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Listeria monocytogenes Infection of the Brain
Published on: October 2, 2018
Listeria Cerebritis with Tumor Necrosis Factor Inhibition
1UW School of Medicine and Public Health, Madison, WI, USA.
Insights
Listeria monocytogenes can cause severe central nervous system infections in immunosuppressed patients. Prophylactic antimicrobial treatment is crucial for immune-suppressed individuals with cerebral edema and TNF inhibition.
Area of Science:
- Neurology
- Infectious Diseases
- Immunology
Background:
- Listeria monocytogenes is a significant CNS pathogen, particularly in immunocompromised individuals.
- Cerebral edema presents non-specifically and can be caused by various conditions, including infections.
- Tumor necrosis factor (TNF) is vital for immune defense against Listeria; immunosuppressants like lenalidomide inhibit TNF.
Observation:
- A 61-year-old female with multiple myeloma on lenalidomide developed cerebral edema and focal neurologic deficits.
- Initial workup, including CSF and blood cultures, was negative for infection.
- Neurologic status deteriorated, leading to fever and a positive blood culture for Listeria monocytogenes.
Findings:
- Despite initial negative workup, the patient's presentation was consistent with Listeria meningoencephalitis.
- Aggressive antimicrobial therapy, including ampicillin, was initiated after diagnosis.
- Autopsy confirmed brain microabscesses indicative of Listeria infection.
Implications:
- Prophylactic antimicrobial therapy for Listeria should be considered in immunosuppressed patients with cerebral edema and TNF inhibition.
- Prompt transfer to a higher level of care is recommended if brain biopsy is needed and cannot be expedited.
- Early suspicion and treatment of Listeria are critical in at-risk populations presenting with neurological symptoms.
Background:
Listeria monocytogenes is historically a central nervous system pathogen of consideration in the very young, very old, and immune suppressed. Diagnosis of Listeria is based on positive bodily fluid culture or PCR testing. Cerebral edema is nonspecific and can be a manifestation of vasculitis, trauma, anoxia, ischemia, infarction, malignancy, or an infectious process. A main mechanism of immune protection against Listeria is tumor necrosis factor (TNF). Lenalidomide, an immunosuppressant, inhibits TNF. Case Presentation. A 61-year-old female with diabetes mellitus 2 and multiple myeloma treated with stem cell transplant and immunosuppressant (lenalidomide) was found to have cerebral edema after presenting with headache for 3 weeks and new focal neurologic deficits. Vitals signs were stable, with no meningeal exam findings and unremarkable initial serum testing. Blood cultures on days 0 and 2 of hospitalization as well as cerebral spinal fluid cultures were negative for infectious organisms. PCR testing of CSF was also negative for microorganisms. Brain biopsy was scheduled but postponed due to outstanding prion testing. The patient's focal neurologic deficits worsened prompting administration of dexamethasone after extensive negative infectious disease workup. By day 6, gross neurologic function deteriorated prompting transfer to higher level of care where the patient spiked a fever and one set of blood cultures revealed Gram-positive bacillus. Aggressive antimicrobial therapy was initiated, excluding ampicillin; however, this was later added. Blood culture further identified Listeria monocytogenes. By day 17, the patient suffered demise. Autopsy revealed brain microabscess lesions consistent with Listeria.
Conclusion:
Clinicians should employ prophylactic antimicrobial treatment for Listeria when caring for those patients presenting with cerebral edema who are immune suppressed with TNF inhibition no matter the initial exam findings, serum testing, and/or radiologic interpretation. If initial workup is negative and brain biopsy is needed to determine the next course of action in the patient with cerebral edema, transfer the patient to a higher level of care if unable to complete biopsy at your facility in an expedient fashion.
