CASE REPORT

meningitis, Listeria monocytogenes

Listeria Monocytogenes Meningitis

Presented is the case of a 42-year-old, previously healthy man with men- Joseph A Wilkinson, MD, CPT, MC
ingitis secondary to Listeria monocytogenes. Following lumbar puncture, Ray F Keate, MD, CPT, MC
empiric therapy with intravenous penicillin was started and he was hospi- Fort Hood, Texas
talized. Subsequently L monocytogenes was proven to be the causative
organism and antibiotic therapy was changed to ampicillin and gentamicin. From the Department of Operational and
The patient's condition improved. He was discharged and continues to do Emergency Medicine, Darnall "Army
Community Hospital, Fort Hood, Texas.
well. There was no evidence at any time of underlying predisposition to
infection. Listeria meningitis in healthy patients and in patients with under-
lying disease is discussed, along with possible implications about choice of Received for publication August t7, t983.
empiric antibiotics. [Wilkinson JA, Keate RF: Listeria monocytogenes men- Accepted for publication November 11,
1983.
ingitis. A n n Emerg Med June 1984;13:474-476.]
The opinions or assertions contained
INTRODUCTION herein are those of the authors and
Patients presenting to the emergency department with the signs and symp- should not be construed as official or as
toms of meningitis frequently are given empiric antibiotic therapy. Treat- representing the opinions of the
ment is based on considerations of the patient's age and premorbid status, Department of the Army or the
Department of Defense.
which determine the organisms that are statistically most likely to be re-
sponsible for the infection. We report an infrequently recognized form of
meningitis to demonstrate that such considerations are not universally ap- Address for reprints: Joseph A Wilkinson,
MD, CPT, MC, Department of Operational
plicable. and Emergency Medicine, DarnalL Army
Community Hospital, Fort Hood, Texas
CASE REPORT 76544,
A 42-year-old man presented with a four-day history of progressive
cephalgia, chills, fever to 40 C, myalgias, nausea, and vomiting. He had been
examined at another facility during the preceding days and had received
symptomatic treatment for a presumed viral illness. He previously had been
in excellent health and had not used any other medications. He had no
known exposure to carriers of organisms likely to cause meningitis. His fam-
ily history was noncontributory. He had no known allergies and only occa-
sionally smoked a pipe or consumed ethanol.
On presentation he was diaphoretic and somewhat lethargic, but oriented
to person, place, and time. Vital signs were as follows: temperature, 39.9 C
orally; pulse, 98/min; respiratory rate, 20/rain; and blood pressure, 130/80
m m Hg. The patient exhibited photophobia, nuchal rigidity, and question-
able Brudzinski's and Kernig's signs. The lungs were clear. Cardiac examina-
tion revealed a grade II/VI systolic ejection murmur. The physical examina-
tion was otherwise unremarkable.
Laboratory examination included a white blood cell count of 16,500, with
64 polymorphonuclears, 23 bands, 10 lymphocytes and 3 mon0cytes; and a
hemoglobin and hematocrit of 14.8 and 48.8, respectively. The blood glucose
was 141 mg/dL. Chest film was normal. Lumbar puncture yielded clear, color-
less cerebrospinal fluid (CSF} with a total white cell count of 100, including
52 polymorphonuclears and 48 lymphocytes, along with 145 crenated and 78
fresh red blood cells. No CSF pressure was obtained. CSF glucose was 68 mg/
dL and protein was 96 mg/dL. CSF Gram stain did not reveal any organisms,
and additional blood and urine cultures were negative.
During the physical examination the patient was given nasal oxygen at a
rate of 3 L/min, and an aspirin suppository. Intravenous {IV)normal saline
was administered cautiously. Because of the presumptive diagnosis of men-

