Listeria monocytogenes Brain Abscess: Controversial Issues for the Treatment-Two Cases and Literature Review

Concomitant Listeria monocytogenes and Streptococcus equinus brain abscess in an immunocompetent individual: a case report

BACKGROUND

Listeria monocytogenes brain abscess is a rare phenomenon that is common in immunocompromised patients. Streptococcus equinus brain abscess has never been reported in the literature to our knowledge. In this case report, we describe a case of brain abscess secondary to Listeria monocytogenes and Streptococcus equinus in an immunocompetent patient with transient low CD4 count.

CASE PRESENTATION

A 27-year-old white, male patient, previously healthy, nonalcoholic, and occasional smoker, presented to the emergency department for confusion and headache. The patient was found to have a left parietal abscess, which was drained and the fluid was sent for culture. Culture grew Listeria monocytogenes and Streptococcus equinus. The patient was treated with intravenous ampicillin followed by oral amoxicillin for a total of 6 weeks. The CD4 count was low initially. However, after the resolution of the infection, the CD4 count came back within normal range. Another brain magnetic resonance imaging was done that showed a significantly decreased hyperintensity within the left parietal subcortical white matter at the site of surgery with significantly decreased enhancement and almost total resolution of the previous abscess.

CONCLUSION

Transient low CD4 count is a rare phenomenon that exposes patients to unusual and atypical infections. Since low CD4 count is transient, patients treated promptly recover from their illness. Our patient developed a Listeria monocytogenes and Streptococcus equinus brain abscess, which is considered rare and has not been previously described in the literature to our knowledge.

Imaging modalities in neurolisteriosis: a literature review

Listeriosis caused by Listeria monocytogenes due to its ability to withstand harsh conditions and form biofilms on post-processed food poses a serious public health issue. It typically manifests itself with fever and gastrointestinal symptoms, but it can escalate with life-threatening conditions, especially in immunocompromised patients, the elderly, oncologically sick, and even pregnant women. The diagnosis is based on blood and cerebrospinal fluid culture growth, but it presents significant challenges due to deceptive findings and low positivity rates, the golden standard includes molecular diagnostic tests such as real-time PCR and metagenomic next-generation sequencing, which offer higher sensitivity and rapid detection. Radiological imaging, particularly magnetic resonance imaging, can play a crucial role in diagnosis of central nervous system (CNS) invasion by L. monocytogenes, enabling the detection of characteristic CNS lesions. The aim of the paper was to sum up the imaging features of L. monocytogenes CNS invasions in conventional imaging techniques, which can potentially speed up the diagnostic workflow for patients presenting with neurological symptoms associated with L. monocytogenes infection, particularly when conventional tests yield inconclusive results.

Clinical characteristics and prognosis of pediatric Listeria monocytogenes meningitis based on 10-year data from a large children's hospital in China

This study aims to summarize the clinical characteristics and prognosis of Listeria monocytogenes (LM) meningitis in children in Chongqing, China. A retrospective analysis of the clinical data and follow-up results of 20 LM meningitis patients admitted to the Children's Hospital of Chongqing Medical University (CHCMU) from January 2012 to December 2022 was performed. The LM meningitis incidence rate was between 0 and 14.3 per 100,000 persons. The median age at onset was 8.98 months. There were five neonate cases, which all had perinatal abnormalities. Seven non-neonatal cases (7/15, 46.7%) had a documented history of contaminated food intake. One case had primary immunodeficiency. The most common symptoms were fever (20/20), altered consciousness (19/20), and vomiting (15/20). Seven cases had seizures, eight cases had cranial nerve involvement, eight cases had positive Babinski sign, and 10 cases had positive meningeal signs. The most common complications were hyponatremia (6/20), hypokalemia (6/20), respiratory failure (5/20), subdural effusion (3/20), and hydrocephalus (2/20). Treatment primarily involved monotherapy or combination therapy with meropenem (15/20) and ampicillin (10/20). Fifteen cases were treated with monotherapy or combination therapy using vancomycin. Twelve cases were successfully followed up from 10 months to 9 years and 6 months, and all had favorable long-term outcomes. LM meningitis incidence in children is low and with nonspecific clinical manifestations. Strengthening food hygiene and safety education, and avoiding infections during pregnancy are important to prevent LM infection in neonates and high-risk individuals. Meropenem and ampicillin are the preferred treatments. Early diagnosis and treatment can improve prognosis.IMPORTANCEThe incidence of LM meningitis is extremely low, and there is currently no standardized treatment. We conducted a retrospective analysis of ten years of data from CHCMU regarding diagnosed LM meningitis cases, aiming to provide clinical evidence for the diagnosis and treatment.

