Listeria monocytogenes meningitis in adults: Comprehensive review and successful therapy with ampicillin and trimethoprim-sulfamethoxazole in a systemic lupus erythematosus patient

Background: Listeria monocytogenes meningitis is a rare disease, but sometimes develops as an opportunistic infection in the immune-compromised hosts. Ampicillin is the most useful agent in the treatment of Listeria meningitis while the third generation cephalosporins are found ineffective in the treatment. Trimethoprim-sulfamethoxazole (TMP- SMX) is an alternative choice. Combination of ampicillin and gentamicin has been regarded as the standard therapy, while ampicillin in combination with TMP-SMX has rarely been recommended but may exert a better effect as reaching higher effective concentrations in the cerebrospinal fluid (CSF). Case Presentation: A 27-year-old woman has history of systemic lupus erythematosus for eight years. The patient was admitted to the hospital due to severe edema of both legs. Initially, there was no decreased visual acuity and muscle power, poor appetite, neck pain, fever, chills, headache, chest pain, sputum production nor arthralgia. However, high fever and new episode of seizure occurred in the ward. Then she was transferred to the intensive care unit. The computed tomography of the brain showed no definite acute intracranial lesion. The CSF routine analysis showed negative bacterium on the Gram stain; total protein, 126.7 mg/dL; glucose, 11 mg/dL and a white blood cell (WBC) count, 611/μL. The magnetic resonance imaging of the brain favored meningoencephalitis. Empirical antibiotic with ceftriaxone was given. Two days later, the CSF and blood cultures yielded Listeria monocytogenes with a penicillin-G MIC of 0.75 mg/L and a TMP-SMX MIC of 0.5 mg/L. Thus antibiotic was changed to ampicillin. Fever was subsided, but seizure episodes were still noted. The repeated CSF analysis showed an increased total protein to 156.1 mg/dL. CSF glucose was recovered to 66 mg/dl, yet WBC count was still 188/μL. The patient has impaired renal function with a creatinine level of 2.56 mg/dL, so gentamicin was not added to avoid adverse effect. Thus combination of ampicillin with TMP-SMX was used to treat the Listeria meningitis of the patient. The clinical condition of meningitis was improved. As difficulty in weaning for the ventilator, she was transferred to a respiratory care ward for a rehabilitation program after a treatment course of parental ampicillin for 30 days and TMP-SMX for 25 days intravenously. Discussion: Central nervous system (CNS) infection by L. monocytogenes in patients with SLE is rare and sometimes fatal. The most common presentation related to the disease was meningoencephalitis yet brain abscess was less frequent. Treatment with ampicillin is generally considered as the agent of choice. Most experts suggest adding gentamicin to ampicillin for treatment of severe Listeria infections such as bacteremia, CNS infection and endocarditis. Nevertheless, gentamicin was bacteriostatic for Listeria and was toxic to the patients, especially with renal function impairment. Conclusion: Trimethoprim-sulfamethoxazole could therefore be considered an alternative drug to obtain a bactericidal effect and to be used in combination with ampicillin, such as in our reported case eventually with a good clinical outcome. Here, we comprehensively review the epidemiology, risk factors, clinical presentation, effective therapy and outcome for Listeria meningitis in adults.