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  • s/p 6 cycles of Cytoxin/Fludarabine 2006 , 4 cycles of Rituxin completed September 2008 While receiving treatment, the patient developed XXX for which he was maintained on prednisone until tapered off in November 2008
  • Listeria

    1. 1. Case Presentation <ul><li>SF is a 55yo male with a PMH significant for: </li></ul><ul><ul><li>CLL diagnosed in May 2002 </li></ul></ul><ul><ul><li>Hemolytic anemia and thrombocytopenia </li></ul></ul><ul><ul><li>Zoster outbreak in August 2008 </li></ul></ul><ul><ul><li>Psoriasis diagnosed 1975 </li></ul></ul>
    2. 2. Case Presentation cont’d <ul><li>The pt originally presented to clinic c/o 5d hx of low-grade fevers, lethargy, and watery diarrhea (5-6 stools/d). At the time, the patient was d/c’ed under the presumption of viral gastroenteritis. </li></ul><ul><li>Two days later, the patient was brought to AMCHER via EMS after his wife woke up to find him sitting on the floor, unaware of where he was. </li></ul><ul><li>The patient had traveled to Long Island with his wife a week prior to falling ill; the patient denies any change in his dietary habits. </li></ul>
    3. 3. Case Presentation cont’d <ul><li>Examination in the ED revealed sinus tach, headache, disorientation to place and time, a GCS of 14, mild ataxic gate, fever to 104, without focal neurologic deficits and a head CT negative for acute bleed. </li></ul><ul><li>Labs: </li></ul>
    4. 4. Case Presentation cont’d <ul><li>Impression: </li></ul><ul><ul><li>Encephalopathy, likely infectious </li></ul></ul><ul><li>Plan: </li></ul><ul><ul><li>LP, CSF and blood Cx </li></ul></ul><ul><ul><li>Empiric Ceftriaxone and Acyclovir </li></ul></ul>
    5. 5. Case Presentation cont’d <ul><li>CSF Results: </li></ul><ul><ul><li>Protein: 290 (15-45) </li></ul></ul><ul><ul><li>Glucose: 25 (40-75) </li></ul></ul><ul><ul><li>WBC: 350 (40% Lymphocytes) </li></ul></ul><ul><li>Culture Results: </li></ul><ul><ul><li>Blood x2 and CSF: isolated Listeria monocytogenes </li></ul></ul>
    6. 6. Case Presentation cont’d <ul><li>ABX switched to Amp/Gent. </li></ul><ul><li>Currently, the patient’s condition has improved greatly. He is now A&Ox3, GCS 16, and is out of bed regularly. </li></ul>
    7. 7. Listeria Karl Robstad, MD Department of Pathology Albany Medical Center
    8. 8. History <ul><li>First described in 1926 in rabbits, named Bacterium monocytogenes. </li></ul><ul><li>Genus changed to Listeria in 1940. </li></ul><ul><li>Recognized as a significant cause of neonatal sepsis and meningitis in 1952 in East Germany. </li></ul><ul><li>Listeriosis is later associated with immunocompromised adults. </li></ul><ul><li>L. monocytogenes was identified as a cause of foodborne illness in 1981… </li></ul>Joseph Lister
    9. 9. History cont’d <ul><li>In 1981, there was a confirmed outbreak of listeriosis in Nova Scotia involving 41 cases, mostly pregnant women and neonates. Eighteen of the patients died. </li></ul><ul><li>The outbreak was epidemiologically linked to the consumption of coleslaw containing cabbage that had been tainted with L. monocytogenes contaminated raw sheep manure. </li></ul>
    10. 10. Listeria monocytogenes <ul><li>Aerobic/facultatively anaerobic, motile, B-hemolytic, gram-positive rod. </li></ul><ul><li>Occurs singly or in short chains. </li></ul>
    11. 11. Pathogenesis <ul><li>Adult infection is thought to result from oral ingestion and intestinal penetration. </li></ul><ul><li>Neonatal infection may occur transplacentally. </li></ul><ul><li>Immunity is based on T-lymphokine activation of macrophages (IL-18) </li></ul><ul><li>Emerging evidence that IFN signaling enhances susceptibility </li></ul><ul><li>The bacterium enters the host cell via internalin binding to E-cadherin. </li></ul>
    12. 12. Pathogenesis cont’d <ul><li>Spread from cell to cell is accomplished without exposure to the extracellular environment. </li></ul><ul><li>The bacterial surface protein ActA binds to profilin (an actin monomer binding protein) which ends in “explosive” polymerization of actin filaments. </li></ul>
    13. 13. Epidemiology <ul><li>There are about 2,500 cases reported per year with a mortality rate around 20%. </li></ul><ul><li>Infection is more to occur sporadically than in outbreaks, more often in the summer. </li></ul><ul><li>Incubation ranges from 6 to 240h and averages 24h. </li></ul>
    14. 14. Epidemiology <ul><li>Listeria monocytogenes is the only species that infects humans. </li></ul><ul><li>The primary habitat is soil and decaying vegetable matter. </li></ul><ul><li>The source of infection in sporadic cases is often not found, but assumed to related to the ingestion of contaminated food. </li></ul>