Clinical Characteristics and Treatment of Listeria monocytogenes Infections in the Central Nervous System

Purpose

Listeria monocytogenes infections are rare in the central nervous system (CNS) and frequently difficult-to-diagnose. Our goal is to assess CNS listeriosis patients' clinical characteristics, diagnosis, treatment, and prognosis.

Patients and Methods

Patients with CNS listeriosis admitted to the Department of neurology, the first medical center of the Chinese PLA general hospital, were enrolled in this study from March 2018 to August 2022.

Results

This study analyzed eight adults, including five males and three females. The average age of onset was (50.25 ± 11.52) years. The clinical manifestations included fever, headache, altered mental status, vomiting, seizures, neck rigidity, hemiplegia and cranial nerve palsies. Cerebrospinal fluid (CSF) tests revealed intracranial hypertension, elevated cell count and protein concentration, and decreased glucose levels. The positive rates of blood and CSF culture were 40% and 28.57%, respectively. All patients underwent CSF metagenomic next-generation sequencing (mNGS), with a 100% positive rate and the specific read number 12-20394. Magnetic resonance imaging (MRI) exhibited leptomeningitis, meningoencephalitis, and brain abscess, and no specific changes were discovered in two patients. All patients received antibiotic treatment, seven were cured, and one died.

Conclusion

Monitoring the proportion of monocytes in blood and mNGS results of CSF can play a crucial role in diagnosing pathogens. Early and sufficient application of two to three sensitive antibiotics with a BBB permeability of 20-30% for at least 2-3 months can significantly improve CNS listeriosis prognosis.

Cerebral abscess due to Listeria monocytogenes infection in silent diabetes mellitus: Case presentation, treatment and patient outcome

Introduction

Invasive listeriosis most often presents as bacteremia or neurolisteriosis. Cerebral infection mostly manifests as meningitis or meningoencephalitis, but cerebral abscesses are a rare manifestation.

Case presentation

We present the rare case of a 51-year old patient with progressive right sided hemiparesis caused by a cerebral abscess due to Listeria monocytogenes infection. The initially suspected cerebral ischemia or bleeding was ruled out. Magnetic resonance imaging led to the suspected diagnosis of an angiocentric lymphoma. An open cerebral biopsy revealed an intracranial abscess formation. After abscess evacuation and identification of Listeria monocytogenes, anti-infective treatment with ampicillin and gentamicin was started. After repeated cerebral imaging with signs of ongoing tissue inflammation after 6 weeks we chose to prolong the therapy with oral amoxicillin until resolution of signs of intracerebral inflammation after 12 weeks, documented by repeated cerebral magnetic resonance imaging. During hospitalization, the patient was diagnosed with diabetes mellitus type II and treatment was initiated. The patient was discharged without any persistent neurologic deficits.

Discussion

For the treatment of bacterial brain abscesses, 4-6 weeks of intravenous antimicrobial treatment after surgical drainage are recommended. However, first line therapy of invasive cerebral listeriosis is not well established. We decided to use a combined treatment using ampicillin and gentamicin, followed by prolonged oral treatment due to ongoing tissue inflammation.

Conclusion

No evidence-based treatment recommendations are available for brain abscess caused by Listeria monocytogenes. We report a case with favorable outcome after anti-infective ampicillin- and gentamicin-based therapy. Systematic assessment of treatment would be desirable.

