Listeria meningitis in a patient with Crohn's disease--a seldom, but clinically relevant adverse event of therapy with infliximab

A 42-year-old man with steroid-dependent Crohn's disease developed fever, vomiting and headache after the second administration of infliximab. Extensive microbiological and biochemical work-up revealed an atypical meningitis caused by Listeria monocytogenes. After antibiotic therapy of 21 days duration, the patient could be discharged from hospital totally recovered without any further complications. As previously demonstrated, TNF-alpha plays an important role in resistance to Listeria monocytogenes. Listeria infections have been reported in 26 patients receiving TNF-alpha inhibitors. An additional therapy with other immunosuppressants increases the risk for Listeria infections. Listeria meningitis is a seldom adverse event of therapy with TNF-alpha inhibitors but is associated with a high lethality. Therefore patients should be informed about the possible adverse event of a Listeria infection during anti-TNF-alpha therapy before receiving immunosuppressive treatment. Furthermore, therapy with TNF-alpha inhibitors should only be executed within a close doctor-patient relationship and in cooperation with specialised centres.     

Three cases of meningitis due to Listeria monocytogenes type Ib

Three infants having Listeria monocytogenes meningitis were admitted to our hospital in the last ten years. They were a nineteen-month-old boy, a two-year-old girl and a five-year-old girl. They were all healthy infants. The two female patients survived, while the male patient died. At autopsy, arachnoid turbid, swollen brain substance and slight bleeding under the cerebellar tent were observed. Judging from the minimal inhibitory concentration of antibiotics against the isolated L. monocytogenes, antibacterial activity of penicillin G and ampicillin was good, whereas that of cefotaxime and latamoxef was poor. In conclusion, for therapy of bacterial meningitis due to unknown origin, the combination of ampicillin and cephalosporins is necessary.     

Listeria monocytogenes infections in patients with AIDS: report of five cases and review

Five patients with AIDS and Listeria monocytogenes infection (three cases of bacteremia and two of meningitis) are reviewed. Four patients had prior or concurrent gastrointestinal illness. Two patients received corticosteroids. A 7- to 21-day course of ampicillin was administered with or without a 7- to 14-day course of gentamicin. This regimen was effective, with no evidence of relapse 7-8 months after therapy was discontinued. The relative infrequency of infection with L. monocytogenes in AIDS patients is unexpected. Tumor necrosis factor (TNF) appears to be essential in the inhibition of Listeria in vivo. Elevated levels of TNF in AIDS patients may be protective against listeriosis and thus help explain the low prevalence of listerial infection in this population. Nonetheless, although L. monocytogenes is an uncommon cause of illness in patients infected with the human immunodeficiency virus, it cannot be dismissed as a cause of undefined meningitis or sepsis.     

Listeria rhombencephalitis mimicking tuberculous meningitis

A previously healthy man developed a progressive neurologic illness characterized by an "aseptic meningitis syndrome," progressive hypoglycorrhachia, and severe brain-stem dysfunction. Initial dramatic response to antituberculosis therapy supported the diagnosis of tuberculous basilar meningitis; however, Listeria monocytogenes eventually grew in a blood culture, and the patient recovered following intravenous ampicillin therapy. The entity of listerial rhombencephalitis should be considered as a treatable cause of acute, progressive brain-stem meningoencephalitis.     

Listeria monocytogenes meningitis in adults. Sixteen consecutive cases 1973-1982

16 adult patients with Listeria monocytogenes meningitis were reviewed to see whether clinical features or initial laboratory findings could discriminate between these patients and patients with purulent meningitis of other causes. Six patients suffered from known predisposing diseases and 4 were alcoholics. The initial clinical picture was indistinguishable from meningitis of other causes. Microscopy of cerebrospinal fluid (CSF) was negative in all cases but 2 where gram-positive rods were seen. CSF cytology and biochemistry could not discriminate from other causes of purulent meningitis although a low leucocyte content and a low percentage of neutrophils were often present. All L. monocytogenes strains isolated were sensitive to ampicillin and aminoglycosides whereas susceptibility to other antibiotics was low or varying. In adult patients suffering from purulent meningitis initial therapy should include ampicillin until an etiological diagnosis is established. The same is true in some cases of febrile encephalopathy with low content of neutrophils in CSF, especially when the glucose content is low.     

Listeria meningitis complicating infliximab treatment for Crohn's disease.

