Arthritis due to Listeria monocytogenes

Unusual Listeria monocytogenes hematogenous infection in total knee replacement treated with one-stage revision surgery

Septic arthritis due to Listeria monocytogenes (LM) is extremely rare and most infections due to this organism are seen in immunocompromised patients. We describe a patient without immunological compromise, with a late total knee arthroplasty infection caused by LM treated with one-stage revision surgery. She had an elevated erythrocyte sedimentation rate (79 mm/h) and C-reactive protein (13 mg/dL). Aspiration of the knee joint yielded purulent fluid; cultures showed LM. The patient was given 6 weeks of intravenous ampicillin, followed by trimethoprim/sulfamethoxazole, and finally amoxicillin orally for 7 months. Two years after revision surgery, radiographs showed no evidence of implant loosening. This is a single case and although one-stage approach seemed to have worked, it should not be recommended on the basis of a single report.

Listeria-associated arthritis in a patient undergoing etanercept therapy: case report and review of the literature

Listeriosis can be a cause of infectious arthritis. Here, we present a case of articular listeriosis in a patient with rheumatoid arthritis receiving treatment with etanercept, a tumor necrosis factor antagonist. We review the literature of articular listeriosis and discuss the role of tumor necrosis factor blockade in precipitating listeriosis.

Listeria Meningitis Associated with Infliximab

OBJECTIVE:

To report a case of Listeria monocytogenes meningitis in a 73-year-old man receiving infliximab for rheumatoid arthritis.

CASE SUMMARY:

A 73-year-old white man taking infliximab for rheumatoid arthritis developed listeria meningitis following his second dose. He was receiving other immunosuppressants; however, these remained constant immediately prior to the infection. Diagnosis was confirmed with L. monocytogenes isolated in the cerebrospinal fluid. The patient received 21 days of antibiotic therapy and recovered without any complications.

DISCUSSION:

L. monocytogenes is a gram-positive, non—spore-forming rod that has been associated with the ingestion of undercooked foods. This organism can cause sepsis or meningitis; however, immunocompromised patients, elderly patients, pregnant women, and neonates appear to be at greater risk for this type of infection. Tumor-necrosis factor-α (TNF-α) plays an important role in resistance to this type of infection, and listeria infections have been reported in 26 patients receiving TNF-α inhibitors. In our patient, the listeria infection occurred following his second course of infliximab, which provides a temporal relationship between the listeria infection and infliximab. However, his underlying rheumatoid arthritis and chronic steroid therapy would also increase his risk for a listeria infection.

CONCLUSIONS:

The listeria infection in our patient was a possible adverse event of infliximab according to the Naranjo probability scale. Because the majority of listeria infections occur in patients who are immunosuppressed, it would be reasonable to provide education for healthcare professionals on preventing these infections in all patients receiving immunosuppressants, including anti—TNF-α therapy. Those at risk due to their underlying health conditions should also be monitored closely.

Is Listeria monocytogenes an Important Pathogen for Prosthetic Joints?

Listeria monocytogenes usually causes meningitis or bacteremia, often in immunocompromised adults, pregnant women, or infants. We report a case of septic arthritis caused by L. monocytogenes in a patient with seronegative rheumatoid arthritis (RA) whose hip replacement was infected. She subsequently died, probably secondary to an adult respiratory distress syndrome, a rare complication of listerial infection. We also reviewed all 18 previously reported cases of septic arthritis caused by L. monocytogenes. The frequency of underlying RA, diabetes, neoplastic disease, and immunosuppressive therapy is prominent, as is the concurrent presence of a previous knee or hip replacement. Thus, the simultaneous presence of immune suppression and certain medical disorders or their treatment and a prosthetic joint should alert the clinician to the possibility that L. monocytogenes is the offending microbial agent. In contrast, in immunocompetent persons the usual Gram-positive cocci such as staphylococci, streptococci, or even pneumococci predominate. Although the outcome of appropriate treatment with penicillin or ampicillin alone (or with an aminoglycoside or trimethoprim/sulfamethoxazole in penicillin-allergic individuals) is usually favorable, complicating medical disorders can lead to death. Cephalosporins are rarely effective antimicrobial agents in patients with listeriosis.

Antimicrobial chemotherapy of human infection due to Listeria monocytogenes

Listeriosis is an uncommon infection, but when it occurs it carries a high mortality rate. Early diagnosis is essential and thereafter appropriate antimicrobial chemotherapy. Ampicillin or penicillin plus gentamicin remains the treatment of choice for most manifestations of listeriosis, and adequate doses must be given, i.e. greater than 6g/day of ampicillin or penicillin. Co-trimoxazole appears to be an excellent alternative agent with good penetration into the cerebrospinal fluid. Vancomycin is an appropriate agent for the treatment of primary bacteraemia but does not cross the blood-brain barrier sufficiently well to be useful in meningitis, while erythromycin may be used to treat listeriosis in cases of pregnancy. Treatment of bacteraemia requires one to two weeks' therapy, while meningitis cases may need to be treated for longer; for example, it has been found that most patients with acute meningitis in the UK were treated for 20 days. Infective endocarditis needs treatment for six to eight weeks. Doses should be varied with patients' altered organ function and antimicrobial serum monitoring performed when appropriate.

A 10 year survey of the epidemiology and clinical aspects of listeriosis in a provincial English city

Between January 1983 and December 1992 29 cases of human listeriosis were recorded in Bristol, giving an incidence for the decade of 0.35 infections/10(5) population/annum. For those less than a year old the incidence was 5.2/10(5) population/annum and for adults increased from 0.029/10(5)/annum for those aged 20-49 years to 0.65/10(5)/annum for those over 80 years of age. Social classes I and II were over represented in those infected while classes IV and V were under represented when compared to the general population. Infection was seasonal with most infections occurring in October and 75.9% cases in the last two quarters of the year. Altogether, 13 (45%) cases were associated with pregnancy while 16 (55%) arose in non-pregnant persons. The incidence of pregnancy-associated infection was 1.23 per 10(4) births. In the first half of the decade, pregnancy-associated infection (62.5%) was more common than infection in non-pregnant adults or juveniles but this preponderance was reversed in the second half (23.1%). Among juvenile/adult infections not associated with pregnancy, bacteraemia became more common than CNS infection as the decade progressed. Among the pregnancy-associated infections were five infected abortions, seven neonatal infections (six systemic and one local) and one maternal infection during pregnancy in which the baby was not infected. The juvenile and adult infections in non-pregnant adults presented as primary bacteraemia in 10 (62.5%) patients and CNS infection in six (37.5%) patients. The overall mortality, excluding abortions, was 27.6% (8/29), being 14.3% (1/7) among affected neonates and 37.5% (6/16) among juveniles and non-pregnant adults. Sequelae of infection were not noted in the neonates but a third of the juveniles or adults with CNS infection were left with residual defects.

Listeria monocytogenes infection in a prosthetic knee joint in rheumatoid arthritis

The prosthetic knee joint of a 64 year old woman with severe rheumatoid arthritis was found to be infected with Listeria monocytogenes. After treatment with intravenous antibiotics, symptoms gradually resolved. She subsequently received prolonged treatment with oral co-trimoxazole and 18 months later remained well.

Listeria monocytogenes septic arthritis following intra-articular yttrium-90 therapy

Listeria monocytogenes is a rare cause of septic arthritis, which usually occurs in a host compromised by systemic illness. Intra-articular irradiation with yttrium-90 is generally free of complication. We report a case of intra-articular sepsis of the knee joint by Listeria monocytogenes acquired under unusual circumstances.