13:6 June 1984 Annals of Emergency Medicine 474/105

LISTERtA MONOCYTOGENES
Wilkinson & Keate
ingitis, 2.4 million units of penicillin
G were administered IV on comple-
tion of the lumbar puncture and be-
fore the results of the CSF Gram stain
were knOwn. The patient Was then ad-
mitted to the hospital.
Medication was changed to chior-
amphenicol 1 g IV every six hours.
Counterimmunoelectrophoresis (CIE)
of the CSF proved negative. Forty-
eight hours after admission, CSF
cultures grew Gram-positive rods and
bacteriologic testing revealed the
organisms to be Listeria m o n o c y t o -
genes. A second l u m b a r p u n c t u r e
showed no organisms on Gram stain,
but s u b s e q u e n t l y grew L m o n o -
cytogenes on culture.
Serologic testing at a referral in-
stitution confirmed infection w i t h
Listeria. Following the initial identifi-
cation two days after admission, the
antibiotic treatment was changed to
ampicillin 18 g I V p e r day and gen-
tamicin 4 mg/kg IV per day. A third
CSF culture obtained 72 hours after
the initiation of ampicillin and gen-
tamicin was negative.
The patient's hospital course was
unremarkable except for persistent
low-grade fevers, and he was dis-
charged on the 17th hospital day He
was readmitted four days after dis-
charge for ataxia with gait drift to the
left, orthostasis, and postmeningitic
left trigeminal neuralgia. Six months
after his second hospitalization he was
asymptomatic except for some mild
malaise. Ten months after his hospi-
talization he was completely asymp-
tomatic. There was no evidence of any
immunologic dysfunction or other un-
derlying systemic disease during the
entire course of care.
DISCUSSION
Meningitis caused by L m o n o c y t o -
g e n e s is u n c o m m o n . In New York
City, where all cases of meningitis are
reportable to the city health depart-
ment, only 53 cases were reported in
an eight-year period. Allowance for
lack of reporting might double that
number.1 This would indicate an an-
nual incidence of approximately one
to two per million population. In an-
other study of 207 patients with men-
ingitis over a period of six and a half
years at Massachusetts General Hos-
pital, only one patient, an infant, was
identified as having L m o n o c y t o g e n e s
meningitis. ~. Our case was more un-
common in that it occurred in an oth-
erwise healthy middle-aged adult,
whereas Iisteriosis usually occurs at
t06/475
the extremes of age3 or in compro,
mised hosts. 4 Compromising factors
include the folloWing: alcoholism, di-
abetes mellitus, heart disease, chronic
cytotoxic drug and/or steroid therapy,
neoplastic disease, and immune defi-
ciency states. 4-7 Approximately 30%
of cases occur in otherwise healthy
adults,8 and there is a significant male
predominance. 3 There is usually no
obvious v e c t o r . 6,9
Patients afflicted with meningitis
exhibit two courses of illness, a fulmi-
nant illness progressing over a day or
less, and a more protracted course de-
veloping over a period of days as was
seen in our patient. 10 The latter
course has been reported in some pa-
tients with LJsteria meningitis. 4
While not all the signs and symp-
toms of meningitis may be seen in
listeriosis, they may include cephal-
gia, chills, flu-like complaints, high
fever, nausea, and vomiting.~l A
p o s i t i v e Kernig's sign and m e n -
ingismus usually are not present in
adults, z2 Patients c o m m o n l y have
varying degrees of mental status al-
terations for approximately a week be-
fore the infection is apparent, and they
may later evidence seizural or focal
neurological aberrations.12 Because
listeriosis may declare itself slowly
and may not cause meningeal signs,
some have cautioned that the pos-
sibility of Listeria meningitis should
be considered in any febrile patient
with neurologic sympt0ms.13
In L i s t e r i a m e n i n g i t i s , the CSF
Gram stain frequently will fail to
d e m o n s t r a t e a causative organism,
and CIE will be negative as was the
case with our patient. His clinical
condition, however, necessitated the
initiation and continuance of anti-
microbial therapy while c u l t u r e r c -
sults were pending. Even if organisms
are present on Gram stain, Listeria
may be decolorized by alcohol and,
therefore, be mistaken for Gram-nega-
tive enteric bacteria or H e m o p h i l u s