Infliximab, a monoclonal antibody directed against tumour necrosis factor-alpha, is an effective therapy for Crohn's disease. Though uncommon, serious opportunistic infections, including reactivation of tuberculosis, have occurred in patients after infliximab administration.Meningitis caused by Listeria monocytogenes developed in a 37-year-old man six days after the second infusion of infliximab. The patient, who also was treated with azathioprine and corticosteroids, had an uneventful recovery after a course of antibiotics. Several other recent reports have implicated infliximab therapy in the development of severe Listeria infections, particularly meningitis and sepsis. With the increasing use of tumour necrosis factor-alpha-neutralizing agents, clinicians should be aware of the risk of opportunistic infections caused by L monocytogenes in patients with Crohn's disease following infliximab treatment.     

Listeriosis in immunosuppressed patients: A cluster of eight cases

Bacteremia due to Listeria monocytogenes developed in eight patients who were receiving immunosuppressive medications during a 15 month period at one hospital. Seven survived. Meningitis was documented in only the four who received kidney transplants. Their neurologic signs were minimal, indicating a need to treat any immunosuppressed patient with Listeria bacteremia for meningitis.During this period the incidence of Listeria bacteremia in immunosuppressed patients greatly exceeded that previously observed in this hospital or reported elsewhere, but the incidence of infection with other opportunistic agents was not increased. As with previously described Listeria outbreaks in nonimmunosuppressed patients, no source or mechanism of spread could be identified. Thus, disease due to L. monocytogenes may occur focally among immunosuppressed populations, a pattern which also appears to be emerging for other opportunistic agents. A patient's exposure to different opportunistic agents may be as important as the kind of immunosuppressive therapy he receives in determining which opportunistic infection he will acquire or even whether any infection will occur.     

Listeria monocytogenes cross-contamination in a nursery [corrected

Molecular evidence of Listeria monocytogenes cross-contamination in a nursery is presented. Listeria monocytogenes serotype 4b was isolated from the blood and the conjunctiva of a baby with neonatal sepsis who was born after septic amnionitis and premature rupture of membrane. Nine days later, the same bacterium was isolated from the cerebrospinal fluid of a second baby presenting with meningitis. Cervical cultures from the second baby's healthy mother were negative for Listeria sp. An in-depth epidemiologic investigation revealed that the same nurse administered routine treatments to both babies in the nursery during a 1-hour interval of time [corrected]. Pulse-field gel electrophoresis analysis of both strains with 2 different restriction enzymes demonstrated that they were identical and differ from other wild strains of L monocytogenes serotype 4b isolated in Israel. This fact strongly suggests that the second baby was infected during admittance to the nursery as a result of a hospital cross-contamination.     

Spontaneous Listeria monocytogenes peritonitis: a population-based study of 13 cases collected in Spain

OBJECTIVES: We aimed to assess the incidence, demographic data, clinical features, and outcome of peritoneal infections due to Listeria monocytogenes in individuals with cirrhosis. METHODS: During a 10-yr study period, 153 cases of invasive listeriosis were recorded in a prospective population-based surveillance project carried out in Barcelona, Spain. RESULTS: Thirteen cases were of spontaneous bacterial peritonitis by L. monocytogenes. Ages of the patients ranged between 29 and 85 yr. In addition to cirrhosis, underlying conditions included diabetes mellitus in four and malignancy in three. Bacteremia was present in six cases (46%). Only one patient with bacteremia developed meningitis. Analysis of the peritoneal fluid showed a mean (SD) protein content of 21.5 (9.6) g/L and leukocyte count of 7,273 (9,171) cells/ml. L. monocytogenes serotype 4b was the serogroup predominantly isolated (61%). The mortality rate was 30.7%. Eight patients received empirical antibiotic treatment with cephalosporins. CONCLUSIONS: In geographical areas with a high incidence of listeriosis, L. monocytogenes should be suspected as a causative pathogen of spontaneous bacterial peritonitis in cirrhosis. Early adjustment of antibiotic therapy is essential to reduce mortality.     

Spontaneous bacterial peritonitis caused by infection with Listeria monocytogenes: a case report and review of the literature

Spontaneous bacterial peritonitis is a frequent and often serious complication of long-standing ascites in the presence of advanced liver disease. Coliform bacteria account for the infection in most cases and are thought to be related to translocation of bacteria from the bowel into the peritoneal cavity. The empiric use of cefotaxime is well established as most of the causative organisms are sensitive to this antibiotic. However, we report on a case of spontaneous bacterial peritonitis in a patient with hepatitis C related cirrhosis who was awaiting liver transplantation caused by infection with Listeria monocytogenes , in which the patient did not improve with empiric antibiotic therapy. This case adds to the 23 others reported in the literature since 1966. Our case raises some concerns about the universal empiric usage of cefotaxime for spontaneous bacterial peritonitis because it does not offer adequate coverage against organisms such as Listeria , enterococci, Pasturella , and anaerobes.     

