Clinical Report Listeria during Pregnancy Prof .Dr. Azar Danesh Dr. Sara Haghshenas 10 April 2017 Iran, Isfahan University of Medical Science

Case-Report … ( Listeria during Pregnancy ) خانم 31 ساله G3L1 Ab1 ( 1 x C/S ) حاملگی فعلی دو قلو با درد زايمانی تب و تاكی‌كاردی تهوع و استفراغ مراجعه کرد. به دلیلForcefull Contraction و پرزنتيشن بريچ و سزارین قبلی و نیز عدم تمایل بیمار به NVDدر سن حاملگی 25 هفته تحت سزارين اورژانس قرارگرفت. AFتيک مکونيوم؛ يكی از قل‌هاIUFD بود. حین سکشن بسيار mal odor بود. نمونه مایع آمنيون جهت کشت فرستاده شد. جواب نمونه ليستريا مونوسيتوژنز گزارش شد. تحت درمان آنتی بیوتيک مناسب قرار گرفت؛ و با حال عمومی خوب مرخص شد. 2

Case-Treatment … ( Listeria during Pregnancy ) خانم 31 ساله G3L1 Ab1 ( 1 x C/S ) هشت روز بعد، بیمار به دلیل درد پهلو و تب و تاكی‌كاردی مراجعه کرد. مشاوره عفونی انجام شد و مجددا آنتی بيوتيک مناسب تجویز شد. تحت Echo Cardiography قرار گرفت که نرمال بوده است. سونوگرافی داپلر عروق اندام تحتانی نرمال بود. به دليل تاكيكاردی تحت اسکن پرفیوژن قرار گرفت؛ كه PTE رد شد. 3

Case-Examination ( Listeria during Pregnancy ) سونوگرافی شكم و لگن سيستم پيلوكاليس در سمت چپ دو گانه و هيدرونفروز خفيف سمت چپ گزارش شد. ادم و التهاب بافت زير جلدي در محل سوچورها تصوير نواحي هايپواكو درسرتاسر محل سوچورها مشهود است؛ كه ميتواند مطرح كننده تغييراتpost surgical باشد. تصوير يك ناحيه هايپواكو با اينترنال اكو به ابعاد 46x43x20 و حجم 20 سی‌سی در سمت چپ محل سوچورها مطرح كننده وجود هماتوم است. 4

Case-Examination ( Listeria during Pregnancy ) سونوگرافی شكم و لگن شستشوی کامل جدار تخلیه هماتوم و ترمیم ثانویه هم انجام شد. در نهایت بیمار با حال عمومی خوب مرخص شد. M.D.C.T. Abdominal: LF side hydro uretronephrosis and adjacent fat stranding of LF–ureter CXR: NL 5

Listeria Bacteria ( Listeria during Pregnancy ) فیگور (بازسازی شده) یک باکتری لیستریا 6

Listeria Bacteria ( Listeria during Pregnancy ) Listeria is an aerobic and facultatively anaerobic, motile, beta–hemolytic, non–spore–forming, short, gram–positive rod that exhibits characteristic tumbling motility by light microscopy. Listeria is a facultative intracellular parasite. Listeria can initially enter cells by a mechanism that may involve binding of a bacterial protein (internalin) to E-cadherin (CDH1) on the host cell. 7

Listeria Bacteria ( Listeria during Pregnancy ) Listeria monocytogenes is an important bacterial pathogen in neonates, immunosuppressed patients, older adults, pregnant women, and occasionally, previously healthy individual. Listeria monocytogenes is thought of as a pathogen that causes invasive disease including meningitis, meningoencephalitis ….. ….. or bacteremia in immunosuppressed patients, individuals at the extremes of age including neonates and older adults, and pregnant women. However, Listeria is also a cause of self-limited febrile gastroenteritis in normal hosts who ingest high numbers of organisms. 8

