Bacterial Meningitis and Sigmoid Diverticulitis Caused by Listeria by nak14542


									Case Communications

Bacterial Meningitis and Sigmoid Diverticulitis Caused by
Listeria Monocytogenes
Ram Elazary MD1, Mahmoud Abu Ghazala MD1, Tomer Adar MD3, Ronny Eichel MD2,
Avraham I. Rivkind MD FACS1 and Gideon Zamir MD1
Departments of 1General Surgery, 2Neurology, and 3Internal Medicine A, Hadassah-Hebrew University Medical Center
(Ein Kerem Campus), Jerusalem, Israel

Key words: meningitis, diverticulitis, peritonitis, Listeria monocytogenes
                                                                                                                    IMAJ 2000;10:546–547

This case report describes a previously             The patient was treated empirically       L. monocytogenes can normally be cultured
healthy woman who suffered from both            with intravenous ceftriaxone and ampicilin.   from human gastrointestinal bacterial
bacterial meningitis and sigmoid diver-         Two days after hospitalization, one set of    flora. The transmission of the bacteria
ticulitis. The meningitis was caused by         blood culture tubes had grown Listeria        to humans is food-borne [2]. There are
the pathogen Listeria monocytogenes, which      monocytogenes. A day later, CSF cultures      well-known groups of patients in whom
can normally be cultured from human             with the same pathogen were positive.         disease can develop from infection with
gastrointestinal bacterial flora. It is well    The patient continued to deteriorate          L. monocytogenes. Pregnant women, usu-
known that hematogenous spread of this          during 6 days of hospitalization and her      ally in the third trimester, comprise one
bacterium causes infection of the central       mental status declined. On the seventh        group. The presentation is sepsis with a
nervous system. However, a search of the        day of hospitalization, abdominal and pel-    tendency towards preterm labor and with
English-language medical literature did         vic computed tomography was performed         no signs of meningitis. The second group
not reveal any reports of a patient with        owing to abdominal tenderness on physi-       constitutes neonates and infants under
perforated colonic diverticulitis causing       cal examination. The CT demonstrated          the age of 3 months. The presentation
the spread of Listeria monocytogenes into the   a large amount of free peritoneal air         is sepsis with or without involvement of
blood and finally into the CNS.                 and several left colon diverticules with      the meninges. The third group of patients
                                                suspected extra-colonic air around them.      comprises immunocompromised patients
Patient Description                             The patient was taken to the operating        and the elderly. It has been reported that
A 79 year old woman was admitted to             room for exploratory laparotomy. During       in the population of patients over the age
the emergency department because of             exploration of the abdomen we found           of 50, meningitis caused by this bacterium
abdominal pain, fever and headaches over        pneumoperitoneum without any fluid            is secondary to infection with Streptococcus
the previous 3 days. Her past medical           or feces contaminating the peritoneum.        pneumoniae.
history included hospitalization 6 years        A perforation at the sigmoid colon was            Diseases caused by infection with L.
prior to the current admission because          demonstrated. Both the descending             monocytogenes may develop as sepsis with-
of uncomplicated sigmoid diverticulitis.        and the sigmoid colon contained many          out a source of infection, or as specific
On examination she appeared ill. She            diverticula. We performed descending and      involvement of organs such as the CNS
was conscious. Blood pressure was               sigmoid colectomy with end-transverse co-     [3], heart, eye, gastrointestinal system,
130/70 mmHg, pulse 98 regular and fever         lostomy and Hartman's rectal pouch. The       bones and lungs. The most common pre-
38ºC. Examination of the head and neck          patient was transferred to the intensive      sentation of CNS infection with L. monocy-
revealed nuchal rigidity. The abdomen was       care unit for further medical manage-         togenes is meningitis. Other presentations
soft without any tenderness. The rest of        ment. Antibiotics (sulphamethoxazole and      of CNS involvement are encephalitis,
the examination was unremarkable. Her           trimpethoprin) against the bacteria were      cerebritis, brainstem infection and intra-
white blood count was 13,400 cells/µl.          continued for 6 weeks. The postopera-         cranial abscess. Hematogenous spread
Blood biochemistry and urine tests              tive course was surgically unremarkable.      is thought to be the means whereby the
were within normal limits. Chest X-ray          However, neurological improvement was         CNS is infected. The presenting symptoms
showed no signs of pneumonia. Because           not achieved.                                 and physical examination signs are the
of the nuchal rigidity and fever, lumbar                                                      same as for any other bacterial men-
puncture was performed. Examination of          Comment                                       ingitis. Examination of the CSF reveals
the cerebrospinal fluid demonstrated 600        Listeria monocytogenes is a Gram-positive     pleocytosis, elevated protein level and
neutrophils/µl, total protein 98 mg/L and       rod-shaped bacterium that usually causes
glucose 4.7 mMol. Gram staining of the          diseases in neonates, pregnant women          CNS = central nervous system
CSF was negative for any bacteria.              and immunocompromised patients [1].           CSF = cerebrospinal fluid

