitis and inverted Takotsubo: neurogenic-stunned myocardium or myocarditis? The American journal of emergency medicine. Elsevier; 2014;32(2):191–e1. Reference #3: Merle-Melet M, Dossou-Gbete L, Maurer P, Meyer P, Lozniewski A, Kuntzburger O, et al. Is amoxicillin-cotrimoxazole the most appropriate antibiotic regimen for listeria meningoencephalitis? Review of 22 cases and the literature. Journal of Infection. Elsevier; 1996;33(2):79–85. DISCLOSURES: No relevant relationships by Ricardo de la Villa, source=Web Response No relevant relationships by Alejandro Diaz Chavez, source=Web Response No relevant relationships by Raymonde Jean, source=Web Response No relevant relationships by Sathish Pondaiah, source=Web Response No relevant relationships by Christine Stavropoulos, source=Web Response