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Keywords:

  • Listeria monocytogenes;
  • Listeriosis;
  • Clinical presentation

Abstract

  1. Top of page
  2. Abstract
  3. 1Introduction
  4. 2Sepsis
  5. 3CNS infection
  6. 4Endocarditis
  7. 5Gastroenteritis
  8. 6Localized infection
  9. 7Infection in pregnancy
  10. References

Listeria monocytogenes is an uncommon cause of illness in the general population. However, this bacterium is an important cause of severe infections in neonates, pregnant women, the elderly, transplant recipients and other patients with impaired cell-mediated immunity. Various clinical syndromes due to L. monocytogenes have been described such as sepsis, central nervous system infections, endocarditis, gastroenteritis and localized infections. A review of the clinical presentation of listeriosis is given in this paper.


1Introduction

  1. Top of page
  2. Abstract
  3. 1Introduction
  4. 2Sepsis
  5. 3CNS infection
  6. 4Endocarditis
  7. 5Gastroenteritis
  8. 6Localized infection
  9. 7Infection in pregnancy
  10. References

Listeria monocytogenes is an uncommon cause of illness in the general population. For some groups including neonates, pregnant women, the elderly, immunosuppressed transplant recipients, and other patients with impaired cell-mediated immunity, this bacterium is an important cause of life-threatening infections including sepsis and meningoencephalitis. However, up to 30% of adults and 54% of children and young adults contracting listeriosis have no apparent immunocompromising condition. It is noted that no significant differences were observed in the frequency of various symptoms between immunosuppressed patients, those with other underlying diseases not treated with immunosuppressive agents, and healthy patients [1–6].

Clinical syndromes described for L. monocytogenes infection in adults are shown in Table 1. Central nervous system (CNS) infections and sepsis are the most frequently observed clinical presentations. The most common form of listeriosis in immunosuppressed patients is reported to be bacteremia (52%), whereas 64% of previously healthy patients have CNS infection [1–4,6].

Table 1.  Clinical syndromes described for L. monocytogenes infection in adults
CNS disease
Meningitis
Meningoencephalitis
Abscess
Sepsis
Endocarditis
Gastroenteritis
Focal infections
Cellulitis
Lymphadenitis
Hepatitis and hepatic abscess
Myocarditis
Arteritis
Endophthalmitis
Cholecystis
Peritonitis
Splenic abscess
Pneumonia
Arthritis
Osteomyelitis
Pericarditis

We reviewed cases of listeriosis reported in Turkish journals between 1987 and 2001. We evaluated 32 cases including six unpublished cases. Clinical features of these 32 cases are shown in Table 2. The diagnosis was based on the isolation of L. monocytogenes from an infection site. Blood cultures were also positive in one case with meningitis and in two cases with meningoencephalitis [7–16].

Table 2.  Clinical presentation and mortality of listeriosis: available reports from Turkey between 1987 and 2001
  1. aMeningitis+sepsis in one case.

  2. bMeningoencephalitis+sepsis in two cases.

  3. cPneumonia and meningitis in two cases.

Number of cases32
Adult (>17 years)23
Child3
Neonate6
Sex 
Female4
Male12
Not reported16
Underlying condition 
Yes14
No11
Neonate6
Unidentified1
Underlying disease 
Leukemia3
Renal tx3
Chronic renal disease2
Multiple myeloma2
Pemphigus1
Coronary heart disease1
Cirrhosis1
Disgerminoma1
Clinical syndrome 
Meningitisa15
Meningoencephalitisb3
Sepsis15
Peritonitis2
Pneumoniac2
Outcome 
Cure (n/%)10/66
Death (n/%)5/33
Unidentified (n)17

Spontaneous bacterial peritonitis due to L. monocytogenes was identified in one case with cirrhosis and peritonitis in one case secondary to continuous ambulatory peritoneal dialysis [14]. The outcome in 15 cases could be identified but in 17 cases, the outcome was not reported. Of 15 cases, five (33%) died [7–16].

2Sepsis

  1. Top of page
  2. Abstract
  3. 1Introduction
  4. 2Sepsis
  5. 3CNS infection
  6. 4Endocarditis
  7. 5Gastroenteritis
  8. 6Localized infection
  9. 7Infection in pregnancy
  10. References

Sepsis without a localized infection is most common in compromised hosts, occurring in 21–43% of cases [1–4,6,17]. The patient often appears severely ill with fever, nausea, vomiting and malaise. Sepsis may progress to disseminated intravascular coagulation, acute respiratory distress syndrome and multi-organ system failure. The clinical features of listerial sepsis are similar to other types of bacterial sepsis and its diagnosis is based on a positive blood culture [1–4,11].

3CNS infection

  1. Top of page
  2. Abstract
  3. 1Introduction
  4. 2Sepsis
  5. 3CNS infection
  6. 4Endocarditis
  7. 5Gastroenteritis
  8. 6Localized infection
  9. 7Infection in pregnancy
  10. References

L. monocytogenes has tropism for the brain as well as for the meninges. Meningitis is the most frequently recognized listerial infection. Clinical syndromes due to L. monocytogenes in CNS are meningitis, meningoencephalitis and abscess formation.

Meningitis, with or without focal neurological signs, is the commonest form of CNS listeriosis. Clinical features of listerial meningitis are similar to that of more common etiologic agents. The onset of infection may be acute or subacute. The clinical picture is usually characterized by high fever, nuchal rigidity, movement disorders such as tremor and/or ataxia, and seizures. Seizures are seen more commonly than in other types of meningitis [1–6,17].

