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Listerial meningitis in a patient with undiagnosed acquired immunodeficiency syndrome: ampicillin should be added to the empirical antibiotic coverage
  1. S-H Tsai1,
  2. S-J Chu1,
  3. C-P Wu1,
  4. N-C Wang2
  1. 1Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
  2. 2Division of Infectious Disease, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
  1. Correspondence to:
 Dr N-C Wang
 No. 325, Cheng-Kung Road, Sec. 2, Neihu 114, Taipei, Taiwan; wang-spring{at}yahoo.com.tw

Abstract

Meningitis is an important differential diagnosis in patients with fever, headache, and/or altered consciousness in the emergency department (ED). With human immunodeficiency virus (HIV) infection becoming increasingly common, patients with acquired immunodeficiency syndrome (AIDS) need to be recognised promptly to facilitate the choice of appropriate antibiotic therapy for potential opportunistic infections. Physicians should be able to recognise a patient with undiagnosed AIDS who presents to the ED and perform further confirmational tests without violating the rights of the patient. Additional tests focusing on discovering potential opportunistic pathogens should be performed. Ampicillin should be added to the empirical regimen for the coverage of Listeria meningocerebritis, which should be considered in all potentially immunocompromised hosts with suggestive clinical presentations. Failure to recognise patients with AIDS and provide antibiotics active against L monocytogenes in such hosts may lead to a catastrophic outcome.

  • AIDS, acquired immunodeficiency syndrome
  • CSF, cerebrospinal fluid
  • ED, emergency department
  • HIV, human immunodeficiency virus, TMP-SMX, trimethoprim-sulfamethoxazole
  • Listeria monocytogenes
  • meningitis
  • myocarditis
  • acquired immunodeficiency syndrome
  • human immunodeficiency virus

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Meningitis is an important differential diagnosis in patients with fever, headache, and/or altered consciousness in the emergency department (ED). With human immunodeficiency virus (HIV) becoming increasingly common, patients with acquired immunodeficiency syndrome (AIDS) need to be recognised promptly to the choice of appropriate antibiotic therapy for potential opportunistic infections.

CASE REPORT

A 37 year old man was brought to the ED having had altered consciousness for 1 day. He had suffered intermittent fever and headache for 3 days prior to admission. He denied having any systemic illness and any use of tobacco or illicit drugs. On arrival, he appeared acutely ill, with a wasted appearance. His vital signs included: blood pressure 108/78 mmHg, respiratory rate 22 breaths/min, pulse rate 116 beat/min, and body temperature 39.4°C.g, Physical examination revealed a Glasgow Coma Scale score of 8 (E2M4V2), marked neck stiffness, and bilateral basal rales on auscultation to the chest. No facial palsy or focal neurological deficit was noticed. The laboratory studies are shown in table 1. Empirical antibiotic treatment with ceftriaxone 2.0 g every 12 hours was begun after two sets of blood cultures were obtained. The electrocardiography demonstrated nonspecific ST segment and T wave abnormalities, and a paroxysmal supraventricular tachycardia that was successfully terminated by adenosine 12 mg bolus intravenously. Chest radiography showed mild pulmonary congestion. Contrast enhanced computed tomography of brain disclosed meningeal enhancement without focal mass lesion. Cerebrospinal fluid (CSF) examination revealed leucocytosis, high protein concentration, and low glucose level, which were consistent with bacterial meningitis (table 1). No organisms were seen on gram and India ink staining. Antigens to Cryptococcus neoformans, Haemophilus influenzae, Streptococcuc pneumoniae, and Neisseria meningitidis were undetectable in the CSF.

Table 1

 Laboratory studies and cerebrospinal fluid (CSF) examinations obtained on admission

The patient required mechanical ventilation; during laryngoscopic examination for orotracheal intubation, oropharyngeal candidiasis was found. On the second day of hospitalisation, norepinephrine and dopamine were administered because of unstable haemodynamic status. HIV infection was confirmed by Western blotting. Blood CD4 cell count was 106/μl. PCR for Mycobacterium tuberculosis and cytomegalovirus from the CSF were negative, as was PCR for Pneumocystis jiroveci after tracheal aspiration. On the third day hospitalisation, preliminary blood and CSF cultures yielded Listeria monocytogenes, which was susceptible to penicillin, ampicillin, and trimethoprim-sulfamethoxazole (TMP-SMX). Ampicillin 2.0 gm every 4 h and TMP-SMX 150 mg every 6 h were started intravenously. Transthoracic echocardiography disclosed mild impairment of left ventricular systolic function, minimal pericardial effusion, and absence of vegetation. From the combination of elevated serum cardiac enzymes and because no underlying cause other than the L monocytogenes infection could be found, a diagnosis of Listeria myocarditis was made. Despite best supportive care, the patient died of septic shock with multiple organ dysfunction syndrome on the fifth day of hospitalisation. Necropsy was not performed.

DISCUSSION

Although the patient was not known to be HIV positive, the presence of oropharyngeal candidiasis and his wasted appearance should have suggested an underlying immunocompromised condition. Early recognition of the immunocompromised state (AIDS in this patient) by ED physicians may lead to prompt treatment and a change in the strategy of choosing suitable antibiotics.

L monocytogenes is an intracellular pathogen, known to cause meningitis or septicaemia in neonates and in adults with immunosuppressive conditions. Central nervous system diseases caused by Listeria include meningitis, diffuse encephalitis, and well localised abscess.1 An unique syndrome of brain stem encephalitis and rhomboencepahlitis characterised by cranial nerve palsies or pontomedullary signs may be observed.2 Patients with Listeria meningitis may have the following particular features: movement disorders (atatxia, tremors, and myoclonus), fluctuating mental status, and seizures, and blood cultures are more likely to be positive. Myocarditis caused by Listeria has been rarely reported.3 Ampicillin plus gentamicin have generally been recommended as the treatment of choice.4 Ampicillin combined with TMP-SMX has been reported to have a lower failure rate and few neurological sequelae than ampicillin combined with an aminoglycoside.5 Third generation cephalosporin and vancomycin are advocated as empirical therapy for community acquired bacterial meningitis in children and adults, owing to the emergence of penicillin and cephalosporin resistant S pneumoniae. Vancomycin is a second line therapy for L monocytogenes, but the emergence of resistant strains has been documented and is suboptimum for listeriosis.6L monocytogenes is inherent resistance to cephalosporin and these agents should not be used alone for empirical treatment of immunocompromised hosts and elderly patients. Ampicillin should be added to the empirical regimen for the coverage of L monocytogenes in adult patients with suspected impaired cell mediated immunity.

In conclusion, physicians should be able to recognise a patient with undiagnosed AIDS if they present to the ED, and provide further confirmation tests without violating the rights of the patient. Additional tests focusing on discovering potential opportunistic pathogens should be performed. Listeria meningocerebritis should be considered in all potentially immunocompromised hosts with suggestive clinical presentations, and ampicillin should be added to the empirical regimen for the coverage of this pathogen. Failure to recognise patients with AIDS and provide antibiotics active against L monocytogenes in such hosts may lead to a catastrophic outcome.

REFERENCES

Footnotes

  • Competing interests: there are no competing interests