1. A Meal To Remember
Rob Bayer
October 16, 2018

2. 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

3. 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

4. Labs
CBC: WBC 11.2, Hgb 7.9, Plt 164 BMP: 134 | 105 | | 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)

5. 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 Nephrology involved
BCs from admission growing GPR in 1/4 -> Listeria

6. 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.

7. Listeria Outbreaks 2018 - Deli Ham (Oct 4): 4 ill, 1 dead
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
Cheese
Ricotta Salata Cheese
2011 – Cantaloupes: 147 ill, 33 deaths
Image: Reuters/NBC News

8. 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

9. 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.

10. References
CDC. “Listeria Outbreaks.” Lorber B. “Listeriosis.” Clininical Infectious Diseases. 1997; 24:1. Allecia J. “CDC Confirms 13 Dead in Listeria Canteloupe Outbreak” NBC News. 27 Sept 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.”