The most common non-meningitic form of CNS listeriosis is encephalitis, involving the brainstem, of which infection is named rhombencephalitis. Patients with listerial meningoencephalitis have subacute onset of illness that is characterized by focal neurological findings in the hindbrain, including ataxia and multiple cranial nerve abnormalities. Fever may be absent or unnoticeable in 15% of cases [1–3].

Analysis of cerebrospinal fluid (CSF) may show a negative Gram stain, pleocytosis, increased protein and normal glucose concentration. CSF culture positive for L. monocytogenes may develop late, and blood cultures may reveal the organism first [1–4]. Eighteen of 32 cases were diagnosed with CNS infection. Of these, nine cases could be evaluated on the basis of the results of CSF analysis (Table 3). Mononuclear cell predominance was observed in three of nine cases with listerial meningitis [7–10].

Table 3.  Analysis of the CSF of nine patients with meningitis [7–10]
VariableNumber of patients
White blood cell count (cells mm−3) 
<5003
500–9991
1000–19992
>20003
Differential count (%) 
Polynuclear predominance6
Mononuclear predominance3
Protein (mg dl−1) 
<1002
100–2995
>3002
Glucose (mg dl−1) 
>503
50–205
<201

L. monocytogenes may also be present within brain abscesses in about 10% of cases when the CNS is involved. Abscesses are particularly likely to occur in the immunosuppressed population, and the subsequent mortality rate is quite high. Twenty-five percent of patients also have meningitis, and almost all patients become bacteremic [1,2].

4Endocarditis

  1. Top of page
  2. Abstract
  3. 1Introduction
  4. 2Sepsis
  5. 3CNS infection
  6. 4Endocarditis
  7. 5Gastroenteritis
  8. 6Localized infection
  9. 7Infection in pregnancy
  10. References

Listerial endocarditis is observed in about 8% of infected adults. It occurs on both native and prosthetic valves. Listeria has been found to preferentially infect left-sided valves and is often a source of systemic bacterial emboli. The mortality rate for listerial endocarditis is approximately 50%. Patients who are diagnosed with listerial endocarditis should be evaluated for an underlying gastrointestinal tract pathology including cancer [1,2,18].

5Gastroenteritis

  1. Top of page
  2. Abstract
  3. 1Introduction
  4. 2Sepsis
  5. 3CNS infection
  6. 4Endocarditis
  7. 5Gastroenteritis
  8. 6Localized infection
  9. 7Infection in pregnancy
  10. References

In a healthy population, consumption of food contaminated with L. monocytogenes usually causes self-limiting febrile gastrointestinal disease presenting with nausea, vomiting and diarrhea. Several outbreaks of febrile gastroenteritis have demonstrated that L. monocytogenes can cause typical food-borne gastroenteritis. Patients become ill within 24–48 h of exposure to the contaminated food. The outbreaks have shown that rice salad, shrimp, chocolate milk, and corn salad are vehicles. This disease should be considered when stool cultures are negative in a patient with acute gastroenteritis. In a few instances, gastroenteritis leads to invasive listeriosis [1–4].

6Localized infection

  1. Top of page
  2. Abstract
  3. 1Introduction
  4. 2Sepsis
  5. 3CNS infection
  6. 4Endocarditis
  7. 5Gastroenteritis
  8. 6Localized infection
  9. 7Infection in pregnancy
  10. References

L. monocytogenes causes not only systemic disease, but also localized infections. Direct inoculation of the organism results in conjunctivitis, skin infection and lymphadenitis. Listerial bacteremia can lead to the development of peritonitis, cholecystitis, hepatitis, pleuritis, splenic abscesses, pericarditis, osteomyelitis and endophthalmitis. This localized infections can be seen as the result of septic emboli with listerial endocarditis. Patients having localized listerial infection usually suffer from an underlying disease [1–3,19].

7Infection in pregnancy

  1. Top of page
  2. Abstract
  3. 1Introduction
  4. 2Sepsis
  5. 3CNS infection
  6. 4Endocarditis
  7. 5Gastroenteritis
  8. 6Localized infection
  9. 7Infection in pregnancy
  10. References

During gestation, cell-mediated immunity is mildly impaired, and pregnant women are prone to develop listerial infection. Although the disease may occur at all stages of gestation, it is most commonly seen during the third trimester. L. monocytogenes may proliferate in the placenta and may escape from usual defence mechanisms.

If the patient has no risk factor for listerial infection, bacteremia is the most common manifestation of listeriosis in pregnancy. The common manifestations of disease are fever, headache, myalgia, arthralgia and malaise. Gastrointestinal symptoms, including abdominal pain and diarrhea, are less common.

Twenty-two percent of perinatal listerial infections result in stillbirth or neonatal death, and premature labor is common among women with listeriosis. Untreated listerial bacteremia is generally self-limiting, if it is complicated by amnionitis, the maternal fever may persist until the fetus is spontaneously or therapeutically aborted. Early diagnosis and antimicrobial treatment of listeriosis during pregnancy can still result in the birth of a healthy infant [1,2,6,20].

References

  1. Top of page
  2. Abstract
  3. 1Introduction
  4. 2Sepsis
  5. 3CNS infection
  6. 4Endocarditis
  7. 5Gastroenteritis
  8. 6Localized infection
  9. 7Infection in pregnancy
  10. References
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