Listeria rhombencephalitis mimicking stroke in a patient with giant cell arteritis
Hayato Shimizu1, Hiroharu Imoto1, Shigeo Hara2
1Department of General Internal Medicine, Kobe City Medical Center General Hospital, 2-1-1 Minami-machi, Minatojima, Chuo-ku, Kobe City, Hyogo, 650-0047, Japan.
Abstract:
Listeria monocytogenes sometimes causes central nervous system infections. However, rhombencephalitis is a rare form of L. monocytogenes infection. Its clinical symptoms and magnetic resonance imaging (MRI) findings are often similar to those of vertebrobasilar stroke. We present the case of a 79-year-old woman with Listeria rhombencephalitis presenting with rhinorrhea and productive cough. She had giant cell arteritis (GCA) treated with prednisolone and methotrexate. She was admitted for loss of appetite, rhinorrhea, and productive cough. These symptoms were alleviated without specific treatment; however, she suddenly developed multiple cranial nerve palsies, and MRI showed hyperintense signals on diffusion-weighted imaging and hypointense signals on apparent diffusion coefficient in the brainstem. Ischemic stroke due to exacerbation of GCA was suspected, and treatment with intravenous methylprednisolone was initiated; however, seizures occurred, and a lumbar puncture was performed. Cerebrospinal fluid and blood cultures revealed L. monocytogenes, and she was diagnosed with Listeria rhombencephalitis. Although antibiotic treatment was continued, the patient died. Thus, when patients with rhinorrhea or productive cough develop sudden cranial nerve palsy, Listeria rhombencephalitis should be considered as a differential diagnosis, and lumbar puncture should be performed.
Insights
Listeria rhombencephalitis is a rare brainstem infection. Early diagnosis via lumbar puncture is crucial for patients with cranial nerve palsies and respiratory symptoms, even if initially resembling stroke.
Area of Science:
- Neurology
- Infectious Diseases
- Neuroimaging
Background:
- Listeria monocytogenes can cause central nervous system infections, with rhombencephalitis being a rare manifestation.
- Rhombencephalitis symptoms and MRI findings can mimic vertebrobasilar stroke, complicating diagnosis.
- Giant cell arteritis (GCA) and its immunosuppressive treatment (prednisolone, methotrexate) can increase susceptibility to infections.
Observation:
- A 79-year-old woman with GCA presented with rhinorrhea and productive cough, initially improving.
- She rapidly developed multiple cranial nerve palsies, with MRI revealing brainstem abnormalities suggestive of stroke.
- Despite suspected GCA exacerbation and initial steroid treatment, seizures prompted lumbar puncture.
Findings:
- Cerebrospinal fluid and blood cultures confirmed Listeria monocytogenes infection, diagnosing Listeria rhombencephalitis.
- The patient's condition deteriorated despite antibiotic treatment, leading to a fatal outcome.
- The case highlights the diagnostic challenge of Listeria rhombencephalitis mimicking other neurological conditions.
Implications:
- Listeria rhombencephalitis should be considered in the differential diagnosis of patients presenting with cranial nerve palsies, especially those with preceding respiratory symptoms.
- Prompt lumbar puncture is essential for identifying Listeria monocytogenes in suspected cases.
- Timely and accurate diagnosis is critical for appropriate management of this rare but severe infection.
