Early-Onset Listeriosis in Prematurity :

A Case Report
YingYing-Yao Chen, KaiKai-Sheng Hsieh, ShuShu-Ming Lin and YungYung-Feng H u a n g
Listeria monocytogenes has been known for several decades, but its infection of newborn infants has been rarely reported in Taiwan. We here report a case of a premature newborn with a gestational age of 31 3/7 weeks and a birth
body weight of 1,070 gm, who was found to have early-onset Listeria sepsis, pneumonia and suspected meningitis.
Unexpected meconium stained amniotic fluid was found at birth. After treatment with ampicillin and gentamicin, her
condition improved gradually. She was discharged on the 59th day with a body weight of 2,712 gm, and complete
eradication
of
the
Listeria
infection.
(Clinical
Neonatology
1998;5(1):
32-34)
Key words: Listeria monocytogenes, Early-onset sepsis, Pneumonia, Prematurity
Listeria monocytogenes was first described by Murray et
al in 1926 [1]. It is a short, motile, gram-positive bacillus, which can cause infection in humans, especially in
immunocompromised individuals, in the elderly, during
pregnancy, and in the neonatal period. When infection
occurs in pregnancy, it can cause premature delivery,
stillbirth or abortion. When infection occurs in newborn
infants, it can present as early- or late- onset sepsis,
pneumonia, and meningitis, similar to infection by group
B streptococci. Hypothermia, poor feeding and lethargy
will be found in these infected newborn infants [2]. In
America and Europe, this bacteria is not uncommonly
reported. In Taiwan, this is a rare infection. Here we report a case of prematurity involving early-onset Listeria
infection.

Case Report
This female premature newborn, with a gestational age of
31 3/7 weeks and a birth body weight of 1,070 gm, was
vaginally delivered, and meconium stained amniotic fluid
was noted. There was a delay of initial crying and the
Apgar score was 5/6 at 1 and 5 minutes. The newborn
was then sent to the intensive care unit under the impression of prematurity with respiratory distress syndrome,
perinatal asphyxia and suspected sepsis. The mothers
history obtained from a local obstetric clinic showed
premature rupture of membranes for 2 days and leukocyDepartment of Pediatrics, Veterans General HospitalKaohsiung
Received: October 7, 1997
Accepted: December 11,1997

32

tosis ( WBC >30,000/cu mm ). No culture of vaginal

discharge was done after delivery. Initially, ampicillin
( 100 mg/kg/day ) and gentamicin ( 5 mg/kg/day ) were
prescribed for prophylaxis of neonatal sepsis.
Beginning on the day of birth, yellowish discharge
from the newborns nose and the endotracheal tube was
observed. Her initial hematology studies showed a white
blood cell (WBC) count 26,400/cumm ( neutrophils :
55%, lymphocytes : 45% ), hemoglobuin (Hgb) level of
12.5 gm/dl, hematocrit level of 36.9%, and platelet count
of 240 000/cu mm. Chest X-ray showed grade II/IV respiratroy distress syndrome. The endotracheal tube was
removed on the 3rd day without dfficulty, and continuous
positive airway pressure via the nasal route was subsequently given.
Unfortunately, frequent apnea and bradycardia were
noted on the 4th day and sepsis was highly suspected.
Cerebral spinal fluid (CSF) from a spinal puncture
showed a WBC count of 2,170 /cu mm ( neutrophils :
90%, lymphocytes : 3%, monocytes : 5%, metamyelocytes : 2% ), red blood cell (RBC ) count of 110,000/cu
mm, protein level of 25 mg/dl, glucose level of 9 mg/dl
( simultaneous blood glucose level : 75 mg/dl ) and no
bacteria growth when cultured. On the same day, the hematology study showed a WBC count of 39,410/cumm
( neutrophils : 55%, lmphocytes 17%, bands 9%, monocytes 8%, metamyelocytes 6%, myelocytes 2%, atypical
lymphocytes 3% ), RBC count of 3,360,000/c.u mm, Hgb
level of 11.9 gm/dl, hematocrit level of 36.4%, and platelet count of 236,000/cu mm. The C-reactive protein level
Reprint requests to: Dr.Yung-Feng Huang, Department
of Pediatrics, Veterans General Hospital-Kaohsiung,
386, Ta-Chung 1st Rd, Kaohsiung, Taiwan, 813, R.O.C.