Listerial Meningitis and Brain Abscess With Coexisting COVID-19 Infection in a Young, Immunocompetent Male: A Case Report

Listeria monocytogenes (LM) is a gram-positive intracellular pathogen that can cause central nervous system infections such as meningitis, meningoencephalitis, rhombencephalitis, or cerebritis. It rarely causes a brain abscess. Listerial meningitis and brain abscess most commonly occur in immunocompromised individuals, neonates, pregnant females, alcoholics, and the elderly. We present a unique case of a young immunocompetent male who presented with listerial meningitis and brain abscess. Coexisting coronavirus disease 2019 (COVID-19) infection was also present. Since LM was not included in the differentials, the standard antibiotic regimen started for the meningitis therapy was ineffective. Remdesivir was administered to treat the coexisting COVID-19 infection. When the lumbar tap polymerase chain reaction pointed out that the causative agent was Listeria, we shifted to ampicillin and gentamicin therapy, to which the patient responded very effectively.LM is an atypical cause of meningitis and brain abscesses. A high index of suspicion is therefore required for early detection and effective treatment of listerial meningitis and brain abscess.

Listeria Bacteremia Presenting With Cerebral Abscess and Endocarditis in an Elderly Patient With Chronic Immune Thrombocytopenia

Central nervous system involvement by Listeria monocytogenes usually presents as meningitis, meningoencephalitis or, less frequently, rhombencephalitis. Listerial brain abscesses are rare. Moreover, only 5-8% of listerial bacteremia is complicated by infective endocarditis (IE). A 70-year-old man with chronic immune thrombocytopenia (ITP) presented to our emergency department with acute onset of altered mental status and right-sided weakness. He was afebrile, with no heart murmurs or peripheral IE stigmata. Neurologic examination showed disorientation, expressive aphasia, and right-sided hemiparesis. Laboratory findings were unremarkable except for leukocytosis and hyponatremia. Brain MRI showed an irregular rim-enhancing lesion in the left frontal lobe, suspicious for a high-grade glial neoplasm. The lesion was excised, and he was started empirically on vancomycin, ceftriaxone, and metronidazole. After blood cultures grew Listeria monocytogenes, antibiotics were de-escalated to ampicillin and gentamicin. Echocardiography showed mitral valve vegetation. By Day 6, his mental status had improved. On Day 9, he was discharged to our inpatient rehabilitation center to complete six weeks on IV ampicillin and IV gentamicin. Pathology of the brain mass was subsequently reported as a listerial brain abscess. Chronic treatment with high-dose oral glucocorticoids and pre-existing ITP have been independently implicated as predisposing factors in listerial brain abscess. There is a propensity to misdiagnose listerial brain abscess as an intracranial neoplasm due to similar clinical/imaging findings. In addition, Listeria monocytogenes is an atypical cause of IE. Therefore, a high index of suspicion is necessary for early recognition and successful treatment of listerial brain abscess and listerial endocarditis in high-risk patients.

Listeria Monocytogenes Brain Abscesses in a Patient with Disseminated Non-Small Cellular Lung Cancer: MRI Findings

Brain abscesses caused by Listeria monocytogenes (LM) are very rare and carry a high mortality risk. We present a patient with disseminated non-small cellular lung cancer (NSCLC) and multiple unusual LM brain abscesses. These abscesses have multiple elongated peripherally enhancing lesions in a characteristic formation that is "worm or tramtrack-like" following the white matter fiber tracts.

NF-κB/ROS and ERK pathways regulate NLRP3 inflammasome activation in Listeria monocytogenes infected BV2 microglia cells

Listeria monocytogenes is a food-borne pathogen responsible for neurolisteriosis, which is potentially lethal in immunocompromised individuals. Microglia are the main target cells for L. monocytogenes in central nervous system (CNS). However, the precise mechanisms by which they trigger neuroinflammatory processes remain unknown. The BV2 microglial cell line and a murine model of L. monocytogenes infection were used for experiments in this study. Listeria monocytogenes induced pyroptosis and nucleotide binding and oligomerization, leucine-rich repeat, pyrin domain-containing 3 (NLRP3) inflammasome activation in BV2. Pharmacological inhibition of the NLRP3 inflammasome attenuated L. monocytogenes-induced pyroptosis. Moreover, inhibition of nuclear factor kappa-B (NF-κB) and extracellular regulated protein kinases (ERK) pathways induced a decrease in caspase1 activation and mature IL-1β-17 secretion. Our collective findings support critical involvement of the NLRP3 inflammasome in L. monocytogenes-induced neuroinflammation and, to an extent, ROS production. In addition, ERK and NF-κB signaling play an important role in activation of the NLRP3 inflammasome, both in vitro and in vivo.

