1. L. monocytogenes meningitis in a child with juvenile idiopathic arthritis treated with a TNF- α antagonist J Banks 1, S Ladhani 1 M Hambly 2, T Bate 2, R Chakraborty 1 1 Department of Infectious Diseases, St. George’s Hospital, Blackshaw Rd, London SW17 OQT, England : 2 Department of Paediatrics, Epsom General Hospital, Dorking Rd, Epsom, Surrey, KT18 7EG, England Case Report Abstract Background –Onset of SOJIA Feb 2006, symptoms unresolved after prednisolone –Diagnosed May 2006 and commenced on methotrexate –Etanercept therapy initiated Dec 2006 after failure to respond Presentation –3 days after returning from family holiday in Tenerife –Profuse watery diarrhoea, vomiting and fever Initial management –Supportive: Intravenous fluids and antipyretics –Improvement over 48 hrs Day 3-4 of admission –Rapid deterioration: swinging fever, rigors, headache, neck stiffness Day 5 –Commenced on intravenous cefotaxime at referring hospital –Transferred to tertiary Paediatric Infectious Disease Unit overnight –Ongoing rapid deterioration with diplopia and altered conscious level –Abduction deficits bilaterally, right esotropia and papilloedema Day 6 – Addition of amoxicillin, aciclovir, ambisome, liposomal amphotericin, azithromycin, rifampicin, isoniazid, ethambutol, pyrazinamide to cover for atypical and opportunistic infections caused by organisms such as L.monocytogenes, herpes viruses, fungi and mycobacteria Day 7 – Untypable L. monocytogenes isolated from enriched broth culture of her cerebrospinal fluid 48hrs after transfer – Antibiotics rationalised to one week of gentamicin and three weeks of high dose amoxicillin given intravenously – Complete resolution of symptoms at the end of treatment References Conclusions Our case highlights the need for paediatricians to consider Listeria monocytogenes as a suspected pathogen in patients presenting with signs of meningitis and/or sepsis whilst on etanercept therapy. Our positive outcome provides support to the rationale for high dose amoxicillin to be added to the empirical treatment of these patients. InvestigationResults WBC7.5x10 9 /L Neutrophils6.0x10 9 /L ESR110 mm/hr CRP158 mg/L CT headNormal Blood culturesNegative on admission Urine cultureNegative Stool cultureLiquid specimen, negative culture CSFOpening pressure >40cmH 2 O Microscopy: 315 x 10 6 /L red blood cells, 1000 x 10 6 /L white blood cells – predominantly lymphocytes Protein 2.8 g/dl Glucose 13 mmol/L (blood sugar 5.4 mmol/L) Tumour necrosis factor alpha (TNF- α ) antagonists are increasingly used for the treatment of a wide range of immune-mediated diseases. However, there are concerns linking their use to a higher susceptibility to severe infections, particularly those caused by intracellular pathogens, with reported mortality rates of up to 30% 1. Etanercept, a fusion protein of the human TNF- α receptor 2 and the Fc portion of human immunoglobulin G, has been licensed and recommended for use in children with juvenile rheumatoid arthritis who either do not respond to, or who are intolerant of, methotrexate 2. We report a case of a 15 year old girl with anti-nuclear antibody positive systemic onset juvenile idiopathic arthritis (SOJIA) treated with prednisolone, methotrexate and etanercept, who presented with an acute gastroenteritis following a recent holiday in Tenerife. Discussion This is the first reported case of L. monocytogenes meningitis occurring in a child on etanercept therapy The use of etanercept and other TNF- α antagonists is increasing, with a concomitant increase in patients vulnerable to an array of unusual infections The use of etanercept in JIA has proven benefit 2, but much is still unknown about the long term risks and potential complications of anti TNF- α therapy. 1N Slifman, S Gershon, J-H Lee et al. ‘Listeria monocytogenes Infection as a Complication of Treatment With Tissue Necrosis Factor α-Neutralizing Agents.’ Arthritis & Rheumatism 2003;48(2):319-324 2 NICE. Guidance on the use of etanercept for the treatment of juvenile idiopathic arthritis. Technology Appraisal Guidance No.35 March 2002