INTRODUCTION: Spontaneous bacterial peritonitis (SBP) is a common complication among patients with cirrhosis and ascites. It is associated with lower survival of 40% at 1 year after the initial episode. Enteric gram-negative bacteria, including Escherichia coli and Klebsiella pneumonia are the most common bacteria causing SBP in these patients, but SBP caused by gram-positive bacteria is increasing. Listeria monocytogenes, a gram-positive rod shaped bacteria, is an unusual cause of SBP in the United States. We describe a patient with cirrhosis and neutropenia who presented with SBP caused by Listeria. CASE DESCRIPTION/METHODS: A 70-year-old female with history of cirrhosis due to autoimmune hepatitis presented to the ER with severe weakness and vomiting. She denied abdominal pain, fever, chills or diarrhea. Laboratory tests were significant for WBC of 0.92thou/mcl, absolute neutrophil count of 0.4thou/mcl, lactic acid at 14.9 mmol/L and creatinine level at 2.45mg/dl. MELD-Na score was 31. Abdominal ultrasound showed large amount of ascites and paracentesis was performed. Ascites fluid studies showed WBC of 37/mm3 with 1.0% neutrophils, 83% of lymphocytes, PMNs of 0.37/mm3, 10% mesothelial cells and macrophages 6%. She was empirically started on cefepime 2g, meropenem 500 mg and vancomycin 1.25g while awaiting cultures. Ascitic fluid culture grew Listeria monocytogenes. Blood cultures and urine culture were negative. She was admitted to ICU, received volume resuscitation with Ringer lactate solution, albumin infusion, and stress-doses of steroids along with vasopressors for two days. Repeated ascitic fluid culture after 7 days showed no growth. She completed antibiotics for 14 days. Patient underwent liver transplantation and had uneventful recovery. DISCUSSION: Listeria is a facultative anaerobe that it is transmitted feco-orally from contaminated food or animal products. Neonates, elderly and immunosuppressed patients are at higher risk to Listeria infection. It is well known to cause gastroenteritis and meningitis, but it is an uncommon cause of SBP. Third generation cephalosporin antibiotics are standard empiric therapy for SBP but it does not cover for uncommon bacteria like Listeria. Lymphocytic predominance in the ascitic fluid in our patient may be secondary to neutropenia however, there are a few reported cases of Listeria causing nonneutrocytic bacterascites. Antibiotic therapy for SBP with third generation cephalosporins may need to be reevaluated in cirrhotic patients with severe neutropenia.