Listeria monocytogenes: Difference between revisions

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Listeria monocytogenes
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βˆ’
== Background ==
 +
==Background==
βˆ’
=== Microbiology ===
 +
===Microbiology===
βˆ’
* Facultatively anaerobic, intracellular, non-sporulating, [[Has catalase test::catalase-positive]], [[Has oxidase test::oxidase-negative]], short, non-branching, [[Has Gram stain::Gram-positive]] [[Has shape::bacillus]] that grows readily on blood agar, producing incomplete Ξ²-hemolysis
  
βˆ’
** Can be [[Has Gram stain::Gram-variable]] and [[Has shape::pleiomorphic]]
  
βˆ’
** Can be initially misidentified as a diphtheroid
  
βˆ’
* 1 to 6 polar flagellae with '''tumbling motility''' at 25ΒΊC
  
βˆ’
** Demonstrates "umbrella" motility in the tube
  
βˆ’
* Can grow at refridgerator temperatures, as low as 4ΒΊC
  
βˆ’
* Doesn't grow on usual stool culture plates
  
βˆ’
* 13 serovars based on cellular O and flagellar H antigens
  
βˆ’
** Most disease from 4b, 1/2a, and 1/2b
  
   
  +
*Facultatively anaerobic, intracellular, non-sporulating, catalase [[Catalase::positive]], oxidase [[Oxidase::negative]], short, non-branching, [[Stain::Gram-positive]] [[Shape::bacillus]] that grows readily on blood agar, producing incomplete Ξ²-hemolysis
βˆ’
=== Epidemiology ===
  
  +
**Can be [[Stain::Gram-variable]] and [[Shape::pleomorphic]]
βˆ’
* In newborns, transmitted vertically from the mother
  
  +
**Can be initially misidentified as a diphtheroid
βˆ’
* In others, it is acquired from ingestion of contaminated food followed by mucosal invasion and bacteremia
  
  +
*1 to 6 polar flagellae with '''tumbling motility''' at 25ΒΊC
βˆ’
* The bacterium can grow at fridge temperatures
  
  +
**Demonstrates "umbrella" motility in the tube
βˆ’
* Both sporadic cases as well as foodborne outbreaks
  
  +
*Can grow at refrigerator temperatures, as low as 4ΒΊC
βˆ’
** Largest outbreak in Canada was associated with deli meats in 2008
  
  +
*Doesn't grow on usual stool culture plates
βˆ’
** Other outbreaks include ice cream (2015), frozen foods (2016), deli meat at a Druxy's in Princess Margaret Hospital (2018), prepackaged salads and kale (2018)
  
  +
*13 serovars based on cellular O and flagellar H antigens
βˆ’
** Refer to the [http://www.inspection.gc.ca/about-the-cfia/newsroom/food-recall-warnings/eng/1299076382077/1299076493846 Canada Food Inspection Agency] for current recalls
  
  +
**Most disease from 4b, 1/2a, and 1/2b
   
βˆ’
=== Pathophysiology ===
 +
===Epidemiology===
βˆ’
* In gut, it is phagocytosed into endothelial cells, then disseminates hematogenously
  
βˆ’
** Endocytosis is aided by LPXTG on the mucosal cell surface and helps it to adhere, as well as E-cadherin, which activates phagocytosis
  
βˆ’
*** Some hypothesize that uptake of Listeria is increased by concurrent GI infections
  
βˆ’
** Listeriolysin O, the major virulence factor, is a pore-forming toxin that prevents T-cell response
  
βˆ’
** Listeriolysin O and phspholipases help is escape the phagosome
  
βˆ’
** Once in the cytoplasm, they activate actin to carry them to the cell membrane, where they push out and form filopods which can be phagocytosed by nearby cells
  
βˆ’
** Moves from cell to cell without time spent outside
  
βˆ’
* In the CNS, it can invade the blood-brain barrier endothelial cells directly, or it can be transported across by cirtculating white blood cells ("Trojan horse" mechanism), or it can be inoculated into oral tissues followed by macrophage phagocytosis and invasion of cranial nerves
  
βˆ’
** The latter may be most important for rhomboencephalitis
  
βˆ’
* Immune response primarily cell-mediated rather than antibody-mediated, since the bacterium doesn't spend any time outside of cells
  
