This gives an overview of a listeria case.

1. Case Based Discussion
DR MUNNA S RAJ
IMT RESIDENT

2. Presenting Complaints
A 68 year old gentleman presented to the ER with
complaints of
Fever with chills and tiredness since 2 weeks
He also had cough since 1 week

3. History Of Presenting Illness
This 68 year old gentlemanpresented to the ER with complaints of
feverand chills since 2 weeks . This was accompanied by cough and
tiredness .
The feverwas intermittent in nature .
There was no associated nausea , diarrhoea, dysuria, headache ,
seizure , disorientation

4. Past History
This 68 year old gentleman is a known case of Diabetes Mellitus ,
Hypertensionsince 10 years on treatment
He is also on treatment for Anemia
He was also diagnosed with CKD ischemic nephropathy on June 2022
He was diagnosed with Coronary Artery Disease with Non ST Elevation
Myocardial infarction for which a Coronary Bypass Grafting with 4 grafts
was done on 14/09/2022 .

5. Family History
No relevant Family history

6. Personal History
Sleep and apetite normal
On Non Vegetarian Diet
h/o Consumptionof raw Salad
h/o constipationrelieved using laxatives
Normal Bladderhabits
No Addictions

7. Drug History
 Atorvostatin 10 mg HS
 MetoprololExtended Release OD
 Dapagliflozin 10 mg OD
 Nitroglycerin 2.6 mg BD
 Ferrous sulphate with Folic Acid 100 mg OD
 Taurine and Acetyl Cysteine BD

8. Summary
 A 68 year old gentleman came to the ER with complaints of fever , chills
and tiredness since 2 weeks. He also had complaints of dry cough . The
fever was continuous in nature . He is a known case of Type 2 Diabetes
mellitus , Hypertension , CKD on treatment and CAD foe which a
CABG was done one month ago . There is no associateddiarrhea ,
dysuria ,vomiting or headache .

9. Differential
diagnosis

10. DD
1. Lower respiratory tract infection
2. Post Operative Bacteremiasecondary to surgical
site infection
3. Intra thoracic collections
4. Mediastinitis
5. Deep vein thrombosis
6. Infective endocarditis
7. Tuberculosis

11. General Examination
Moderately built and nourished
Height – 165 cm
Weight – 60 kgs
BMI – 21.4 kg/m sq

12. Vitals
Pulse – 76/min , Regular Rhythm , normal in
volumeand character , no radiofemoral
delay
BP-130/70 mmhg on right arm in sitting
position
Respirarory Rate – 18/min
SpO2 – 98% in Room Air
Temperature – 101 F

13. General examination
 Pallor +
 No Icterus , Cyanosis , Clubbing , Lymphadenopathy , Edema
 Vein graft scar on left leg

14. Systemic Examination
Respiratory System – Normal Vesicular breath sounds , Air entry bilaterally equal , No
added sounds
Cardiovascular System – Sternotomy scar + , S1 S2 heard , no murmurs
Gastrointestinal System – Abdomen distended , non tender, no organomegaly ,
Bowel sounds heard
Nervous system – Conscious , Oriented , No Focal Neurological Defects

15. Surgical site examination
 Sternotomy site inspected
Median sternotomy scar present
Measures 7.5 inch , healed
No discharge
No local rise in temperature

16. Investigations planning
 CBC
 URE
 CRP
 ESR
 LFT
 RFT
 ECG
 USG Abdomen
 Blood Cultures
 Urine Cultures

17. Initial Investigation Report
 TC – 12700
 Poly – 62.6
 Lymphocytes – 26
 Monocytes – 7.16
 Eosinophils – 2.8
 Basophils – 0.5
 ANC – 7938
 ALC – 3390

18.  Hb – 9.8
 PCV – 29.4
 MCV – 87.8
 MCH – 29.3
 MCHC – 33.4
 RDW – 14.6
 Platelet – 2.17 lakhs

19.  URE – within normal limits
 Bil total – 0.6
 Bil Conjugated – 0.2
 AST – 16
 ALT-15
 ALP-51
 Albumin- 4.6
 Globulin – 2.9

20.  K – 4.2
 Na- 144
 Cr –2.3
 Ca – 9.3
 HbA1c – 7.7
 D Dimer – 1415
 CRP –98
 HBSAg : -ve
 HIV : -ve
 HCV : -ve

21. Chest X Ray

22. ECG
Normal sinus rhythm
75 bpm
LAD
P waves normal
PR interval normal
ST depression in V4 V5 V6
T wave inversion V3 to V6 , lead 1 , aVL
Lateral Wall Ischemia

