(607) A Rare Case of Severe Listeria Meningitis in the ICU With Meaningful Neurological Recovery

Introduction: Listeria monocytogenes infection is rare and has one of the highest mortality rates amongst food-borne illnesses in the USA. Listeriosis typically affects those who are immunocompromised, aged > 65, pregnant, and infants.1 We present a case of a critically ill female with listeria meningitis who made meaningful neurological recovery due to early recognition and proper antimicrobial treatment initiation.

Description: A 63-year-old female, with a past medical history of HTN, HLD, COPD, and breast cancer in remission, was admitted to the ICU due to respiratory failure requiring mechanical ventilation in a setting of progressive neurological symptoms. Before admission, the patient had returned from a trip to Portugal, where she reportedly ate cheese. She presented with severe back pain that progressed to severe gait instability, weakness, and encephalopathy. Head CT and MRI were consistent with leptomeningitis. Within 48 hours of her back pain, the patient was started empirically on acyclovir, ampicillin, ceftriaxone, and vancomycin for CNS coverage. Lumbar puncture was positive for listeria by PCR. Antimicrobials were then narrowed to TMP-SMX and Ampicillin for a total 21-day course. In addition, the patient completed a 4-day course of decadron 10 mg every 6 hours and a 5-day course of IV levetiracetam. Her ICU course was further complicated by dysautonomia, HTN, and ventilator dyssynchrony, which were managed effectively with pregabalin 50 mg twice per day, clevidipine drip, and midazolam boluses respectively. The patient was successfully extubated after 13 days. Repeat MRI showed significant interval improvement in CNS findings. At discharge to acute rehab, she had remarkable improvement in her mental status, quadriparesis, and urinary retention.

Discussion: Listeria meningitis has a high mortality rate if not recognized early. History is critical, like in our patient who recently traveled to an endemic area of Lisbon with reported Listeria outbreaks since 2014. Our case demonstrates the importance of early multi-modal antimicrobial initiation and management of other comorbidities to effectively treat severe listeria meningitis in the critical care setting.

References:
1. Rogalla, D. and Bomar, P.A. (2022) Listeria monocytogenes. StatPearls Publishing, Treasure Island (FL).