A Meal To Remember Rob Bayer October 16, 2018

Case – 92 yo M CC: Weakness, fall, diarrhea HPI: PMH: 1 day of explosive, watery, non-bloody diarrhea; 7-8 episodes/day Collapsed in driveway carrying groceries out of car -> ED No n/v, abdominal pain Felt chills while laying in driveway (1.5 hours in rain), ow denies f/s/c Had some ‘bad tasting’ sausage and ‘liver chops’ 1 day prior PMH: Afib (warfarin, ppm in place) CHF (EF 35%) CKD3 Pseduogout

Meds: Bumex, finasteride, valsartan, warfarin, carvedilol, vitamin D Social Hx: Former smoker, quit 1967; 1-2 glasses/wine ~once/week Lives alone, 2 adult sons in area Ambulates with a rollator Exam: HR 70s (paced), BP 145/52, RR 20, T 101.8 General: Frail appearing CV: Irregular, 2/6 SEM (not new) Lungs: CTAB Abd: s/nt/nd, no ascites

Labs CBC: WBC 11.2, Hgb 7.9, Plt 164 BMP: 134 | 105 | 87 4.2 | 19 | 2.2 CK 830 Procal 2.0 Lactate 1.3 UA unremarkable Enteric Panel: +C.Diff +E.Coli (EPEC) +Yersinia Enterocolitis +Plesiomonas shigella (1.4)

Initial Hospital Course HD1: Started on ciprofloxacin, oral vancomycin HD2: Ongoing fevers (100.1 – 101), acutely hypotensive -> improved with fluids Low stool output. AXR/CT without megacolon. Rectal vancomycin started. GI, General Surgery involved. HD 3: Cr up to 4.1. Nephrology involved BCs from admission growing GPR in 1/4 -> Listeria

Listeria Monocytogenes Small, Gram+ rod with “tumbling” motility. Grows as low as 4oC Most cases sporadic, but outbreaks associated with cheeses, deli meats, ice cream, others Most morbidity in neonates, immunocompromised, elderly Wide range of clinical disease: Asymptomatic Febrile gastroenteritis Bacteremia Abscess formation Meningitis/cerebritis/rhomboencephalitis Diagnosis: Culture, or PCR (hly gene/listeriolysin O). Stool culture also possible.

Listeria Outbreaks 2018 - Deli Ham (Oct 4): 4 ill, 1 dead 2017 - Vulto Creamery Soft Raw Milk Cheese 2016 Frozen Vegetables Raw Milk Packaged Salads 2015 Soft Cheeses Ice Cream 2014 Commercially Produced, Prepackaged Caramel Apples Bean Sprouts Cheese Dairy Products 2013 - Cheese 2012 - Ricotta Salata Cheese 2011 – Cantaloupes: 147 ill, 33 deaths Image: Reuters/NBC News

Listeria - Tx First Line: Ampicillin or Penicillin G Second Line: Trimethoprim-Sulfamethoxazole CNS infection, endocarditis, neonates: Add gentamycin Avoid steroids in CNS infection - ?increased mortality Duration: 2 weeks for bacteremia 3-4 weeks for CNS infection (gentamycin for ~7-14d, or until improving) Longer for immunocompromised, abscess, PJI, endocarditis, etc

Back To Our Patient No further fevers, BP normalized by HD3. No evidence for meningitis. Repeat blood cultures negative. Treated for gasteroenteritis + c.diff + listeriosis: 3 days ciprofloxacin 14 days ampicillin 2 days rectal vancomycin (stopped with return of antegrade function) 15 days oral vancomycin Hospital course complicated by ICU delirium, but eventually recovered well and discharged to TCU on HD 18. Creatinine normalized by time of discharge, and did not require dialysis.

References CDC. “Listeria Outbreaks.” https://www.cdc.gov/listeria/outbreaks/index.html Lorber B. “Listeriosis.” Clininical Infectious Diseases. 1997; 24:1. Allecia J. “CDC Confirms 13 Dead in Listeria Canteloupe Outbreak” NBC News. 27 Sept 2011 http://www.nbcnews.com/id/44689523/ns/health-food_safety/t/cdc-confirms-dead-listeria-cantaloupe-outbreak/ Shoham S, Bartlett J. “Listeria Monocytogenes.” Johns Hopkins ABX Guide. Thonnings S, et al. “Antibiotic treatment and mortality in patients with Listeria monocytogenes meningitis or bacteremia”. Clinical Microbiology and Infectious Diseases. 2016; 22:725. Youtube. “Listeria with Tumbling Motility.” https://www.youtube.com/watch?v=fjD_ruKmSfA