23. USG Abdomen
 Showed bilateral renal parenchymal echoes withmaintained CMD
and mild urinary bladder wall thickening , mild prostatomegaly

24. CT Chest
CT Chest was done to look for any fluid collection in chest
But showed no obviousmediastinal fluid collection
Minimal dependent linear atelectatic band in basal segments of b/l
lower lobes
Apparent ground glassing in bilateral lower lobes – likely
gravitatioonal / poor breath holding changes

25. ECHO
Was done to rule out the possibility of Infective Endocardirtis
No vegetations were seen in echo

26. Course in hospital
The initial lab values revealed Leukocytosis , Anemia , raised
inflammatory markers and elevated serum creatinine
Blood and urine cultures were
sent
He was started Empirically
on
Inj CEFAPERAZONE
+SULBACTUM

27. Hospital Course
The patient s symptoms didn’t improve and he continued to have
feverand chills . Adequate DVT prophylaxis was done with Heparin
No
symptomatic
improvement
Another set of
cultures were
sent
Antibiotics
escalated to inj
MEROPENEM

28. Meropenem dose adjustment
Cockcroft Gault Creatinine clearence estimates shouldbe used for drug
dosing in patients with renal impairment .
CrCl Dose
25-50 500 mg – 1g bd
10-25 250 mg – 500 mg bd
<10 250 mg – 500 mg od
Cr Cl in this patient = { [140 – age (yr) ]x weight (kg)/ [72 x serum Cr (mg/dl)]
= [140 –68 ]x 58 / 72 x 2.3 = 26.7
Hence inj Meropenm 1g was given BD

29. Second set of blood cultures grew Gram Positive
Bacilli on 2 bottles
Subsequently MALDI-TOF mass spectrometry was
done

30. MALDI-TOF Mass Spectrometry
 Detected the presence of Listeria Monocytogenes
Score value : 2.21 [ >2.0 - highly probable species
identification ]

31. Culture positive for
Listeria
Patient Therapeutically
started on inj AMPICILLIN

32. Inj Meropenm 1g BD was
continued for a total of 1
week
Inj Ampicillin 2g iv Q4H
was started
therapeutically planned
to be given for a total
duration of 1 week on an
OP basis after discharge .
During the course of his
treatment , his counts
improved and he
became
symptomatically better
and was discharged .

33.  He was readmitted 3 days later with a similar presentation
Possible causes of readmission :
* Treatment failure
* Non Compliance to treatment
* Another community acquired infection

34. He was found to be Covid Positive , however due to
financial constraint , the patient requested for discharge
on the condition that they would quarantine at home .

35. Diagnosis
Listeria Monocytogenes Bacteremia

36. LISTERIOSIS
Listeria Monocytogenes is an
important bacterial pathogen
in neonates ,
immunosuppressed patients ,
older adults , pregnant women
, and occassionally previously
healthy adults
L.monocytogenes causes
invasive diseases including
meningitis , meningo
encephalitis and bacteremia
in susceptible patients such as
immunosuprerssed patients ,
individuals at extremesof age
and pregnant women

38. Microbiology
 Listeria is a short Gram positive rod that
occurs singly or in short chains . However
the identificationof listeria in gram
staining is difficult . Listeria may resemble
pneumococci , diphterioids or
hemophilus species
 Listeria is aerobic and facultatively
anerobic and grows wellin refrigeration
temperature
 Listeria produces a characteristic
apperance on blood agar withsmall
zones of clear beta hemolysis around
each colony . They are motile and non
spore forming and exhibits
characteristic tumbling motility by light
microscopy

40. Symptoms

41. Clinical
manifestations
In Non pregnant individuals
Gastroenteritis – Listeria febrile gastroenteritis
Invasive disease – invasive Listeriosis ( mean incubation
period 11 days )
Blood stream infection - bacteremia
CNS involvement – Meningoencephalitis
In preganant patients
Febrile gastroenteriris and bacteremiausually diagnosed
in 3rd trimester
Fetal and neonatal infection can be severe leading to IU
fetal demise

