Spontaneous Bacterial Peritonitis (SBP) as a Rare Complication of Invasive Listeriosis: A Closer Look at Empiric SBP Coverage

Abstract

Introduction: Listeria monocytogenes is an anaerobic gram-positive rod that is transmitted from contaminated food or animal products. Listeriosis is a rare but deadly disease with approximately 1600 cases per year and mortality rate of approximately 16%. Rarely, listeria has been shown to cause spontaneous bacterial peritonitis (SBP), with approximately 50 cases reported in literature. We present a rare case of invasive listeriosis manifesting with bacteremia, pericarditis, and spontaneous bacterial peritonitis. Case Report: A 58-year old female with past medical history of decompensated alcoholic cirrhosis and poorly controlled diabetes presented with a one week history of shortness of breath and dyspnea on exertion. Initial workup revealed severe pericarditis with early cardiac tamponade physiology and patient underwent urgent pericardiocentesis and pericardial window procedures. Following the procedure, the patient developed fevers and abdominal pain. Blood cultures were obtained and paracentesis was performed that revealed an absolute neutrophil count of 15,700 cells/mm3. The patient was empirically started on a third generation cephalosporin for empiric SBP coverage. Subsequently she developed high fevers and worsening sepsis and blood and peritoneal fluid cultures both grew listeria monocytogenes. Antimicrobial therapy was switched to piperacillin-tazobactam with progressive clinical improvement. The patient was discharged to rehab facility after a one month hospitalization and finished a prolonged treatment course with trimethoprim-sulfamethoxazole. Upon further questioning she did admit to frequently eating soft cheeses and deli meats; however, no absolute source of infection was identified. Discussion: Listeria often results in self-limited gastroenteritis in normal hosts, but may manifest with severe invasive disease in immunocompromised or pregnant patients. Listeria has been infrequently reported as a cause of SBP and is often associated with poor clinical outcomes in these cases. Empiric coverage for spontaneous bacterial peritonitis usually involves a third generation cephalosporin to provide coverage for enterobacteriaceae such as E. Coli or Klebsiella species. In our patient, conventional SBP empiric coverage failed to appropriately treat her infection and the patient clinically worsened. Atypical organisms such as listeria may circumvent empiric SBP coverage, making clinical suspicion for these organisms paramount in select cases.