Listeria Infection ( Listeria during Pregnancy ) Listeriosis in pregnancy occurs most commonly during the 3rd trimester. Fever, chills, and back pain may occur as presenting features of listeriosis in pregnant women. a nonspecific flu-like illness is the most common presentation. the infection may be mild, resolve without therapy, and the diagnosis missed if blood cultures are not obtained. Listerial infection in pregnant women can lead to fetal death, premature birth, or infected newborns. 9

the Situations (1) ( Listeria during Pregnancy ) Obstetricians may receive calls from pregnant patients who have ingested a food implicated in an outbreak of listeriosis that frequently receives wide media publicity. it is reasonable to reassure the asymptomatic patient and to recommend cultures of stool and blood for patients with any symptoms, including diarrhea. 10

the Situations (2) ( Listeria during Pregnancy )   the diagnosis of Listeria infection may be suspected from the clinical findings. However, there is no clinical way to separate Listeria infection from many other infectious diseases that can lead to fever and constitutional symptoms. 11

Consideration! ( Listeria during Pregnancy ) as a result, the diagnosis can only be established by culture. Stool culture for Listeria is not indicated in patients with systemic listeriosis. There are no specific clinical indicators of listerial bacteremia. Thus, obtaining blood cultures should be considered: in any pregnant woman who is febrile, when no alternative explanation. 12

the Treatment (1) ( Listeria during Pregnancy ) the antibiotic of choice for Listeria infection is: Ampicillin or Penicillin G Pregnant women with isolated listerial bacteremia can be treated with Ampicillin alone (2 gr I.V. every 4 hours). Patients who are allergic to Penicillin, should be skin tested and desensitized, or treated with Trimethoprim-Sulfamethoxazole. we treat listerial central nervous system (CNS) infections, endocarditis, and infections in neonates and immunocompromised patients with combination therapy, with the bactericidal agent Gentamicin being added to achieve synergy. 13

the Treatment (2) ( Listeria during Pregnancy ) for cotrimoxazole, usual dose ranges 10–20 mg/kg (based on the trimethoprim component) IV per day divided every 6 to 12 hours, with the higher end of the dosing range used in patients who are severely ill. Trimethoprim-sulfamethoxazole should be avoided during the first trimester, since folic acid metabolism may be affected, and during the last month of pregnancy to avoid kernicterus in the fetus. 14

the Treatment (3) ( Listeria during Pregnancy ) Imipenem and Meropenem have excellent vitro activity against Listeria. these drugs may prove to be useful for listerial infections. Linezolid is active against Listeria but clinical experience is limited to case reports. Vancomycin is an alternative. both Erythromycin and Tetracyclines have in vitro activity against Listeria. 15

the Summary (1): ( Listeria during Pregnancy ) for pregnant women (consumed a food that was recalled due to Listeria contamination) but who are afebrile and have mild symptoms that do not strongly suggest listeriosis. for Example; a minor gastrointestinal or influenza-like illness [ mild myalgias, mild nausea, vomiting or diarrhea ] expectant management (as for asymptomatic individuals) is reasonable. 16

the Summary (2): ( Listeria during Pregnancy ) for pregnant women exposed to L. monocytogenes, who have a fever >38.1°C (100.6°F) and other signs or symptoms consistent with listeriosis for whom no other cause of illness is known, should be simultaneously tested !! (with blood cultures) and treated for presumed listeriosis. 17

the Summary (3): ( Listeria during Pregnancy ) Blood–Cultures are the standard method for diagnosing infection, but if an amniocentesis is performed, it usually shows meconium staining and gram-positive rods. the response to therapy is monitored clinically: (temperature, clinical signs, and symptoms) FoodNet study, among women of reproductive age (15 to 44 years), pregnant women were at much greater risk of listeriosis than non-pregnant women. for unknown reasons, women with twin or triplet pregnancies are at increased risk (risk ratio 3.8 compared with single pregnancies) 18

a Clinical Analysis … ( Listeria during Pregnancy ) 16 patients by age–average (30.0 ± 4) years old all had an acute onset of illness (≤ 2 weeks), the median time from onset to presentation was 2.5 days. Clinical manifestations included fever (93.8% 15/16), leukocytosis (78.6% 11/14) chorioamnionitis (77.8% 7/9), gastrointestinal symptoms (37.5% 6/16) and fetal movement decrease (31.3% 5/16). a very high proportion of Adverse Pregnancy Outcomes occurred (15/16, 93.8%). 8 fetal losses, in total, and 7 neonates were complicated with listeria sepsis and treated successfully. 19

Thank You! for the attention any Question? Dr. Sara Haghshenas 10 April 2017 Iran, Isfahan University of Medical Science