   
  +
*In newborns, transmitted vertically from the mother
βˆ’
=== Risk Factors ===
  
  +
*In others, it is acquired from ingestion of contaminated food followed by mucosal invasion and bacteremia
βˆ’
* Mostly around impaired cellular immunity
  
  +
*The bacterium can grow at fridge temperatures
βˆ’
* Lymphoma, pregnancy, AIDS, and corticosteroid immunosuppression, especially in transplant recipients
  
  +
*Both sporadic cases as well as foodborne outbreaks
βˆ’
* In AIDS and transplantation, may be prevented by ''Pneumocystis'' prophylaxis
  
  +
**Largest outbreak in Canada was associated with deli meats in 2008
βˆ’
* Use of anti-TNF-alpha medications
  
  +
**Other outbreaks include ice cream (2015), frozen foods (2016), deli meat at a Druxy's in Princess Margaret Hospital (2018), prepackaged salads and kale (2018)
βˆ’
* Antacids that lower stomach acidity
  
  +
**Refer to the [http://www.inspection.gc.ca/about-the-cfia/newsroom/food-recall-warnings/eng/1299076382077/1299076493846 Canada Food Inspection Agency] for current recalls
   
  +
===Pathophysiology===
βˆ’
== Clinical Presentation ==
  
   
  +
*In gut, it is phagocytosed into endothelial cells, then disseminates hematogenously
βˆ’
* Incubation period for invasive disease is 30 days (range 11 to 90)
  
  +
**Endocytosis is aided by LPXTG on the mucosal cell surface and helps it to adhere, as well as E-cadherin, which activates phagocytosis
  +
***Some hypothesize that uptake of Listeria is increased by concurrent GI infections
  +
**Listeriolysin O, the major virulence factor, is a pore-forming toxin that prevents T-cell response
  +
**Listeriolysin O and phspholipases help is escape the phagosome
  +
**Once in the cytoplasm, they activate actin to carry them to the cell membrane, where they push out and form filopods which can be phagocytosed by nearby cells
  +
**Moves from cell to cell without time spent outside
  +
*In the CNS, it can invade the blood-brain barrier endothelial cells directly, or it can be transported across by cirtculating white blood cells ("Trojan horse" mechanism), or it can be inoculated into oral tissues followed by macrophage phagocytosis and invasion of cranial nerves
  +
**The latter may be most important for rhomboencephalitis
  +
*Immune response primarily cell-mediated rather than antibody-mediated, since the bacterium doesn't spend any time outside of cells
   
βˆ’
=== Bacteremia ===
 +
===Risk Factors===
βˆ’
* Most common presentation outside of neonatal period is as a non-specific febrile illness
  
βˆ’
* Can cause non-specific febrile illness, often with a prodrome of diarrhea and nausea, myalgias
  
   
  +
*Mostly around impaired cellular immunity
βˆ’
=== Febrile gastroenteritis ===
  
  +
*[[Lymphoma]], [[pregnancy]] (especially third trimester), advanced [[HIV]], and [[Corticosteroids|corticosteroid]] immunosuppression, especially in transplant recipients
βˆ’
* Diarrhea, nausea, and vomiting, often with fever
  
  +
*In HIV and transplantation, may be prevented by ''[[Pneumocystis jirovecii|Pneumocystis]]'' prophylaxis
βˆ’
* Associated with foodborne outbreaks, including chocolate milk, cold corn and tuna salad, cold smoked trout, deli meat
  
  +
*Use of [[TNF-Ξ± inhibitors|anti-TNF-Ξ± medications]]
βˆ’
* Non-invasive in healthy patients
  
  +
*Antacids that lower stomach acidity
βˆ’
* Needs high innoculum
  
   
  +
==Clinical Manifestations==
βˆ’
=== CNS infection ===
  
βˆ’
* Causes a spectrum of CNS disease from meningitis to encephalitis to rhombencephalitis to abscesses
  
   
  +
*Incubation period for invasive disease is [[Usual incubation period::30 days]] (range [[Incubation period range::11 to 90 days]])
βˆ’
==== Meningitis ====
  
βˆ’
* A bacterial meningitis with high mortality, usually in very young, old >50 years, pregnant, or immunocompromised
  
βˆ’
** Malignancy is the most common risk factor, followed by transplantation, alcohol use disorder, immunosuppression, diabetes, and HIV
  
βˆ’
* Symptoms include subacute presention of fevers, nausea, and headache, with meningismus, and altered and fluctuating mental status
  
