Letter to the Editor
Rhombencephalitis due to Listeria monocytogenes: A case study
A propósito de un caso: rombencefalitis por Listeria monocitogenes
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Gómez Eguílaz, M.Á. López Pérez, O. Blasco Martínez, M.S. García De Carlos" "autores" => array:4 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Gómez Eguílaz" "email" => array:1 [ 0 => "mgomeze@riojasalud.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M.Á." "apellidos" => "López Pérez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "O." "apellidos" => "Blasco Martínez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "M.S." "apellidos" => "García De Carlos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Hospital San Pedro de Logroño, La Rioja, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Hospital Fundación de Calahorra, La Rioja, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "A propósito de un caso: rombencefalitis por Listeria monocitogenes" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 793 "Ancho" => 861 "Tamanyo" => 77717 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Head CT. Oedema and small fourth ventricle: signs of intracranial hypertension.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Listeria monocytogenes</span> normally affects multiple organs. In exceptional cases, it may involve the brainstem in a condition called rhombencephalitis. Rhombencephalitis due to <span class="elsevierStyleItalic">Listeria</span> is a rare disease that strikes previously healthy individuals.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The course of the disease is biphasic<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>; the patient initially presents non-specific virus-like symptoms, after which neurological symptoms occur (initially, progressive brainstem signs and cranial nerve deficits followed by obnubilation and seizures).</p><p id="par0010" class="elsevierStylePara elsevierViewall">Diagnosis is not easy. In up to 60% of all cases, CT scan results are normal but pontine involvement is typical in MRI scans. Blood culture results may be negative<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and lumbar puncture may yield a low white blood cell count and normal protein and glucose levels in CSF.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Differential diagnosis is performed to rule out infection (TB, fungus, HSV), inflammatory processes, lymphoma, or paraneoplastic syndromes. Treatment consists of intravenous ampicillin<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> dosed at 150 to 300<span class="elsevierStyleHsp" style=""></span>mg/kg/day over at least 6 weeks. Its prognosis depends on how early treatment is started. Mortality is 100% in untreated cases and 30% in treated ones. Neurological sequelae persist in 61% of the total patients.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Our patient was a 50-year-old man with no relevant medical history who came to the emergency department with symptoms of dizziness without spinning sensation and right facial paraesthesia. The only finding from the examination was right facial hypoaesthesia. As the head CT revealed no anomalies, the patient was discharged.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Five days later, he returned to the emergency room with diplopia and low-grade fever. In addition to sensory alterations, the examination found that he could not walk in tandem gait. Doctors performed a laboratory analysis, chest radiography, and electroencephalography; all yielded normal results. CSF analysis found 10 white cells (75% neutrophils), a glucose level of 58<span class="elsevierStyleHsp" style=""></span>mg/dL, and protein level of 51.8<span class="elsevierStyleHsp" style=""></span>mg/dL. Given a suspected diagnosis of acute