Listeria monocytogenes osteomyelitis

Listeria monocytogenes is usually an opportunistic pathogen causing either meningitis or bacteremia in adults. Focal infection outside the central nervous system occurs infrequently. We describe two cases of osteomyelitis caused by L monocytogenes. Certain characteristics of L monocytogenes may make cure difficult, particularly in a deep-seated focus such as bone, and may warrant special consideration when planning therapy.     

Listeria monocytogenes meningitis in a human immunodeficiency virus-positive patient undergoing hemodialysis

Listeria monocytogenes bacteremia without meningitis has been reported in patients who have undergone long-term hemodialysis and have transfusional iron overload. On the other hand, cases of Listeria bacteremia without meningitis have occurred sporadically among the acquired immunodeficiency syndrome population, mostly homosexuals. There have been no reports of Listeria meningitis occurring among persons who are antibody positive to human immunodeficiency virus or are intravenous drug abusers having chronic renal failure and undergoing hemodialysis. This patient represents the first case of Listeria bacteremia and meningitis to occur in an intravenous drug abuser who is human immunodeficient antibody positive, is receiving hemodialysis, and has transfusional iron overload.     

Acute bacterial meningitis in adults. A 12-year review

One hundred three episodes of acute bacterial meningitis in adults hospitalized in Edmonton's 2 largest hospitals from 1985 to 1996 were reviewed. Cases complicating neurosurgery were excluded. Most cases were community-acquired (87%). Twenty-three cases remained culture-negative, and there was no statistical relation between culture negativity and antibiotic pretreatment. Streptococcus pneumoniae was the predominant pathogen (52.5%), but Listeria monocytogenes was the second most common isolate, accounting for 12.5% of culture-positive cases. Compared to non-listerial meningitis, those with listeriosis were more likely to have negative cerebrospinal fluid (CSF) Gram stains (p = 0.07), CSF leukocyte counts < 1,000 cells/mm3 (p < 0.003), and normal CSF glucose (p = 0.006). Bacterial antigen detection was found to be of low sensitivity: 33% in all patients, but only 9% in cases with negative CSF Gram stains. The overall mortality was 18%, with 15 deaths directly attributable to acute meningitis; the case-fatality rates for S. pneumoniae and L. monocytogenes were 24% and 40%, respectively. Mortality was significantly higher among those with seizures (34% versus 7%, respectively; p < 0.001; OR = 17.6). Despite the urgency of acute bacterial meningitis, there were considerable delays in the institution of empiric antibiotics; mortality rates were slightly higher in those who experienced such a delay (16% versus 7% respectively; p = 0.18).     

Recurrence of Listeria monocytogenes meningitis

A case of Listeria monocytogenes meningitis in a 3-year-old boy which relapsed after chloramphenicol treatment is described. The patient was subsequently successfully treated with ampicillin and gentamicin and made a complete recovery. In vitro studies confirmed the inadequacy of chloramphenicol therapy. The value of combination therapy, as evidenced by chessboard and killing-curve techniques with the strain, is discussed.     

Five cases of listeriosis in the elderly

We reported five cases of listeriosis (sepsis and meningitis) in the elderly in our hospital during the last 4 years, where no cases of listeriosis had been found. These 5 cases had diabetes mellitus, lung cancer, chronic respiratory failure, gastric ulcer and aplastic anemia respectively as their underlying diseases. At the onset of listeriosis, 3 cases received corticosteroid and 3 cases received H2-blocker. 2 patients were cured and 3 patients died. Three autopsy cases had meningitis or meningoencephalitis and 2 cases of these autopsy cases had granulomatous changes in these spleens. In serotypes of Listeria monocytogenes (L. monocytogenes), 4 cases were 4b and 1 cases was 1b. All 5 strains were resistant to 3rd generation cephems. Wide uses of 3rd generation cephems and H2-blocker may be one of the reasons for the recent increase of listeriosis. Ingestion of contaminated food is the pathogenetic mechanism for initiating L. monocytogenes infections. And following the change of eating habits and the increase of imported foods, food-born listeriosis may increase. We suppose the increase of L. monocytogenes infections and must give attention to L. monocytogenes infections.     

