A case of Listeria monocytogenes meningitis complicated by Hydrocephalus and Intraventricular hemorrhage: A review of treatment options and outcomes

Gerstein, Shawn; Gautam-Goyal, Pranisha; Goyal, Sameer

We present a case of a 62 year old female with a past medical history significant for multiple myeloma status post stem cell transplant 16 months prior and subsequently treated with pomalidomide and biweekly dexamethasone, and well controlled diabetes who initially was brought to the hospital by her family for headaches beginning that morning. Subsequently she became more lethargic, confused, and febrile to a temperature of 102 degrees Fahrenheit. On arrival to the emergency department she was found to be septic, with a fever of 103. 2 possible infiltrate on chest x-ray concerning for pneumonia, a urinalysis concerning for urinary tract infection, and a respiratory viral panel by PCR which was positive for coronavirus. The patient was initiated on vancomycin and piperacillin-tazobactam empirically. Initial CT scan of the head was largely unremarkable, showing only mild prominence of the ventricles and global cerebral volume loss (Fig. 1) . The patient was admitted to the medical wards, where she had rapid deterioration of her clinical status resulting in obtundation, acute hypoxic respiratory failure and septic shock requiring intubation and vasopressors. The infectious work up revealed Escherichia coli bacteremia thought to be secondary to a urinary source. On the second day of admission she was escalated to meropenem, but she continued to spike fevers with no improvement in mental status despite weaning off sedation. On the 6th day of admission, a repeat CT scan of her head revealed a new hydrocephalus with transependymal flow and questionable midbrain lucency (Fig. 2) . Subsequent Magnetic Resonance Imaging of the brain showed intraventricular hemorrhage. An external ventricular drain (EVD) was placed emergently by neurosurgery, and the resulting cerebrospinal fluid analysis showed 22 nucleated cells with 35 % neutrophils and 35 % lymphocytes, an elevated protein of 84 and low normal glucose of 49, though cerebrospinal fluid glucose was less than 60 percent of serum glucose. Cerebrospinal fluid PCR returned positive for Listeria monocytogenes and antimicrobials were changed to ampicillin, in addition to ceftriaxone to cover for E coli bacteremia. The patient was later started on gentamicin to add double coverage for Listeria and was given a dose of intrathecal amikacin. After 5 days the EVD was clamped, and when subsequent CT showed no further enlargement of the ventricles, the EVD was removed 8 days after originally having been placed. The patient showed improvement in mental status, first localizing to voice and then partially following commands. She was successfully extubated on hospital day 16. Upon further questioning, her spouse mentioned that the patient had been to an international barbecue a week prior to admission, and might have eaten uncooked food there, illuminating the possible source of infection.