βˆ’
* Focal neurologic deficits
  
βˆ’
* Can sometimes have movement disorders, including ataxia, termors, and myoclonus, as well as seizures
  
βˆ’
* Two thirds have neutrophil-predominant CSF
  
βˆ’
* Mortality 15-30%
  
βˆ’
* Even if cured, can be left with permanent focal neurologic deficits
  
   
  +
===Bacteremia===
βˆ’
==== Encephalitis/Cerebritis ====
  
βˆ’
* Localized parenchymal infection that can lead to abscess formation
  
βˆ’
* Altered consciousness and cognitive dysfunction
  
βˆ’
* CSF cultures only positive about half the time
  
βˆ’
* Can mimic herpes encephalitis
  
   
  +
*Most common presentation outside of neonatal period is as a non-specific febrile illness
βˆ’
==== Rhombencephalitis ====
  
  +
*Can cause non-specific febrile illness, often with a prodrome of diarrhea and nausea, myalgias
βˆ’
* Brainstem encephalitis
  
βˆ’
* Can occur in health adults
  
βˆ’
* Diphasic illness, with prodrome of fever, headache, nausea, and vomiting lasting 4 days, followed by asymmetric cranial nerve deficits, cerebellar dysfunction, and focal neurological deficits
  
βˆ’
* Half of patients have respiratory failure
  
βˆ’
* CSF often only mildly abnormal
  
   
βˆ’
==== Brain abscess ====
 +
===Febrile Gastroenteritis===
βˆ’
* Often bacteremic and concurrent meningitis
  
βˆ’
* Can have abscesses in unusual locations, including subcortical abscesses of the thalamus, pons, and medulla
  
   
  +
*Diarrhea, nausea, and vomiting, often with fever
βˆ’
=== Spinal cord infection ===
  
  +
*Associated with foodborne outbreaks, including chocolate milk, cold corn and tuna salad, cold smoked trout, deli meat
βˆ’
* Rare cases
  
  +
*Non-invasive in healthy patients
  +
*Needs high innoculum
   
βˆ’
=== Endocarditis ===
 +
===CNS Infections===
βˆ’
* Can affect both native and prosthetic valves
  
βˆ’
* Mortality 50%
  
   
  +
*Causes a spectrum of CNS disease from meningitis to encephalitis to rhombencephalitis to abscesses
βˆ’
=== Neonatal listeriosis ===
  
βˆ’
* Stillbirth or spontaneous abortion is common, related to disseminated listeriosis called granulomatosis infantiseptica
  
βˆ’
** Widespread abscesses and granulomas, especially in liver and spleen
  
βˆ’
** ''Listeria'' can be isolated from meconium
  
βˆ’
* Can also present in prematurity as early-onset sepsis, probably acquired in utero
  
βˆ’
** ''Listeria'' can be isolated from conjunctiva, ear, nose, throat, meconium, amniotic fluid, placenta, blood, and sometimes CSF
  
βˆ’
* Can also present in term births as late-onset meningitis (~2 weeks post-partum)
  
βˆ’
** Probably acquired during delivery, since it is far less common with cesarean section
  
   
  +
====Meningitis====
βˆ’
=== Other sites of infection ===
  
βˆ’
* Conjunctivitis, skin infection, and lymphadenitis
  
βˆ’
* Hepatitis, liver abscesses, cholecystitis, perintonitis, splenic abscesses, pleural and pulmonary infections, septic arthritis, osteomyelitis, necrotizing fasciitis, pericarditis, myocarditits, arteritis, and endophthalmitis
  
   
  +
*A bacterial meningitis with high mortality, usually in very young, old >50 years, pregnant, or immunocompromised
βˆ’
== Diagnosis ==
  
  +
**Malignancy is the most common risk factor, followed by transplantation, alcohol use disorder, immunosuppression, diabetes, and HIV
βˆ’
* Can be directly seen in blood or CSF, and cultured
  
  +
*Symptoms include subacute presention of fevers, nausea, and headache, with meningismus, and altered and fluctuating mental status
βˆ’
** Grows on blood agar with incomplete beta-hemolysis
  
  +
*Focal neurologic deficits
βˆ’
** Can also do cold-enrichment, incubating the plates at 4 to 10 ΒΊC
  