    15. 18. Epidemiology cont’d <ul><li>Increased risk is seen in: </li></ul><ul><ul><li>Neonates </li></ul></ul><ul><ul><li>Elderly </li></ul></ul><ul><ul><li>Immunocompromised patients </li></ul></ul><ul><ul><ul><li>Particularly those with lymphoma or on chronic corticosteroid therapy. </li></ul></ul></ul><ul><ul><li>Pregnant women </li></ul></ul>
    16. 19. Epidemiology cont’d <ul><li>Increased incidence also seen with: </li></ul><ul><ul><li>Solid Tumors </li></ul></ul><ul><ul><li>Transplant patients (esp. renal) </li></ul></ul><ul><ul><li>Diabetes </li></ul></ul><ul><ul><li>ESRD </li></ul></ul><ul><ul><li>Iron Overload (including hemochromotosis) </li></ul></ul><ul><ul><li>Collagen Vascular Diseases </li></ul></ul><ul><ul><li>Colonoscopy </li></ul></ul>
    17. 20. Manifestations <ul><li>Febrile Gastroenteritis </li></ul><ul><ul><li>Occurs in after the ingestion of a large inoculum. </li></ul></ul><ul><ul><li>Symptoms include fever, watery diarrhea, nausea, vomiting, headache and muscle/joint pain. </li></ul></ul><ul><ul><li>Symptoms usually resolve spontaneously after 48h. </li></ul></ul><ul><ul><li>Risk of invasive disease is quite low in immunocompetent patients. </li></ul></ul><ul><li>Focal Infections </li></ul><ul><ul><li>Skin abscess, pneumonia, subactue endocarditis, hepatitis, etc. </li></ul></ul>
    18. 21. Manifestations cont’d <ul><li>Pregnancy-Related Infection </li></ul><ul><ul><li>Most often 3 rd trimester </li></ul></ul><ul><ul><li>Symptoms include fever, chills, back pain </li></ul></ul><ul><ul><li>Consider blood cultures </li></ul></ul>
    19. 22. Manifestations cont’d <ul><li>Neonatal Infection </li></ul><ul><ul><li>Can transfer across the placenta, or be acquired during birth. </li></ul></ul><ul><ul><li>Infants born with listerial infections may show disseminated abscesses and/or granulomas in multiple internal organs. </li></ul></ul><ul><ul><li>Usually results in stillbirth or death within days. </li></ul></ul>
    20. 23. Listerial Pneumonia
    21. 24. Manifestations cont’d <ul><li>CNS Infection </li></ul><ul><ul><li>L. monocytogenes is the most common bacterial isolate in immunocompromised patients with meningitis. </li></ul></ul><ul><ul><li>Presents as: </li></ul></ul><ul><ul><ul><li>Meningoencephalitis </li></ul></ul></ul><ul><ul><ul><li>Cerebritis </li></ul></ul></ul><ul><ul><ul><li>Rhomboencephalitis </li></ul></ul></ul>
    22. 25. Manifestations cont’d <ul><li>Meningoencephalitis </li></ul><ul><ul><li>Symptoms vary from mild confusion to coma. </li></ul></ul><ul><ul><li>Focal neurologic deficits point to an encephalitic component. </li></ul></ul><ul><ul><li>Seizures may be seen late. </li></ul></ul>
    23. 26. Manifestations cont’d <ul><li>Cerebritis </li></ul><ul><ul><li>Direct hematogenous invasion of brain parencyma with no or little involvement of the meninges. </li></ul></ul><ul><ul><li>Usually manifests with focal neurologic deficits. </li></ul></ul><ul><ul><li>Rarely, patients may develop brain abscesses. </li></ul></ul>
    24. 27. Manifestations cont’d <ul><li>Rhomboencephalitis </li></ul><ul><ul><li>Biphasic course </li></ul></ul><ul><ul><ul><li>1: headache, fever, nausea, vomiting. </li></ul></ul></ul><ul><ul><ul><li>2: cranial nerve palsies, ataxia, tremor  decreased consciousness, seizures and hemipareisis </li></ul></ul></ul>
    25. 28. Diagnosis <ul><li>Symptoms can be rather non-specific, however a good history may suggest the entity clinically. </li></ul><ul><li>MRI to rule out brain invasion. </li></ul><ul><li>CSF analysis is only suggestive of bacterial origin (elevated protein, decreased glucose). </li></ul><ul><li>Positive blood and CSF cultures. </li></ul><ul><ul><li>Not uncommon for negative CSF and positive blood in meningitis patients. </li></ul></ul>
    26. 29. Gram Stain
    27. 30. Motility
    28. 31. Blood Agar
    29. 32. Catalase (+)
    30. 33. Bile Esculin
    31. 34. Motility Agar
    32. 35. Vitek
    33. 36. Treatment <ul><li>Sensitivities not conducted for Listeria. </li></ul><ul><li>Ampicillin or PCN-G in low risk patients. </li></ul><ul><li>Add Gentimycin to high risk patients. </li></ul><ul><li>Treat for 2 weeks. </li></ul>
    34. 37. References <ul><li>Marc Lecuit, D Michael Nelson, Steve D Smith, Huot Khun, Michel Huerre, Marie-Cécile Vacher-Lavenu, Jeffrey I Gordon, Pascale Cossart . Proc Natl Acad Sci U S A. 2004 Apr 20;101 (16):6152-7 15073336 (P,S,G,E,B) Cited:8 Targeting and crossing of the human maternofetal barrier by Listeria monocytogenes: role of internalin interaction with trophoblast E-cadherin. </li></ul><ul><li>Prtizker. Hot Dog Recall Due to Listeria Risk. </li></ul><ul><li>Gefland M. Clinical manifestations and diagnosis of Listeria monocytogenes infection. UpToDate. 2008 </li></ul><ul><li>Gefland M.Treatment prognosis and prevention of Listeria monocytogenes infection. UpToDate. 2008 </li></ul><ul><li>Gefland M. Epidemiology and pathogenesis of Listeria monocytogenes infection. UpToDate. 2008 </li></ul>
    35. 38. Thank you.