meningoencephalitis, the patient was admitted and initially treated with antibiotics and acyclovir. He remained stable during hospitalisation with no infectious signs and no changes in the examination. To complete the work-up, we performed serology tests (HIV, <span class="elsevierStyleItalic">Coxiella</span>, <span class="elsevierStyleItalic">Bartonella</span>, hepatitis B, cytomegalovirus, herpesvirus 1, 2 and 6, Epstein-Barr virus, and <span class="elsevierStyleItalic">Leptospira</span>); autoimmunity test, blood cultures, and CSF cultures; all results were negative. A second cerebrospinal fluid examination found 36 white cells (83% lymphocytes), glucose 58<span class="elsevierStyleHsp" style=""></span>mg/dL, proteins 57.7<span class="elsevierStyleHsp" style=""></span>mg/dL, and ADA 5.9<span class="elsevierStyleHsp" style=""></span>U/L. Brain MRI (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) showed inflammatory lesions in the cerebellar peduncles.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Based on negative results from cultures and the suspicion of a non-infectious inflammatory process, doctors suspended acyclovir and antibiotics. On the fifth day the patient's condition worsened, and he presented ataxia, increased nystagmus and right-sided dysmetria, so doctors started dexamethasone treatment. The patient improved, although diplopia, hypoaesthesia, and mild right-sided dysmetria persisted. He was then discharged with pending tests: serology for hepatitis C, <span class="elsevierStyleItalic">Listeria</span>, and <span class="elsevierStyleItalic">Legionella</span>; oligoclonal bands; routine MRI; full-body PET scan).</p><p id="par0035" class="elsevierStylePara elsevierViewall">Two days later he was hospitalised again with headache, restlessness, and low-grade fever. The key finding in the examination was dysarthria. A new head CT (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) revealed oedema and a small fourth ventricle, signs compatible with intracranial hypertension. The patient was referred to the neurosurgery department and underwent emergency decompressive craniectomy. CSF sample cultures were negative, but the culture repeated a week later tested positive for a <span class="elsevierStyleItalic">Listeria</span> strain sensitive to ampicillin. The patient's condition improved after treatment with that antibiotic and he was asymptomatic 6 months later.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">The point to ponder in this case is the precise fact that infection had been ruled out due to negative results from all of the cultures. Given a similar case, doctors should recall that MRI may prove useful in the search for symptom aetiology when characteristic lesions are present (brainstem inflammation, especially in the pons near the fourth ventricle).</p><p id="par0045" class="elsevierStylePara elsevierViewall">In conclusion cases of meningoencephalitis, especially those showing brainstem symptoms and MRI evidence of typical pontine lesions, should be treated with ampicillin to cover <span class="elsevierStyleItalic">Listeria</span> even if culture results are negative.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Gómez Eguílaz M, López Pérez MÁ, Blasco Martínez O, García De Carlos MS. A propósito de un caso: rombencefalitis por <span class="elsevierStyleItalic">Listeria monocitogenes</span>. Neurología. 2014;29:250–251.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 846 "Ancho" => 927 "Tamanyo" => 80400 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">T1-weighted brain MRI. Lesion suggesting inflammation of the cerebellar peduncles.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 793 "Ancho" => 861 "Tamanyo" => 77717 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Head CT. Oedema and small fourth ventricle: signs of intracranial hypertension.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical manifestations and diagnosis of <span class="elsevierStyleItalic">Listeria monocytogenes</span> infection" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M.S. 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| 2023 September | 194 | 11 | 205 |