  +
*Can sometimes have movement disorders, including ataxia, termors, and myoclonus, as well as seizures
βˆ’
** Growth may be inhibited by usual stool culture plates
  
  +
*Two thirds have neutrophil-predominant CSF
βˆ’
* Serology to listeriolysin O can be helpful in non-invasive disease
  
  +
*Mortality 15-30%
βˆ’
* PCR is possible for CSF and tissue, detecting the ''hly'' gene that encodes listeriolysin O
  
  +
*Even if cured, can be left with permanent focal neurologic deficits
βˆ’
* MRI can diagnose abscess (vs meningitis)
  
   
  +
====Encephalitis/Cerebritis====
βˆ’
== Management ==
  
βˆ’
* Good supportive care
  
βˆ’
* It has intrinsic resistance to cephalosporins
  
βˆ’
* [[Ampicillin]] 2 g IV q4h is standard
  
βˆ’
** Delayed bactericidal activity
  
βˆ’
* [[TMP-SMX]] 5/25 mg/kg IV q8h is second-line
  
βˆ’
* If severe, can combine [[ampicillin]] and [[TMP-SMX]]
  
βˆ’
** Lower failure rate with fewer neurological sequelae than amp/gent
  
βˆ’
* [[Vancomycin]] and [[meropenem]] can be considered third-line
  
βˆ’
* [[Daptomycin]] and [[linezolid]] have in vitro activity
  
βˆ’
* Duration
  
βˆ’
** Bacteremia: 2 weeks
  
βˆ’
** CNS involvement: 3 weeks
  
βˆ’
** Rhomboencephalitis or abscess: at least 6 weeks with serial imaging
  
βˆ’
** Endocarditis: 4 to 6 weeks
  
   
  +
*Localized parenchymal infection that can lead to abscess formation
βˆ’
== Prevention ==
  
  +
*Altered consciousness and cognitive dysfunction
βˆ’
* Follow good food preparation practices
  
  +
*CSF cultures only positive about half the time
  +
*Can mimic herpes encephalitis
   
  +
====Rhombencephalitis====
βˆ’
=== General Recommendations ===
  
βˆ’
==== Washing and Handling Food ====
  
βˆ’
* Rinse raw produce under tap-water, including produce you later peel
  
βˆ’
* Scrub firm produce with a clean brush
  
βˆ’
* Dry it with a clean cloth
  
   
  +
*Brainstem encephalitis
βˆ’
==== Clean and Safe Kitchen ====
  
  +
*Can occur in health adults
βˆ’
* Wash everything
  
  +
*Diphasic illness, with prodrome of fever, headache, nausea, and vomiting lasting 4 days, followed by asymmetric cranial nerve deficits, cerebellar dysfunction, and focal neurological deficits
βˆ’
* Make sure your freezer freezes
  
  +
*Half of patients have respiratory failure
βˆ’
* Clean fridge spills quickly
  
  +
*CSF often only mildly abnormal
   
βˆ’
==== Cook Meat Well ====
 +
====Brain Abscess====
βˆ’
* Cook it to safe internal temperature
  
βˆ’
* Use pre-packaged stuff as quickly as possible
  
βˆ’
* Use leftovers within 3 to 4 days
  
   
  +
*Often bacteremic and concurrent meningitis
βˆ’
=== Safer Foods ===
  
  +
*Can have abscesses in unusual locations, including subcortical abscesses of the thalamus, pons, and medulla
βˆ’
* No unpasteurized milk or milk products
  
   
  +
===Spinal Cord Infection===
βˆ’
=== Higher-risk Persons ===
  
βˆ’
==== Meats ====
  
βˆ’
* No hot dogs, deli meats, fermented or dry sausages, unless they are cooked to 165ΒΊF before serving
  
βˆ’
* Avoid getting hot dog juice or other meat juice on things
  
βˆ’
* Don't eat pate or meat spreads that aren't canned, and refridgerate after opening
  
   
  +
*Rare cases
βˆ’
==== Cheeses ====
  
βˆ’
* Only eat soft cheeses if they are made with pasteurized milk
  
   
βˆ’
==== Seafood ====
 +
===Endocarditis===
βˆ’
* No refrigerated smoked seafood unless it is cooked or canned
  