influenzae.7,9 When cultures later re-
veal the characteristic short, Gram-
positive rods, often they are mistaken
for contaminating diphtheroids and
the Listeria is not reported.7, 9 Another
deceptive feature of meningitic list-
eriosis is the frequent predominance
of CSF mon0nuclear cells that may
falsely suggest fungal, tuberculous, or
viral etiologies.lZ
The initial drug chosen ideally is di-
rected by CSF Gram stain results. If
those results are negative or delayed
for some reason, therapy should be di-
Annals of Emergency Medicine
rected at the organisms statistically
most likely, based on the patient's age
and premorbid status. Our previously
h e a l t h y middle-aged p a t i e n t m o s t
likely Would be at risk for Streptococ-
cus p n e u m o • i a e or N e i s s e r i a m e n -
ingitidis, lo For this reason high-dose
IV penicillin was begun in the emer-
gency department.
Penicillin has been reported to be ef-
fective against Listeria, as is the usu-
ally recognized drug of choice, am-
picillin.8,1o However, Buchner and
Schneierson7 have shown in a review
of the literature that several strains of
Listeria may be resistant to penicillin.
For this reason ampicillin, alone zo or
in combination with gentamicin,14 is
the commonly preferred therapeutic
regimen. Tetracyc!ine7 anG pending
further clinical trials, combined tri-
methoprim-sulfamethoxazole i5 also
have been suggested.
L m o n o c y t o g e n e s meningitis carries
an overall mortality of 30%; however,
in healthy adults the mortality ap-
proaches only 13%. 8
Our case illustrates an infrequently
recognized form of meningitis that
may present to the emergency depart-
ment. The diagnosis may be delayed
by the lack of the usual signs and
symptoms of meningitis and by a de-
ceptive laboratory presentation. List-
eria meningitis may therefore be more
c o m m o n than is currently r e a l i z e d .
Our case also demonstrates a possible
oversight in the institution of empiric
antibiotic therapy as it is currently
done in the emergency setting.
REFERENCES
1. Cherubin CE, Marr JS, sierra MF, et al:
Listeria and Gram-negative bacillary-
meningitis in New York City, 1972-1979.
A m J Med 1981;71:199-209.
2. Dodge PR, Swartz MN: Bacterial men-
i n g i t i s - A review of selected aspects, 1.
General clinical features, special prob-
lems and unusffal meningeal reactions
mimicking bacterial meningitis. N Engl J
Med 1965;272'.725-731.
3. Lavetter A, Leedom JM, Mathies AW, et
al: Meningitis due to Listeria mono-
cytogenes, a review of 25 cases. N Engl J
Med 1971;285:598-603.
4. Burke D, Ward W, Ludey M: Listeriosis
in man. Med J Aust 1973;1:292-294.
5. Iwarson S, Larson S: Outcome of List-
eria monocytogenes infection in compro-
mised adults, a comparative study of sev-
enty-two cases. Infection t979;7:54-56.
6. Seeliger HPR, Finger H:, Listeriosis, in
Remington JS, Klein lO (eds): Infectious
Disease of the Fetus and Newborn Infant.
13:6 June 1984
Philadelphia, WB Saunders, 1976, p 333-
365.
7. Buchner LH, Schneierson SS: Clinical
and laboratory aspects of Listeria mono-
c y t o g e n e s infection. A m J M e d 1968;
45:904-921.
8. Nieman RE, Lorber B: Listeriosis in
adults. A changing pattern. Report of
eight cases and review of the literature,
1968-1978. Rev Infect Dis 1980;2:207-227.
9. Hone R, Marshall P, Cran H: Listeria
monocytogenes meningitis in a healthy
adult. Journal of the Irish Medical Asso-
ciation 1972;65:81-82.
10. Nankervis GA: Bacterial meningitis.
Med Clin North A m 1974;58:581-592.
11. Larsson S, Cronberg S, Winblad S:
Clinical aspects on 64 cases of juvenile
and adult listeriosis in Sweden. Acta Med
Scand 1978;204:503-508.
12. Simpson JF: Listeria monocytogenes
meningitis: An opportunistic infection. J
Neurol Neurosurg Psychiatry 1971;34:
657-663.
13. Yersin BR, Glauser MP, Regli F: Infec-
tions a Listeria monocytogenes chez l'
adulte. Schweiz Med Wochenschr 1981;
111:1596-1602.
14. Scheld WM, Fletcher DD, Fink FN, et
al: Response to therapy in an experimen-
tal rabbit model of meningitis due to List-
eria monocytogenes. J Infect Dis 1979;
140:287-294.
15. Winslow DL, Pankey GA: In vitro ac-
tivities of trimethoprim and sulfamethox-
azole against Listeria m o n o c y t o g e n e s .
A n t i m i c r o b Agents Chemother 1982;22:
51-54.

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