A 75 year old female with a past medical history of coronary artery disease, hypertension, pre-diabetes mellitus, chronic obstructive pulmonary disease, prior left lobe cavitary lesion of unknown etiology, and tobacco use presented to the ED after being found nonresponsive on the couch. Family reports the patient said she had emesis the night before and felt as if she had a “stomach bug”. MRI shows T2 hyperintensities in the right MCA distribution. CSF results as follows.
| White Blood Cells | 300 |
| Red Blood Cells | 12 |
| Protein | 990 |
| Glucose | 79 |
| Cryptococcal antigen | Negative |
| Fungal culture | No fungi isolated |
| HSV | Negative |
Laboratory findings
CSF was sent to the microbiology lab for bacterial and fungal smears and cultures. No fungi were identified. Cryptococcal antigen was negative. HSV was also negative. CSF Gram stain shows gram positive bacilli. CSF culture showed a small, white, smooth, translucent appearance on sheep blood agar. In semi-solid agar after overnight incubation at room temperature, an umbrella shaped pattern of motility was seen. The organism was identified as Listeria monocytogenes by MALDI-TOF mass spectrometry.
Discussion
Listeria spp. is a genus of gram positive, aerobic, facultative intracellular, catalase positive bacteria. Listeria monocytogenes is a common colonizer in the environment (animals, soil, vegetable matter) and occasionally colonizes the human gastrointestinal tract. Listeria prefers colder environments and can be found as a food contaminant, most notably in milk, raw vegetables, cheese, and meats. In addition, colonized mothers can pass Listeria monocytogenes to the fetus.1
Listeria monocytogenes has 3 notable virulence factors:2
- Listeriololysin O: a hemolytic toxin that allows for survival within phagocytes
- Act A: induces actin polymerization that facilitate cell-to-cell spread
- Siderophores: organisms capable of scavenging iron from human transferrin to enhance cell growth
Neonates, immunocompromised individuals, and the elderly are more likely to acquire infection. Infection can present as bacteremia and CNS infections including meningitis, encephalitis, brain abscesses, and spinal cord infections. Listeria monocytogenes is the 3rd most common cause of meningitis behind Streptococcus pneumoniae and Neisseria Meningitidis. In neonates, an in-utero infection can cause granulomatous infantisepticum leading to systemic infection and stillbirth.3 Listeria monocytogenes can also present as gastroenteritis.
References
- Allerberger F. Listeria: growth, phenotypic differentiation and molecular microbiology. FEMS Immunol Med Microbiol. 2003;35(3):183-189. doi:10.1016/S0928-8244(02)00447-9
- Bailey & Scott’s Diagnostic Microbiology – Elsevier eBook on VitalSource, 14th Edition – 9780323433792. https://evolve.elsevier.com/cs/product/9780323433792?role=student
- Engelen-Lee JY, Koopmans MM, Brouwer MC, Aronica E, van de Beek D. Histopathology of Listeria Meningitis. Journal of Neuropathology & Experimental Neurology. 2018;77(10):950-957. doi:10.1093/jnen/nly077
-Nicholas Taylor, DO is a 1st year anatomic and clinical pathology resident at the University of Vermont Medical Center.
-Christi Wojewoda, MD, is the Director of Clinical Microbiology at the University of Vermont Medical Center and an Associate Professor at the University of Vermont.
Lablogatory 