βˆ’
* Canned seafood is safe
  
   
  +
*Can affect both native and prosthetic valves
βˆ’
==== Melons ====
  
  +
*Mortality 50%
βˆ’
* Wash hands after handling the melon
  
  +
βˆ’
* Scrub the melon clean and drug it well, sanitizing the brush between uses
  
  +
===Neonatal Listeriosis===
βˆ’
* Don't keep cut pieces for longer than 7 days
  
  +
βˆ’
* Don't leave out for longer than 4 hours
  
  +
*Infection in first and second trimester frequently result in intrauterine fetal death
  +
*Later in pregnancy, stillbirth or spontaneous abortion is common
  +
*Presents in prematurity or neonatal period as early-onset sepsis, likely acquired in utero during third trimester
  +
**Disseminated listeriosis called '''granulomatosis infantiseptica'''
  +
**Widespread abscesses and granulomas, especially in lungs, liver, and spleen
  +
**Can have a miliary pattern on chest x-ray
  +
**''Listeria'' can be isolated from conjunctiva, ear, nose, throat, meconium, amniotic fluid, placenta, blood, and sometimes CSF
  +
*Can also present in term births as late-onset meningitis (~2 weeks post-partum)
  +
**Probably acquired during delivery, since it is far less common with cesarean section
  +
*Mortality in neonatal infections is high at around 45%
  +
  +
===Other Sites of Infection===
  +
  +
*Conjunctivitis, skin infection, and lymphadenitis
  +
*Hepatitis, liver abscesses, cholecystitis, perintonitis, splenic abscesses, pleural and pulmonary infections, septic arthritis, osteomyelitis, necrotizing fasciitis, pericarditis, myocarditits, arteritis, and endophthalmitis
  +
  +
==Diagnosis==
  +
  +
*Can be directly seen in blood or CSF, and cultured
  +
**Grows on blood agar with incomplete beta-hemolysis
  +
**Can also do cold-enrichment, incubating the plates at 4 to 10 ΒΊC
  +
**Growth may be inhibited by usual stool culture plates
  +
*Serology to listeriolysin O can be helpful in non-invasive disease
  +
*PCR is possible for CSF and tissue, detecting the ''hly'' gene that encodes listeriolysin O
  +
*MRI can diagnose abscess (vs meningitis)
  +
  +
==Management==
  +
  +
*Good supportive care
  +
*It has intrinsic resistance to cephalosporins
  +
*[[Ampicillin]] 2 g IV q4h is standard
  +
**Delayed bactericidal activity
  +
*[[TMP-SMX]] 5/25 mg/kg IV q8h is second-line
  +
*If severe, can combine [[ampicillin]] and [[TMP-SMX]]
  +
**Lower failure rate with fewer neurological sequelae than amp/gent
  +
*[[Vancomycin]] and [[meropenem]] can be considered third-line
  +
*[[Daptomycin]] and [[linezolid]] have in vitro activity
  +
*Duration
  +
**Bacteremia: 2 weeks
  +
**CNS involvement: 3 weeks
  +
**Rhomboencephalitis or abscess: at least 6 weeks with serial imaging
  +
**Endocarditis: 4 to 6 weeks
  +
  +
==Prevention==
  +
  +
*Follow good food preparation practices
  +
  +
===General Recommendations===
  +
====Washing and Handling Food====
  +
  +
*Rinse raw produce under tap-water, including produce you later peel
  +
*Scrub firm produce with a clean brush
  +
*Dry it with a clean cloth
  +
  +
====Clean and Safe Kitchen====
  +
  +
*Wash everything
  +
*Make sure your freezer freezes
  +
*Clean fridge spills quickly
  +
  +
====Cook Meat Well====
  +
  +
*Cook it to safe internal temperature
  +
*Use pre-packaged stuff as quickly as possible
  +
*Use leftovers within 3 to 4 days
  +
  +
===Safer Foods===
  +
  +
*No unpasteurized milk or milk products
  +
  +
===Higher-risk Persons===
  +
====Meats====
  +
  +
*No hot dogs, deli meats, fermented or dry sausages, unless they are cooked to 165ΒΊF before serving
  +
*Avoid getting hot dog juice or other meat juice on things
  +
*Don't eat pate or meat spreads that aren't canned, and refridgerate after opening
  +
  +
====Cheeses====
  +
  +
*Only eat soft cheeses if they are made with pasteurized milk
  +
  +
====Seafood====
  +
  +
*No refrigerated smoked seafood unless it is cooked or canned
  +
*Canned seafood is safe
  +
  +
====Melons====
  +
  +
*Wash hands after handling the melon
  +
*Scrub the melon clean and drug it well, sanitizing the brush between uses
  +
*Don't keep cut pieces for longer than 7 days
  +
*Don't leave out for longer than 4 hours
   