42. Treatment
 First line therapy – AMPICILLIN 2g IV every 4
hours ( adult dose ) for 2 weeksfor
bacteremia/ 3 weeks for meningitis / 4 to 6
weeks for infectiveendocarditis and even
longer for immunocompromisedpatients
 PENICILLIN G 4 millionunits every 4 hours
 In patients with penicillinallergy
management with TMP-SMX has been
reported
 Other drugs used : vancomycin, Linezolid
, Tetracycline , Macrolidesand 4 th
generation quinolones

43.  If Dexamethasone is initiated for
bacterial meningitis , it should be
discontinued once Listeria is identified
since it has not been proven to be
benificial for Listeria Meningitis
 Furthermore in a nationwide study in
France ( MONALISA study ) , it has
been found the included 252 cases of
CNS Listeriosis, use of Dexamethasone
was associated withincreased
mortality

44. Prevention

45. Listeria in adults – Truly rare or rarely
diagnosed in India ?
Journal of The association of physicians of india , vol 65 , july 2017
Arjun Rajalakshmi , Ram Gopalakrishnan ,P Senthur Nambi , P Vishnu Rao , V Ramasubramonian

48. Discussion
 All four of patients had a good outcome with timely antibiotic therapy.
 The preferred agent is penicillinor ampicillin, whilegentamicin is added for synergy for
the initial 2 weeks in the treatment of bacteremia in those with severely impaired T-cell
function and in all cases of meningitis, encephalitis, brain abscess and endocarditis.
 The best alternative agent is trimethoprim-sulfamethoxazole, especially for patients with
anaphylactic beta-lactam allergy.
 Cephalosporins which are usually recommended for SBP, are bacteriostaticfor L.
monocytogenes while chloramphenicol is associated with failure and relapse and
hence both are not recommended.

49. Discussion
 Treatment duration is 2 weeks for bacteremicpatients, 3 weeks for
meningitis, 6 weeks for brain abscess and rhombencephalitis and 4-
6 weeks for endocarditis.1 Listerial gastroenteritis is self-limited
and treatment is not warranted.
 Preventing listeriosis requires proper food hygiene: thoroughly
washing raw vegetables, cooking vegetables and meat and
avoiding soft cheese and unpasteurised milk. In immune-
compromised groups, trimethoprim-sulfamethoxazole givenfor
pneumocystisprophylaxis will be effective in preventing listeriosis as
well.

50. Conclusion
 Listeriosisis not uncommon in India and is probably under-diagnosed.
 The disease should be considered in the differential diagnosis of meningitis and sepsis
in cell mediated immune compromisedhosts, especially those with impaired T cell
mediated immune response.
 Cultures of blood and other involved fluids readily grow Listeria, and the laboratory
should be alerted to this possibility.
 Ampicillinshould be part of the empiric regimen for meningitis in these patients and
outcome is generally verygood withearly and appropriate antibiotic therapy as in
our patients.

51. Q n A
 Which characteristic of L.monocytogenes increase the risk of
infection in immunocompromised patients ?
A L.monocytogenes can reproduce at refrigeration temperatures
B. L.Monocytogenesmutiplies intracellularly
C. L.Monocytogenes are Gram positiveorganisms
D.L.Monocytogenescultures are easily confused with diphterioids

52. Answer
 B . L.monocytogenes multiplies intracellularly
Hence requiring Cell MediatedImmunity thus immunocompromised
patients are at high risk as are neonates and elderly

53. Q n A
 Those patients at highest risk for L.monocytogenes infection (
immunocompromisedpatients , pregnant women, the elderly)
should avoid eatingwhich of the followingfoods
A Egg
B Milk
C. Soft cheese
D . Vegetables

54. Answer
 C Soft cheese
Soft cheeses like feta , brie etc as well as deli meats , unpasturised mils
, smoked seafoods unless they have been cooked to an internal
temperature of 165 F

55. Q n A
 Listeria Monocytogenes shows which of the following
characteristics ?
A. It can grow in refrigeration temperature
B. It is an extracellular pathogen
C. It is a gram negativecoccus
D. It is strictly a human pathogen

56. Answer
 A
Listeria monocytogenesgrow optimally at 30 to 37 degree C but is
capable of growthat 4 degree C . Thus refrigeration does not reliably
suppress the growthin food . L monocytogenes is a catalase positive ,
gram positive obligate intracellular pathogen . These organisms are
found in catlle , other warm bloodedanimals and fish , where they
can cause the disease

57. THANK YOU