Listerial brain abscess in a patient with chronic lymphocytic leukemia treated with fludarabine

Cerebral Abscess Caused by Listeria monocytogenes: Case Report and Literature Review

BACKGROUND

 Listeria monocytogenes is an opportunistic gram-positive, facultative intracellular bacterium that causes invasive diseases mostly in pregnant women and immunosuppressed patients. Despite the predilection toward the central nervous system (CNS), it usually causes meningitis and meningoencephalitis, whereas brain abscesses are very uncommon.

CASE PRESENTATION

 We describe the case of a 69-year-old homeless patient with a brain abscess due to L. monocytogenes who was successfully treated surgically by a guided stereotactic aspiration and antibiotic therapy with ampicillin and gentamicin. Our patient was discharged after 4 weeks of therapy without neurologic deficits. Additionally, we provide a review of the literature of brain abscesses caused by L. monocytogenes.

CONCLUSIONS

 This case highlights the need to drain cerebral abscesses and culture pus to correctly treat patients with antibiotics, especially given the high mortality rate of this infectious entity.

Multiple cerebral abscesses because of Listeria monocytogenes: three case reports and a literature review of supratentorial listerial brain abscess(es)

BACKGROUND

Central nervous system involvement often follows bacteremia because of Listeria monocytogenes. Meningitis is clinically the most common manifestation, while brain abscess occurs in about 1% of patients. Brain abscess is usually solitary but in recent years, probably in part because of the availability of computerized tomography and magnetic resonance imaging, several reports have described two or more separate supratentorial abscesses.

METHODS

We have described three patients with listerial brain abscesses and reviewed the North American and European literature of brain abscess(es) because of L. monocytogenes through December 2001. We have evaluated the role of underlying diseases and therapeutic immunosuppression on the development of solitary or greater than one brain abscess.

RESULTS

In contrast to meningitis, where immunosuppression does not predispose either to disease incidence or to higher mortality, patients with solitary and particularly those with more than one supratentorial abscess usually are immunosuppressed either by disease or by therapy. Corticosteroids in particular are significant predisposing factors, especially in those patients with two or more brain abscesses. Mortality resulting from listerial brain abscess, whether solitary or multiple, is nearly three times higher than nonlisterial brain abscess, probably in part because of both underlying diseases and immunosuppressive therapy.

CONCLUSIONS

Therapy with high-dose ampicillin in combination with gentamicin appear to be the drugs of choice, followed by trimethoprim/sufamethoxazole and vancomycin. In general, antimicrobial therapy appears to be satisfactory treatment without surgical intervention.

Infection and immunity in chronic lymphocytic leukemia

Patients having chronic lymphocytic leukemia (CLL) are at increased risk for infectious morbidity and mortality. The predisposition to infections in CLL patients has many components, including both immunodeficiency related to the leukemia itself (humoral and cellular immune dysfunction) and the results of cumulative immunosuppression related to CLL treatment. The risk of infectious complications increases with the duration of CLL, reflecting the natural history of the disease and the cumulative immunosuppression related to its treatment. Hence, in early, untreated CLL, the infectious risk is mainly related to hypogammaglobulinemia, and infections by encapsulated bacteria are common. However, in patients having advanced CLL, particularly those who receive the newer purine analogues, neutropenia and defects in cell-mediated immunity appear to be the major predisposing factors. An expanded spectrum of pathogens, including opportunistic fungi, Pneumocystis carinii, Listeria monocytogenes, mycobacteria, and herpesviruses, are seen in that setting. The changing spectrum of infections in this latter group of patients mandates a newer approach to prophylaxis and therapy.

Opportunistic pulmonary infections with fludarabine in previously treated patients with low-grade lymphoid malignancies: a role for Pneumocystis carinii pneumonia prophylaxis

The high incidence of opportunistic pulmonary infections in fludarabine-treated patients at Walter Reed Army Medical Center (WRAMC) and in the literature are described. A CancerLit search of fludarabine from June 1983-April 1994 with subsequent cross referencing and a retrospective review of all patients receiving fludarabine at WRAMC was performed. A total of 2,269 patients with low-grade lymphoid malignancies who received 7,547 + cycles of fludarabine were identified from the literature. Seventy-three (3.2%) of these patients developed opportunistic infections. Seventy-one (97%) of these infections occurred in patients who were pretreated with alkylator regimens or corticosteroids. Forty-five (2%) of these were of respiratory origin and associated with a 56% mortality rate. In contrast, 6 of the 21 patients (29%) treated with fludarabine at WRAMC developed opportunistic pulmonary infections which included three Pneumocystis carinii (PCP), one PCP/disseminated Candidiasis, one Mycobacterium avium intracellulare, and one Aspergillus niger pneumonia. These infections developed during and after treatment with fludarabine in alkylator-resistant patients who had received corticosteroids before (n = 6), during (n = 1), or after (n = 4) fludarabine therapy. Lack of PCP prophylaxis was the only significant (P = .018) variable that differentiated patients who developed opportunistic pulmonary infections. Corticosteroid treatment before, during, or after fludarabine treatment in patients with alkylator-resistant, low-grade lymphoid malignancies who have not received PCP prophylaxis is associated with an increased risk of opportunistic pulmonary infections. Aggressive work-up of pulmonary syndromes and PCP prophylaxis in these patients should be considered during and after treatment with fludarabine.

Late listeriosis after fludarabine plus prednisone treatment

Fludarabine plus prednisome treatment in patients with chronic lymphocytic leukaemia has recently been correlated with an increased incidence of Listeria monocytogenes infections. We observed a patient with chronic lymphocytic leukaemia who received fludarabine plus prednisone and developed a fatal listeriosis 7 months later. A further case of listeriosis has recently been described in a man who developed the infection 2 years after successful fludarabine treatment while he had a normal CD4 lymphocyte count. These cases suggest that the risk period for the development of such an unusual infection could be unexpectedly and unpredictably long. This data could be important in the evaluation of a possible antibacterial prophylaxis schedule and in the wariness about the potential danger of food known to contain L. monocytogenes.