 
{{DISPLAYTITLE:''Listeria monocytogenes''}}
  
{{DISPLAYTITLE:''Listeria monocytogenes''}}

Latest revision as of 09:51, 26 November 2020

Background

Microbiology

  • Facultatively anaerobic, intracellular, non-sporulating, catalase positive, oxidase negative, short, non-branching, Gram-positive bacillus that grows readily on blood agar, producing incomplete Ξ²-hemolysis
    • Can be Gram-variable and pleomorphic
    • Can be initially misidentified as a diphtheroid
  • 1 to 6 polar flagellae with tumbling motility at 25ΒΊC
    • Demonstrates "umbrella" motility in the tube
  • Can grow at refrigerator temperatures, as low as 4ΒΊC
  • Doesn't grow on usual stool culture plates
  • 13 serovars based on cellular O and flagellar H antigens
    • Most disease from 4b, 1/2a, and 1/2b

Epidemiology

  • In newborns, transmitted vertically from the mother
  • In others, it is acquired from ingestion of contaminated food followed by mucosal invasion and bacteremia
  • The bacterium can grow at fridge temperatures
  • Both sporadic cases as well as foodborne outbreaks
    • Largest outbreak in Canada was associated with deli meats in 2008
    • Other outbreaks include ice cream (2015), frozen foods (2016), deli meat at a Druxy's in Princess Margaret Hospital (2018), prepackaged salads and kale (2018)
    • Refer to the Canada Food Inspection Agency for current recalls

Pathophysiology

  • In gut, it is phagocytosed into endothelial cells, then disseminates hematogenously
    • Endocytosis is aided by LPXTG on the mucosal cell surface and helps it to adhere, as well as E-cadherin, which activates phagocytosis
      • Some hypothesize that uptake of Listeria is increased by concurrent GI infections
    • Listeriolysin O, the major virulence factor, is a pore-forming toxin that prevents T-cell response
    • Listeriolysin O and phspholipases help is escape the phagosome
    • Once in the cytoplasm, they activate actin to carry them to the cell membrane, where they push out and form filopods which can be phagocytosed by nearby cells
    • Moves from cell to cell without time spent outside
  • In the CNS, it can invade the blood-brain barrier endothelial cells directly, or it can be transported across by cirtculating white blood cells ("Trojan horse" mechanism), or it can be inoculated into oral tissues followed by macrophage phagocytosis and invasion of cranial nerves
    • The latter may be most important for rhomboencephalitis
  • Immune response primarily cell-mediated rather than antibody-mediated, since the bacterium doesn't spend any time outside of cells

Risk Factors

Clinical Manifestations

  • Incubation period for invasive disease is 30 days (range 11 to 90 days)

Bacteremia

  • Most common presentation outside of neonatal period is as a non-specific febrile illness
  • Can cause non-specific febrile illness, often with a prodrome of diarrhea and nausea, myalgias

Febrile Gastroenteritis

  • Diarrhea, nausea, and vomiting, often with fever
  • Associated with foodborne outbreaks, including chocolate milk, cold corn and tuna salad, cold smoked trout, deli meat
  • Non-invasive in healthy patients
  • Needs high innoculum

CNS Infections

  • Causes a spectrum of CNS disease from meningitis to encephalitis to rhombencephalitis to abscesses

Meningitis

  • A bacterial meningitis with high mortality, usually in very young, old >50 years, pregnant, or immunocompromised
    • Malignancy is the most common risk factor, followed by transplantation, alcohol use disorder, immunosuppression, diabetes, and HIV
  • Symptoms include subacute presention of fevers, nausea, and headache, with meningismus, and altered and fluctuating mental status
  • Focal neurologic deficits
  • Can sometimes have movement disorders, including ataxia, termors, and myoclonus, as well as seizures
  • Two thirds have neutrophil-predominant CSF
  • Mortality 15-30%
  • Even if cured, can be left with permanent focal neurologic deficits

Encephalitis/Cerebritis

  • Localized parenchymal infection that can lead to abscess formation
  • Altered consciousness and cognitive dysfunction
  • CSF cultures only positive about half the time
  • Can mimic herpes encephalitis