Isolated Cerebral Mucormycosis in Immunocompetent Adults who Inject Drugs: Case Reports and Systematic Review of the Literature

Background

Mucormycosis involves life-threatening rapidly progressive angioinvasion with infiltration across tissue planes, resulting in necrosis and thrombosis, most commonly seen in the setting of immunocompromised states. We describe 2 cases of isolated cerebral mucormycosis in immunocompetent adults and describe this syndrome in detail in the context of a systemic literature review.

Methods

Using the criteria (1) isolated cerebral disease, (2) mucormycosis (by polymerase chain reaction, culture, or pathology), and (3) affected an immunocompetent individual, we identified 53 additional cases from 1969 to 2020.

Results

Of these 55 cases, ~60% occurred in men, >70% were in patients under age 35, 92% were associated with intravenous drug use, and >85% had infection centered in the basal ganglia. Many presented with cranial nerve deficits, headache, focal weakness, or altered mental status.

Conclusions

No patient survived without amphotericin, and steroid administration was associated with worse outcomes. Given the current opioid crisis, this syndrome may be seen more frequently.

Fever and temporal headache in a 70-year-old male with presumed large vessels vasculitis

BACKGROUND

Listeria monocytogenes is an opportunistic pathogen that causes severe infections of the Central Nervous System, such as meningitis or meningoencephalitis, and brain abscesses. Abscesses account for approximately 1-10% of CNS listerial infections and are observed in 1% of all listerial infections.

METHODS

We describe a case of 70-year-old male patient who had several admissions in different hospitals over the last 8 weeks.

RESULTS

He suffered from intermittent fever for over a month, recurrent episodes of headaches, disorientation and other neurological symptoms. His condition was misdiagnosed as giant cell arteritis and initially the patient was started on corticosteroids. MRI of the brain revealed the presence of multiple brain abscesses and the cerebrospinal fluid study confirmed the presence of Listeria Monocytogenes. The patient was started on ampicillin and he completed a 6 weeks' course of treatment.

CONCLUSIONS

This case emphasizes the need to include rare pathogens in the differential diagnosis when possible CNS infections are involved, as well as to show that in many cases some auto-immune diseases are overdiagnosed.

[Listeriosis of the Central nervous system]

OBJECT

To study the main causes of severe course and high mortality in patients with nervous form of listeriosis.

MATERIALS AND METHODS

The analysis of the course of Listeria meningoencephalitis (LM) in 36 patients aged from 9 to 85 years, who were treated in the Infectious clinical hospital No. 2 DZM (IKB No. 2 DZM). Along with standard examination methods, blood and cerebrospinal fluid (CSF) polymerase chain reaction tests were performed to identify Listeria monocytogenes. The sensitivity of the pathogen to antibiotics was determined by serial dilutions on the WalkAway 96 Plus device of Siemens, USA.

RESULTS

LM in 84% of cases developed in patients with disorders in the immune system, in particular, with infection with the human immunodeficiency virus - in 25% of cases. The clinical picture of the disease, changes in CSF were not typical for bacterial purulent meningitis of another etiology. It is noted that LM is characterized by early involvement of the substance and ventricles of the brain in the process.

CONCLUSION

Severe course and high mortality are due to atypical picture of the disease, late diagnosis, low bioavailability of the pathogen for antibiotics (intracellular persistence of the pathogen) and frequent resistance to them. The mortality from the nervous form of listeriosis was 33.3%.

Listeria monocytogenes rhombencephalitis in a patient with multiple sclerosis during fingolimod therapy

OBJECTIVE

To describe a case of Listeria monocytogenes rhombencephalitis in a patient receiving fingolimod.

METHODS

This is a case study.

RESULTS

Our patient developed acute rhombencephalitis with hydrocephalus induced with Listeria monocytogenes while on fingolimod. Shunt surgery was performed for the hydrocephalus and patient recovered partially after medical and surgical therapy.

CONCLUSION

We describe the first probable case of fingolimod-associated Listeria monocytogenes rhombencephalitis in a patient with multiple sclerosis. Clinicians should be aware of listeriosis and implement measures for its prevention.