A fatal case of listeria meningitis associated with diabetes mellitus and cirrhosis

Central nervous system infection with Listeria monocytogenes. 33 years' experience at a general hospital and review of 776 episodes from the literature

We reviewed 776 previously reported and 44 new cases of CNS listeriosis outside of pregnancy and the neonatal period, and evaluated the epidemiologic, diagnostic, and therapeutic characteristics of this infection. Among patients with Listeria meningitis/meningoencephalitis, hematologic malignancy and kidney transplantation were the leading predisposing factors, but 36% of patients had no underlying diseases recognized. The infection occurred throughout life, with a higher incidence before the age of 3 and after the age of 45-50 years. Fever, altered sensorium, and headache were the most common symptoms, but 42% of patients had no meningeal signs on admission. Compared with patients with acute meningitis due to other bacterial pathogens, patients with Listeria infection had a significantly lower incidence of meningeal signs, and the CSF profile was significantly less likely to have a high WBC count or a high protein concentration. Gram stain of CSF was negative in two-thirds of cases of CNS listeriosis. One-third of patients had focal neurologic findings, and approximately one-fourth developed seizures over their course. Mortality was 26% overall, and was higher among patients with seizures and those older than 65 years of age. Relapse occurred in 7% of episodes. Ampicillin for a minimum of 15-21 days (with an aminoglycoside for at least the first 7-10 days) remains the treatment of choice. Cerebritis/abscess due to L. monocytogenes, without meningeal involvement, is less common but may be diagnosed by blood cultures and CNS imaging, or by stereotactic biopsy. Longer antibiotic therapy (at least 5-6 weeks) is needed in the presence of localized CNS involvement.

Bacterial meningitis in cirrhosis: review of 16 cases

BACKGROUND

Although bacterial infections are frequent in patients with liver cirrhosis, only isolated cases of bacterial meningitis have been reported.

METHODS

We have reviewed a series of 16 cases of bacterial meningitis in patients with cirrhosis, diagnosed in a single hospital over a 30-year period.

RESULTS

Thirteen patients had alcoholic cirrhosis. On presentation, all patients had fever and most of them had an abnormal mental status (coma in 11 cases), but neck stiffness was not present or was delayed for more than 24 h in seven (43.7%) patients. The cerebrospinal fluid white cell count was always elevated, higher than 1000/microl in ten cases. The cerebrospinal fluid culture was positive in 14 (87.5%) patients. Gram-negative bacilli (mainly E. coli) and L. monocytogenes were the most frequent pathogens, accounting for nine cases. In contrast, S. pneumoniae and N. meningitidis were found in only four cases. Concurrent bacteremia was present in 12 (75%) cases. Ten patients (62.5%) died. Death was meningitis-related in seven patients and due to decompensated liver cirrhosis after clinical recovery from meningitis in the three other patients. Child-Pugh class C was associated with a higher mortality rate (80%, versus 33% for Child-Pugh class A-B), although the difference did not reach statistical significance.

CONCLUSIONS

Bacterial meningitis should be suspected in every patient with cirrhosis presenting with a febrile coma. If lumbar puncture must be delayed, or if no causative agent can be identified on cerebrospinal Gram stain despite elevated cerebrospinal fluid white cell count, empirical antimicrobial therapy should be started straightaway with ampicillin plus a third-generation cephalosporin in sufficient doses.

Disseminated listeriosis presenting as acute hepatitis. Case reports and review of hepatic involvement in listeriosis

We report three cases of disseminated listeriosis that presented as acute hepatitis characterized by striking increase of liver function test values and fever. Peak serum transaminases (SGOT) for each of three patients were 5,380, 2,350, and 443 mu/ml respectively. The correct diagnosis was not suspected in any of the patients until blood and cerebrospinal fluid cultures obtained routinely in the course of evaluation for fever grew Listeria monocytogenes. When antibiotic therapy was instituted, serum transaminase values plummeted in two patients; these two were eventually cured of their infection. The third patient succumbed to his infection; postmortem examination showed miliary abscesses of the liver which revealed L. monocytogenes. Review of the literature for previous reports of hepatic involvement in adult patients with listeriosis shows that hepatitis is an unusual mode of presentation. However, since we observed these three cases over a one-year period, we suspect this may not be an uncommon occurrence.