DISSEMINATED LISTERIOSIS: A DEADLY TRIPLICATE

Abstract

SESSION TITLE: Atypical Cases of SepsisSESSION TYPE: Rapid Fire Case ReportsPRESENTED ON: 10/19/2022 12:45 pm - 1:45 pmINTRODUCTION: Listeria monocytogenes is a gram-positive bacillus with significant pathogenicity, responsible for an estimated 10% of bacterial meningitis. We present a case of disseminated listerial infection in association with an indwelling peritoneal catheter.CASE PRESENTATION: A 65-year-old male presented to the ED due to 4 days of worsening encephalopathy associated with abdominal pain, fevers and jaundice. Medical history was significant for hepatocellular carcinoma on nivolumab, NASH cirrhosis, and recurrent ascites managed with an indwelling peritoneal catheter. Initial labs were concerning for an elevated WBC of 25.3 with neutrophil predominance and lactic acid of 10.8. Ammonia was elevated at 111 and total bilirubin elevated at 3.8. CT head revealed no acute intracranial abnormality. CT abdomen revealed moderate ascites and cirrhotic liver with large hepatic mass. Paracentesis revealed cloudy yellow fluid, with a polymorphonucleated cell count of 9,035, diagnostic of bacterial peritonitis. He was treated with IV fluids, antibiotics and albumin. His encephalopathy was presumed to be secondary to hepatic encephalopathy and he was treated with lactulose enemas and rifampin.Overnight, he became hypotensive and was transferred to the ICU. He was increasingly encephalopathic despite a decreasing serum ammonia level. EEG revealed non-convulsive status epilepticus and he was subsequently intubated. MRI revealed diffuse periventricular flair signals compatible with meningitis. An LP was performed with an opening pressure of 20 cm of H2O, cell count of 185 cells per cm3 and protein count of 984 mg/dL. Cultures from peritoneal fluid, blood and CSF revealed gram positive rods which speciated to Listeria monocytogenes on hospital day 2. The patient was initiated on ampicillin and gentamicin was added for synergy. His clinical course was complicated by progressive shock, hypoxemia and ongoing seizure activity despite maximal antiepileptic therapy. Unfortunately, he expired on hospital day 5.DISCUSSION: Listeria infection is foodborne and commonly presents with bacteremia, meningitis and gastroenteritis. Invasive infection is associated with a poor prognosis. Mortality approximates 30% with meningitis and 46% with bacteremia. Standard treatment involves ampicillin or penicillin G. Combination with an aminoglycoside may be helpful based on in vitro synergy; A retrospective analysis reported significantly better survival in patients receiving combination therapy. Cases of listeria peritonitis have been reported in association with peritoneal dialysis catheters, however, such cases are exceedingly rare with 19 such cases reported since 1983. Whether such cases are associated with catheter associated spread of infection versus foodborne infection remains to be elucidated.CONCLUSIONS: Given the high mortality rates and need for altered antibiotic regimens, we urge clinician consideration of this pathogen.Reference #1: Pagliano P, Ascione T, Boccia G, De Caro F, Esposito S. Listeria monocytogenes meningitis in the elderly: epidemiological, clinical and therapeutic findings. Infez Med 2016;24(2):105-11. (https://www.ncbi.nlm.nih.gov/pubmed/27367319).Reference #2: Liatsos GD, Thanellas S, Pirounaki M, Ketikoglou I, Moulakakis A. Listeria monocytogenes peritonitis: presentation, clinical features, treatment, and outcome. Scand J Gastroenterol 2012;47(10):1129-40. DOI: 10.3109/00365521.2012.704935.Reference #3: Charlier C, Perrodeau É, Leclercq A, et al. Clinical features and prognostic factors of listeriosis: the MONALISA national prospective cohort study. The Lancet Infectious Diseases 2017;17(5):510-519. DOI: 10.1016/s1473-3099(16)30521-7.DISCLOSURES: No relevant relationships by Carla CopelandNo relevant relationships by Anneka HuttonNo