(INTENT ia General ene, Wire Hostal, ued, Hew Zealna Correspondence to DeWare Hobs rmctsie@hotmatcom ecpid 26 Feoray 2015 ® ‘CrossMark To ce: fobs a case Rep Pblshed one [pose indade Day Mart ea] 10.1 136-2044 209178 CASE REPORT Colovesical fistula presenting as Listeria monocytogenes bacteraemia Mark Hobbs SUMMARY We presenta case of colovesical fistula presenting with a dinical yndrome of urosepsis subsequently demonstrated to be due to Listeria monocjtagenes bacteraemia. The patient had a history of previous rectal cancer with 3 low anterior resection and @ covering ileostomy that had been reversed 6 months prior t this presentation. L. monocytogenes was aso isolated among raed enteric organisms on urine cutur There were no symptoms of sgns of acute gastrointestinal Istetiosis or rmeningsencephaltis Tis unusual scenario prompted concer regarding the possibilty of communication between bawel and blade, which was subsequently confirmed with CT and a contrast enema, The patient recovered well with intravenous amoxiiln and to date has decined surgical management of his colovesical fistula. Ths case ilusates the importance of considering bowel pathology when enteric organisms such as Listeria are folated from unusual sites. BACKGROUND Listeria monocytogenes is an uncommon human pathogen that most often causes a sellimiting fastointestinal lines in immune-competent hosts bur can cause life-threatening bacteraemia and men ingoencepbalits typically in the elderly oF immune compromised (including pregnant women and neo- rac’). Les common presentations inclade endocar- dis and oxcoarticolar infection.” L. monocytogenes infection has previously been associated with bowel pathology, but infection of the urinary tract is excemely unas. ‘CASE PRESENTATION A 69-yearold man was admitted to the internal ‘medicine service via the emergency department after a fall at home. The fall occurred following 48h of fever, chills, dysuria and increased urinar frequency, and 24h of delirium and light- hheadedness. The patient had an extensive medical history including obesity, hypertension, dyslipidac- ria, obstructive sleep apnoca and type 2 diabetes ‘mellitus, with complications including renal impair- ‘ment (CKD2) and neuropathy. He also had an extensive surgical history with 2 previous diagnosis of rectal cancer treated with a low anterior resec- sion following neoadjuvant radiotherapy 3 years prior to this presentation, Owing t0 a positive leak test at the time of chis intial surgery, a covering loop ileostomy was formed, Prior to reversal of this stoma the patient underwent a contrast enema, which revealed a small, contained anastomotic leak. ‘This was not amenable to closure and, aware of the risks, he proceeded to reversal of the stoma Gmonths prior to this presentation. Since the stoma reversal he had returned to hospital ewice for rectal bleeding. On the latter occasion, 1 month prior to the current admission, a small rectal ulcer ‘yas noted for which he received treatment with steroid enemas and antibiotics, [At presentation, the patient was febrile with a temperature of 39°C and tachycardie at 120 bpm, but normotensive, His blood sugar was elevated at 14.9 mmol/L, His respiratory rate and oxygen sarur- ation were normal. Examination of the cardiac and respiratory systems was normal and the abdomen ‘was obese with multiple surgical scars and mild ten: demess in the suprapubic region, A midstream urine sample revealed >1000%10" white cell couns/l, and bacteria were seen on microscopy. Blood culsures and routine blood tests were drawn Fluid resuscitation and empiric intravenous cefurox- ime and gentamicin were administered. On che second day of admission, one of the initial blood cultures was reported to be positive for Gram-positive cocci resembling streptococci, ‘The cefuroxime was changed to intravenous amoxicilinclavulanic acid to cover the possibilty fof enterococcal urosepsis. On the third day of admission this organism was formally identiied as a Gram-positive bacillus L, monocytogenes (peni- The isolation of bacteria (especialy from blood) that are not ‘typical pathogens forthe site of infection being treated should prompt further questioning and investigation to identity reason for ther presence > Listeria isan uncommon but important cause of human sisease and is a member of the bowel flora in approximately 5% of humans. > Recutrent urinary infection and passing gas or debris inthe Utne are typical symptoms, and should alert the lncian to the possibly ofa colovescal fistula, > Colovesical fistula is a rae but well recognised complication ‘of pelvic surgery and of primary bowel pathology such as diverticular disease or Crohn's disease. > seria is inteinsicaly resistant to cephalosporins but remains susceptible to penicln antibiotic. Trimethoprim-sulfamethoxazole isthe second line drug of choice in peniciln-allergc cases, Combination teatment is ‘commonly used fo serous infection such as that involving ‘the central nervous system, [Acknowledgements The autor wous Ve a acoaledge the asisanee of Br Stephen Mere in the eng te manset. Thay wou abo ie to Setnaledge te hard werk 2nd vate conan fo theca tts patent of the csc micabology boaay sta ac the ectus Diseases tar, Competing interests Nove. Patient consent Obssne, Provenance and peer review Net crisionedeerally eer eeu, REFERENCES 1 Later 5. Lita manggens Mandl Bene, al Re Masel Dau, ar Beart’ ncpes and Pcie of cous Disses 27th a, Praia, Pk: Chul nastoe Fbeer, 2010207 2707-14, 2 Sede, Pawson Diss pens mening Baby heaps. fu / Cin Merl ic Ds 201332 1225-3 3 insects Adah Kal Chie ype arte wth sera rangtageesfecn. 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