Listeria monocytogenes peritonitis in cirrhotic patients: first description in Brazil

Two cases of spontaneous bacterial peritonitis (SBP) caused by Listeria monocytogenes in cirrhotic patients are reported. In one of the cases, the microorganism was isolated from pleural effusion and ascites. SBP is a serious and common complication of patients with ascites caused by hepatic cirrhosis and the culture of the ascitic fluid is an important tool for the diagnosis and for the more appropriate treatment. Although a third generation cephalosporin has usually been employed for empiric treatment of SBP, it does not provide adequate coverage against Listeria spp. In such cases the use of ampicillin (with or without sulbactam) or sulfamethoxazole-trimethoprim is recommended. The last one is used for secondary prophylaxis, instead of norfloxacin. To summarize, Listeria monocytogenes infection is a rare cause of SBP, whose treatment should be specific for the bacteria.     

In Process Citation

To review the epidemiology, risk factors, clinical features and outcomes of Listeria monocytogenes infection in the Eastern Townships of Quebec, a retrospective study was completed over the period 1976 to 1995. Cases were identified from positive cultures and diagnosis given by the infectious diseases service of the Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec. A total of 12 cases were in the study. Septicemia not related to pregnancy (four of 12) and meningitis (six of 12) were the major clinical presentations. There was one case of listeriosis associated with pregnancy and one case of granulomatosis infanti septica. Ten patients had at least one predisposing underlying condition. Only one death was related to L monocytogenes infection. Neurological sequelae were observed in half of the cases of meningitis, whereas no sequelae were noted in cases of septicemia. In conclusion, listeriosis is predominantly a disease of elderly and immunosuppressed patients. The clinical presentation and outcome are not different from those reported in other industrialized countries.     

Listeria monocytogenes encephalitis mimicking Herpes Simplex virus encephalitis: the differential diagnostic importance of cerebrospinal fluid lactic acid levels

Listeria monocytogenes is a common cause of bacterial meningitis in elderly patients and in those with impaired cellular immunity. The most common central nervous system infection caused by L. monocytogenes is acute bacterial meningitis; meningoencephalitis is uncommon and encephalitis is rare. Early diagnosis of L. monocytogenes meningitis is difficult because only 50% of cerebrospinal fluid (CSF) Gram stains are negative. L. monocytogenes is one of the few central nervous system pathogens associated with red blood cells in the CSF. When L. monocytogenes presents as encephalitis with red blood cells in the CSF, the clinical presentation mimics most closely herpes simplex virus (HSV)-1 encephalitis. Because the therapies for L. monocytogenes and HSV-1 are different, early diagnostic differentiation is clinically important. The CSF lactic acid is the best way to rapidly differentiate between these two entities; the CSF lactic acid level is elevated in L. monocytogenes but is not elevated in HSV-1 encephalitis. The case presented is an elderly man with chronic lymphocytic leukemia who presented with encephalitis. Advanced age and chronic lymphocytic leukemia predispose him to a wide variety of pathogens, but the rapidity and severity of his clinical presentation made L. monocytogenes and HSV-1 encephalitis the most likely diagnostic possibilities. The CSF Gram stain was negative, but the elevated CSF lactic acid levels with encephalitis and red blood cells in the CSF indicated L. monocytogenes as the most likely pathogen. We present a case of L. monocytogenes encephalitis mimicking HSV-1 encephalitis. While receiving ampicillin therapy, the patient remained unresponsive for more than 1 week and then suddenly regained consciousness and recovered without neurologic sequelae.     

Listeria monocytogenes pericarditis in a chronically hemodialyzed patient

We describe the third documented case of Listeria monocytogenes pericarditis. This occurred in a 54-year-old woman with end-stage renal failure on chronic hemodialysis. Her initial presentation was one of Listeria monocytogenes bacteremia, which apparently responded to two weeks of cefazolin sodium therapy. After cessation of therapy the patient returned with Listeria monocytogenes pericarditis, this responding completely to four weeks of erythromycin therapy. We could not rule out coexisting endocarditis, especially since we found high levels of circulating immune complexes which subsided as the patient's condition improved. Further immunological studies displayed a decrease in cellular functions. This case illustrates the importance of Listeria monocytogenes as a human pathogen in immunocompromised patients. Listeria should be included among the potential causative agents of pericarditis in such patients.