relevant relationships by Melissa Jordan SESSION TITLE: Atypical Cases of Sepsis SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Listeria monocytogenes is a gram-positive bacillus with significant pathogenicity, responsible for an estimated 10% of bacterial meningitis. We present a case of disseminated listerial infection in association with an indwelling peritoneal catheter. CASE PRESENTATION: A 65-year-old male presented to the ED due to 4 days of worsening encephalopathy associated with abdominal pain, fevers and jaundice. Medical history was significant for hepatocellular carcinoma on nivolumab, NASH cirrhosis, and recurrent ascites managed with an indwelling peritoneal catheter. Initial labs were concerning for an elevated WBC of 25.3 with neutrophil predominance and lactic acid of 10.8. Ammonia was elevated at 111 and total bilirubin elevated at 3.8. CT head revealed no acute intracranial abnormality. CT abdomen revealed moderate ascites and cirrhotic liver with large hepatic mass. Paracentesis revealed cloudy yellow fluid, with a polymorphonucleated cell count of 9,035, diagnostic of bacterial peritonitis. He was treated with IV fluids, antibiotics and albumin. His encephalopathy was presumed to be secondary to hepatic encephalopathy and he was treated with lactulose enemas and rifampin. Overnight, he became hypotensive and was transferred to the ICU. He was increasingly encephalopathic despite a decreasing serum ammonia level. EEG revealed non-convulsive status epilepticus and he was subsequently intubated. MRI revealed diffuse periventricular flair signals compatible with meningitis. An LP was performed with an opening pressure of 20 cm of H2O, cell count of 185 cells per cm3 and protein count of 984 mg/dL. Cultures from peritoneal fluid, blood and CSF revealed gram positive rods which speciated to Listeria monocytogenes on hospital day 2. The patient was initiated on ampicillin and gentamicin was added for synergy. His clinical course was complicated by progressive shock, hypoxemia and ongoing seizure activity despite maximal antiepileptic therapy. Unfortunately, he expired on hospital day 5. DISCUSSION: Listeria infection is foodborne and commonly presents with bacteremia, meningitis and gastroenteritis. Invasive infection is associated with a poor prognosis. Mortality approximates 30% with meningitis and 46% with bacteremia. Standard treatment involves ampicillin or penicillin G. Combination with an aminoglycoside may be helpful based on in vitro synergy; A retrospective analysis reported significantly better survival in patients receiving combination therapy. Cases of listeria peritonitis have been reported in association with peritoneal dialysis catheters, however, such cases are exceedingly rare with 19 such cases reported since 1983. Whether such cases are associated with catheter associated spread of infection versus foodborne infection remains to be elucidated. CONCLUSIONS: Given the high mortality rates and need for altered antibiotic regimens, we urge clinician consideration of this pathogen. Reference #1: Pagliano P, Ascione T, Boccia G, De Caro F, Esposito S. Listeria monocytogenes meningitis in the elderly: epidemiological, clinical and therapeutic findings. Infez Med 2016;24(2):105-11. (https://www.ncbi.nlm.nih.gov/pubmed/27367319). Reference #2: Liatsos GD, Thanellas S, Pirounaki M, Ketikoglou I, Moulakakis A. Listeria monocytogenes peritonitis: presentation, clinical features, treatment, and outcome. Scand J Gastroenterol 2012;47(10):1129-40. DOI: 10.3109/00365521.2012.704935. Reference #3: Charlier C, Perrodeau É, Leclercq A, et al. Clinical features and prognostic factors of listeriosis: the MONALISA national prospective cohort study. The Lancet Infectious Diseases 2017;17(5):510-519. DOI: 10.1016/s1473-3099(16)30521-7. DISCLOSURES: No relevant relationships by Carla Copeland No relevant relationships by Anneka Hutton No relevant relationships by Melissa Jordan