| 2023 August | 134 | 8 | 142 |
| 2023 July | 169 | 9 | 178 |
| 2023 June | 153 | 12 | 165 |
| 2023 May | 189 | 6 | 195 |
| 2023 April | 251 | 17 | 268 |
| 2023 March | 182 | 18 | 200 |
| 2023 February | 140 | 8 | 148 |
| 2023 January | 110 | 19 | 129 |
| 2022 December | 103 | 18 | 121 |
| 2022 November | 88 | 14 | 102 |
| 2022 October | 86 | 12 | 98 |
| 2022 September | 82 | 22 | 104 |
| 2022 August | 102 | 22 | 124 |
| 2022 July | 63 | 5 | 68 |
| 2022 June | 57 | 21 | 78 |
| 2022 May | 53 | 20 | 73 |
| 2022 April | 58 | 19 | 77 |
| 2022 March | 58 | 15 | 73 |
| 2022 February | 59 | 12 | 71 |
| 2022 January | 94 | 15 | 109 |
| 2021 December | 85 | 15 | 100 |
| 2021 November | 48 | 7 | 55 |
| 2021 October | 76 | 11 | 87 |
| 2021 September | 49 | 10 | 59 |
| 2021 August | 38 | 5 | 43 |
| 2021 July | 25 | 11 | 36 |
| 2021 June | 28 | 14 | 42 |
| 2021 May | 33 | 8 | 41 |
| 2021 April | 102 | 35 | 137 |
| 2021 March | 62 | 20 | 82 |
| 2021 February | 42 | 13 | 55 |
| 2021 January | 77 | 11 | 88 |
| 2020 December | 35 | 14 | 49 |
| 2020 November | 46 | 15 | 61 |
| 2020 October | 34 | 4 | 38 |
| 2020 September | 30 | 10 | 40 |
| 2020 August | 40 | 13 | 53 |
| 2020 July | 29 | 9 | 38 |
| 2020 June | 46 | 11 | 57 |
| 2020 May | 28 | 21 | 49 |
| 2020 April | 26 | 1 | 27 |
| 2020 March | 28 | 5 | 33 |
| 2020 February | 27 | 9 | 36 |
| 2020 January | 34 | 8 | 42 |
| 2019 December | 38 | 9 | 47 |
| 2019 November | 24 | 15 | 39 |
| 2019 October | 13 | 2 | 15 |
| 2019 September | 23 | 7 | 30 |
| 2019 August | 19 | 9 | 28 |
| 2019 July | 22 | 19 | 41 |
| 2019 June | 63 | 15 | 78 |
| 2019 May | 155 | 39 | 194 |
| 2019 April | 43 | 59 | 102 |
| 2019 March | 14 | 11 | 25 |
| 2019 February | 11 | 10 | 21 |
| 2019 January | 12 | 8 | 20 |
| 2018 December | 10 | 10 | 20 |
| 2018 November | 25 | 9 | 34 |
| 2018 October | 30 | 18 | 48 |
| 2018 September | 9 | 3 | 12 |
| 2018 August | 6 | 11 | 17 |
| 2018 July | 2 | 6 | 8 |
| 2018 June | 7 | 4 | 11 |
| 2018 May | 18 | 5 | 23 |
| 2018 April | 9 | 2 | 11 |
| 2018 March | 7 | 5 | 12 |
| 2018 February | 16 | 3 | 19 |
| 2018 January | 7 | 6 | 13 |
| 2017 December | 16 | 3 | 19 |
| 2017 November | 11 | 11 | 22 |
| 2017 October | 22 | 4 | 26 |
| 2017 September | 18 | 15 | 33 |
| 2017 August | 21 | 8 | 29 |
| 2017 July | 16 | 6 | 22 |
| 2017 June | 13 | 23 | 36 |
| 2017 May | 23 | 7 | 30 |
| 2017 April | 20 | 34 | 54 |
| 2017 March | 28 | 16 | 44 |
| 2017 February | 24 | 13 | 37 |
| 2017 January | 34 | 5 | 39 |
| 2016 December | 33 | 12 | 45 |
| 2016 November | 28 | 7 | 35 |
| 2016 October | 46 | 7 | 53 |
| 2016 September | 89 | 15 | 104 |
| 2016 August | 54 | 11 | 65 |
| 2016 July | 27 | 4 | 31 |
| 2016 June | 35 | 11 | 46 |
| 2016 May | 14 | 14 | 28 |
| 2016 April | 22 | 24 | 46 |
| 2016 March | 31 | 24 | 55 |
| 2016 February | 29 | 11 | 40 |
| 2016 January | 18 | 19 | 37 |
| 2015 December | 26 | 13 | 39 |
| 2015 November | 30 | 20 | 50 |
| 2015 October | 29 | 17 | 46 |
| 2015 September | 30 | 12 | 42 |
| 2015 August | 26 | 6 | 32 |
| 2015 July | 36 | 8 | 44 |
| 2015 June | 22 | 6 | 28 |
| 2015 May | 30 | 10 | 40 |
| 2015 April | 47 | 14 | 61 |
| 2015 March | 38 | 8 | 46 |
| 2015 February | 24 | 1 | 25 |
| 2015 January | 35 | 7 | 42 |
| 2014 December | 29 | 10 | 39 |
| 2014 November | 12 | 8 | 20 |
| 2014 October | 27 | 7 | 34 |
| 2014 September | 35 | 6 | 41 |
| 2014 August | 33 | 8 | 41 |
| 2014 July | 35 | 12 | 47 |
| 2014 June | 29 | 17 | 46 |
| 2014 May | 47 | 25 | 72 |
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