546    R. Elazary et al.                                                                                        •   Vol 10   •   July 2008
                                                                                                                Case Communications

usually normal glucose concentration. In      the patient presented with abdominal          though, there is probably no substitute
only 30% of patients does the CSF stain       pain on admission, CNS infection, L.          for repeated and meticulous physical
positively for L. monocytogenes and usually   monocytogenes bacteremia and perforation of   examinations of the patient.
the diagnosis is approved only after L.       the colonic diverticula indicated a primary
monocytogenes has been isolated in CSF or     infection of sigmoid colon diverticulitis     References
blood cultures. The treatment of choice       initiated by the bacteremia, meningitis       1. Schlech WF 3rd. Foodborne listeriosis.
is intravenous penicillin for 2 weeks in      and finally perforation of the colon. A          Clin Infect Dis 2000;31:770–5.
immunocompetent patients and 6 weeks          search of the English medical literature      2. Benshushan A, Tsafrir A, Arbel R, Rahav
                                                                                               G, Ariel I, Rojansky N. Listeria infection
for immunocompromised patients. An            for reports of colonic diverticulitis that       during pregnancy: a 10 year experience.
alternative treatment for patients who        progressed to meninigitis was fruitless.         IMAJ 2002;4:776–80.
cannot tolerate penicillin is sulfamethoxa-   We assume that the patient was a host         3. Lavetter A, Leedom JM, Mathies AW Jr,
zole combined with trimethoprim. The          of L. monocytogenes in the gastrointestinal      Ivler D, Wehrle PE. Meningitis due to
role of corticosteroid as an adjuvant         bacterial flora and that the hollow viscous      Listeria monocytogenes. A review of 25
                                                                                               cases. N Engl J Med 1971;285:598–603.
therapy for meningitis is not known in        perforation allowed contamination of the      4. Rohde H, Horstkotte MA, Sobottka I,
meningitis caused by L. monocytogenes. It     peritoneum [4] and spread of the bacte-          Klose H, Mack D. Spontaneous bacterial
is worth mentioning that L. monocytogenes     ria to the blood and the CSF. However,           peritonitis due to Listeria monocytogenes
utilizes iron as a virulent factor. It is     we did find several reports of patients          in a patient with primary pulmonary
recommended that iron supplement treat-       with colitis such as inflammatory bowel          hypertension. Eur J Clin Microbiol Infect Dis
ment in patients with iron deficiency be      disease who developed L. monocytogenes        5. Chiba M, Fukushima T, Koganei K, Naka-
postponed for the duration of infection       bacteremia [5]. Observations from the            mura N, Masamune O. Listeria monocy-
with L. monocytogenes.                        current patient supported the fact that          togenes in the colon in a case of fulmi-
   The patient described here suffered        when L. monocytogenes bacteremia is found        nant ulcerative colitis. Scand J Gastroenterol
from meningitis caused by the pathogen        the physician must intensively seek out          1998;33:778–82.
L. monocytogenes, whose isolation from        the origin of the infection. However, the
blood cultures has been noted. This labo-     source of infection may be difficult to
                                                                                            Correspondence: Dr. R. Elazary, Dept. of
ratory finding is probably evidence for he-   find, especially in cases of debilitated      General Surgery, Hadassah Medical Center
matogenous spread of the bacterium. The       patients with impaired mental status          (Ein Kerem Campus), P.O. Box 12000, Jeru-
patient was finally diagnosed to also have    who have difficulties expressing their        salem 91120, Israel.
perforation of sigmoid colon diverticula.     complaints. Early and wide-ranging use        Phone: (972-2) 677-8800
Despite attempting to connect our clinical    of imaging modalities may help in find-       Fax: (972-2) 644-9412
findings to a single disease, the fact that   ing the origin of infection. Ultimately       email:

    Fibromyalgia and IVIG
   Fibromyalgia (FM) is a chronic, distressing disorder that         strength were also very common and significantly elevated in
   affects mainly women in the prime of life. The diagnosis          FM patients (P < 0.0001). Chronic inflammatory demyelinating
   relies on subjective criteria of ongoing pain, tender points,     polyneuropathy (CIDP) including stocking hypoesthesia, proximal
   fatigue, mild cognitive impairment and other manifestations.      muscle weakness and electrodiagnostic abnormalities were
   The etiology of the disorder is unclear, but a subgroup of        documented in 16 FM patients (33%) vs. only 2 controls (5%)
   FM patients exhibited clinical and serological features of        (P = 0.005). After treatment with IVIG (400 mg/kg/day for 5
   immune deregulation. Recently Caro et al. evaluated the           days) in 15 patients with CIDP and FM, a significant improve-
   presence of immune-mediated demyelinating polyneuropathy          ment in pain, tenderness and muscle strength as well as a
   and response to therapy with intravenous immunoglobulin           non-significant decrease in fatigue and stiffness were noted.
   G (IVIG) in 58 FM patients compared with 26 rheumatic and         Thus, it might be concluded that a substantial subgroup of
   52 non-rheumatic subjects. Paresthesias was found in 76% of       FM patients have clinical findings suggestive of CIDP for which
   FM patients compared to 20% in controls (P < 0.0001), and         IVIG therapy might be beneficial.
   stocking distribution hypoesthesia in 88% of FM patients                                                 Rheumatology 2008;47:208
   vs. none of the controls (P < 0.0001). Weakness and muscle                                                          Nancy Agmon-Levin

     • Vol 10 • July 2008                                           Meningitis and Diverticulitis due to L. monocytogenes               547

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