Clinical Neonatology 1998 Vol.5 No.1

Early-Onset Listeriosis
was 0.26 mg/dl.
No bacteria was found on the Gram stain of the yellowish discharge from respiratory tract, and its culture
did not grow any bacteria. A chest X-ray on the 5th day
disclosed a diffuse infiltrate over the lung fields bilaterally, especially the right upper and right middle lobes.
The Gram stain from the blood culture showed gramnegative bacilli on the 2nd day. On the 3rd day, the Gram
stain revealed what appeared to be gram-positive cocci in
chains. Finally, the organism was verified to be Listeria
monocytogenes on the 5th day. Therefore, the dose of
ampicillin was increased to 200 mg/kg/day. Two other
lumbar punctures were performed. One done on the 11th
day showed a protein level of 4,500 mg/dl and glucose
level of 95 mg/dl; the other puncture performed on the
17th days showed a protein level 1,926 mg/dl and glucose level of 82 mg/dl. Cultures of CSF grew no bacteria.
No white cell count was done due to the small amount of
CSF available. The leukocytosis in peripheral blood and
the yellowish discharge, which persisted for more than 10
days, improved gradually after antibiotic treatment for 18
days. Throughout the whole course, no fever or rash was
noted. Finally, the infant was discharged on the 59th day
uneventfully with a body weight of 2,712 gm.

Discussion
The Listeria species can be found in our environment, e.g.
in soil, water, various animals, and contaminated foods.
Foodborne listeriosis has been well-documented [3]. Listeria infection is commonly classified into four clinical
groups: (1) listeriosis during pregnancy, (2) listeriosis in
the newborn infant, (3) central nervous system, and (4)
other: septicemia with pharyngitis and mononucleosis,
oculoglandular, or cervicoglandular [4].
When infection with Listeria occurs during pregnancy,
the patient may have an asymptomatic carrier state, the
duration of which is unknown . Moreover, infection of
the fetus might not occur during or after the carrier state
[4].
The pathogenesis of perinatal Listeria infection is not
very clear,but maternal listeriosis can be transmitted to
the fetus by an ascending or transplacental route [4].
Since the mother in our case had a history of premature
rupture of membranes for 2 days and leukocytosis
>30,000 /cu mm, infection was highly suspected. Examination of the placenta has been proposed as being useful
in the diagnosis of prenatal listeriosis [5], and the presence of macroabscesses in the placenta is the most characteristic finding. The placental weight in our case was
350 gm, which was within the normal range, and no abscess was found by the obstetrician.

Clinical Neonatology 1998 Vol.5 No.1

In neonatal infection, listeriosis may be manifested either as early- or as late-onset sepsis, similar to group B
streptococcal infection. Early-onset infection can be acquired by transplacental infection or aspiration from the
birth canal during delivery, but the timing of late-onset
transmission is not clear. Late-onset infection can happen
between the 2nd and 5th weeks of life, and more commonly involves the central nervous system [2]. Serotypes
Ia, Ib, and IVb are the predominant infecting serotypes in
all cases of human listeriosis. The distribution of these
serotypes is significantly different between the early- or
late-onset patients. In addition, the birth body weight of
an early-onset infected neonate is usually less than that of
the neonate with late-onset infection [6]. When neonatal
listeriosis exists, isolation of the newborns secretions
and excretions is necessary, because there may be nosocomial cross-infection in nurseries [7]. Common use of a
rectal thermometer among neonates has been considered
to be one mode of transmission [8]. Certainly handwashing is an important method to prevent spreading the disease.
In the past, reports of Listeria infection occurring in
Taiwan were scarce, even among immunocompromised
adults [9,10]. Only one case of a premature neonate with
a gestational age of 28 weeks and a birth body eight of
1,180 gm was reported [10]. The rare prevalence here
may be due to our food habits differing from those of
other countries. Contaminated milk products, meat,
ready-to-eat foods [11], and raw vegetable products have
been considered to be major sources of infection [12].
Also, incorrect judgement of culture results due to the
coccobacilli shape and changeable gram-positive stain
may contribute to the low prevalency rate in Taiwan. In
addition, this organism frequently is thought to be a contaminant because of its similarity to diphtheroids. Therefore, the laboratory should be informed when this infection is suspected [2].
Meconium staining in amniotic fluid of premature
newborns, especially those of less than 32 weeks gestation, has been documented in reports of Listeria infection
[4]. It is very important to keep this in mind. Early detection by gram stains and cultures of blood, urine, or any
secretion is necessary to prevent deterioration. In our
case, meningitis was suspected due to low glucose level
( 9 mg ) and leukocytosis in CSF of the first lumbar
puncture. Chest X-ray showed diffuse parenchymal infiltrates on the 5th day, which suggested the presence of
aspiration pneumonitis [2].
Leukocytosis with predoninant polymorphonuclear
cells in peripheral blood was also seen in our case.
Throughout the whole course, the monocytes increased,
and the numbers were between 5 and 13 % of the total
number of white cells. L. monocytogenes had been well

33

YY Chen, KS Hsieh, SM Lin, et al

documented as being to manufacture a monocytosisproducing agent [4], which could shorten the generation
time of monocyte precursors in vivo [13].
Ampicillin, penicillin G, and trimethoprim-sulfame
thoxazole are currently the accepted antibiotics for treating listeriosis. Erythromycin and tetracycline are alternative agents, but cephalosporins, quinolones, and oxacillin
have little effect [14-16]. Aminoglycosides have been
recognized as being able to provide synergistic effects in
treatment [17-19]. This synergism may be especially
helpful in improving outcomes for neonates and premature infants with Listeria infection.

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