Rhombencephalitis

  • Brainstem encephalitis
  • Can occur in health adults
  • Diphasic illness, with prodrome of fever, headache, nausea, and vomiting lasting 4 days, followed by asymmetric cranial nerve deficits, cerebellar dysfunction, and focal neurological deficits
  • Half of patients have respiratory failure
  • CSF often only mildly abnormal

Brain Abscess

  • Often bacteremic and concurrent meningitis
  • Can have abscesses in unusual locations, including subcortical abscesses of the thalamus, pons, and medulla

Spinal Cord Infection

  • Rare cases

Endocarditis

  • Can affect both native and prosthetic valves
  • Mortality 50%

Neonatal Listeriosis

  • Infection in first and second trimester frequently result in intrauterine fetal death
  • Later in pregnancy, stillbirth or spontaneous abortion is common
  • Presents in prematurity or neonatal period as early-onset sepsis, likely acquired in utero during third trimester
    • Disseminated listeriosis called granulomatosis infantiseptica
    • Widespread abscesses and granulomas, especially in lungs, liver, and spleen
    • Can have a miliary pattern on chest x-ray
    • Listeria can be isolated from conjunctiva, ear, nose, throat, meconium, amniotic fluid, placenta, blood, and sometimes CSF
  • Can also present in term births as late-onset meningitis (~2 weeks post-partum)
    • Probably acquired during delivery, since it is far less common with cesarean section
  • Mortality in neonatal infections is high at around 45%

Other Sites of Infection

  • Conjunctivitis, skin infection, and lymphadenitis
  • Hepatitis, liver abscesses, cholecystitis, perintonitis, splenic abscesses, pleural and pulmonary infections, septic arthritis, osteomyelitis, necrotizing fasciitis, pericarditis, myocarditits, arteritis, and endophthalmitis

Diagnosis

  • Can be directly seen in blood or CSF, and cultured
    • Grows on blood agar with incomplete beta-hemolysis
    • Can also do cold-enrichment, incubating the plates at 4 to 10 ΒΊC
    • Growth may be inhibited by usual stool culture plates
  • Serology to listeriolysin O can be helpful in non-invasive disease
  • PCR is possible for CSF and tissue, detecting the hly gene that encodes listeriolysin O
  • MRI can diagnose abscess (vs meningitis)

Management

  • Good supportive care
  • It has intrinsic resistance to cephalosporins
  • Ampicillin 2 g IV q4h is standard
    • Delayed bactericidal activity
  • TMP-SMX 5/25 mg/kg IV q8h is second-line
  • If severe, can combine ampicillin and TMP-SMX
    • Lower failure rate with fewer neurological sequelae than amp/gent
  • Vancomycin and meropenem can be considered third-line
  • Daptomycin and linezolid have in vitro activity
  • Duration
    • Bacteremia: 2 weeks
    • CNS involvement: 3 weeks
    • Rhomboencephalitis or abscess: at least 6 weeks with serial imaging
    • Endocarditis: 4 to 6 weeks

Prevention

  • Follow good food preparation practices

General Recommendations

Washing and Handling Food

  • Rinse raw produce under tap-water, including produce you later peel
  • Scrub firm produce with a clean brush
  • Dry it with a clean cloth

Clean and Safe Kitchen

  • Wash everything
  • Make sure your freezer freezes
  • Clean fridge spills quickly

Cook Meat Well

  • Cook it to safe internal temperature
  • Use pre-packaged stuff as quickly as possible
  • Use leftovers within 3 to 4 days

Safer Foods

  • No unpasteurized milk or milk products

Higher-risk Persons

Meats

  • No hot dogs, deli meats, fermented or dry sausages, unless they are cooked to 165ΒΊF before serving
  • Avoid getting hot dog juice or other meat juice on things
  • Don't eat pate or meat spreads that aren't canned, and refridgerate after opening

Cheeses

  • Only eat soft cheeses if they are made with pasteurized milk

Seafood

  • No refrigerated smoked seafood unless it is cooked or canned
  • Canned seafood is safe

Melons

  • Wash hands after handling the melon
  • Scrub the melon clean and drug it well, sanitizing the brush between uses
  • Don't keep cut pieces for longer than 7 days
  • Don't leave out for longer than 4 hours
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