Listeria monocytogenes Joint Infection

AUTHORS:
Vladimir Orlov, DO¹ • Sandeep A. Gandhi, MD^1,2

AFFILIATIONS:
¹Peconic Bay Medical Center, Northwell Health, Riverhead, New York
²New York Institute of Technology College of Osteopathic Medicine, Old Westbury, New York

CITATION:
Orlov V, Gandhi SA. Listeria monocytogenes joint infection. Consultant. 2021;61(4):e19-e20. doi:10.25270/con.2020.06.00003

Received February 2, 2020. Accepted May 11, 2020. Published online June 8, 2020. 

DISCLOSURES:
The authors report no relevant financial relationships.

CORRESPONDENCE:
Sandeep A. Gandhi, MD, 200 Hawkins Ave #1362, Ronkonkoma, NY 11779 (sanganmd@gmail.com)

An 87-year-old woman with a medical history of hypertension, depression, right humeral fracture, and right orbital and maxillary fractures presented after a nonsyncopal fall and subsequent bruising on the right rib cage with worsening pain. The initial workup revealed multiple right rib fractures in the posterior right chest wall. In addition, there was displacement of the right femoral head, for which she underwent a hip arthroplasty. The patient’s medications were omeprazole, 20 mg/d for gastrointestinal tract symptoms, as well as enalapril, 10 mg/d, amlodipine, 5 mg/d, and citalopram, 10 mg/d.

Two weeks later, the patient presented with high fevers and a white blood cell count of 14,500/µL. Subsequently, she underwent a right hip incision and drainage; wound cultures grew antibiotic-pansensitive Listeria monocytogenes. Her blood cultures were negative for bacteria. There had been no consumption of raw milk, cheese, or undercooked meat. She was treated with amoxicillin, 250 mg/d, planned for lifelong antibiotic suppressive therapy.

Discussion. Listeriosis is an infectious disease caused by the gram-positive, catalase-positive, rod-shaped, and facultative intracellular motile bacterial pathogen L monocytogenes. Listeriosis is most commonly transmitted to humans through ingestion of contaminated food such as cold cuts, contaminated produce, and especially unpasteurized milk products. Listeriosis is a reportable disease in the United States.¹

Risk factors for listeriosis include an immunocompromised state, such as certain autoimmune conditions, and any other systemic inflammation that alters the mucosal antigenic properties. Our patient’s risk factors included advanced age and recent joint surgery. We suspect that the mechanism of pathogenesis in this patient’s case was recent surgical intervention at the femoral acetabular joint. We were not able to determine any other source of listeriosis in our patient. It is also possible that a local inoculum from a small injury on the right hip could be the etiology.

This disease is asymptomatic in the vast majority of immunocompetent individuals. Symptoms can be mild flulike exanthems or febrile gastroenteritis. However, listeriosis can be invasive and spread beyond the gastrointestinal tract and may result in severe symptoms; this occurs most commonly in high-risk groups such as immunocompromised, elderly, or pregnant persons. More than 69% of cases in nonpregnant adults occur in persons with cancer, with HIV disease, who are organ transplant recipients, or who are on corticosteroid therapy.²

Clinically, listeriosis manifests as sepsis and meningitis. The most common central nervous system (CNS) manifestation of listeriosis is meningoencephalitis. It can range from a mild illness with fever and altered mental status to a fulminant course with coma and toxic metabolic encephalitis; however, many patients do not have signs of meningeal irritation.

The pathophysiology of the bacterial infection involves invasion of host cells with a virulence factor protein internalin A, which adheres to the protein E-cadherin in the cells of the intestinal epithelium/blood–brain barrier, and the placenta.³

One of the most nefarious phenotypic characteristics is the ability of Listeria to migrate from cell to cell via the use of actin comet tails. Once the infiltration has occurred, the bacteria then proliferate by evading the phagosome (via listeriolysin phospholipase O). Recent microbiological studies have shown that the listeriolysin O also plays a role in deactivating T-cell receptors and impairing T-cell activation by antigen-presenting cells, a direct countermeasure to the adaptive immune response.⁴

The diagnosis of listeriosis is multimodal. One common method is by direct culture growth in broth media. Another is by a spinal tap, especially in a high-risk group such as pregnant women. The median incubation period is 11 days, with 90% of cases occurring within 28 days,⁵ which is consistent with the presentation of our patient.

Listeriosis in pregnancy most often occurs in the third trimester and can lead to fetal death, premature birth, or infected newborns. Obtaining a blood culture is crucial and should be considered in any pregnant woman or immunocompromised individual who is febrile and in whom no alternative explanation of signs and symptoms is apparent.

The treatment of listeriosis is case-dependent, and no treatment is required in immunocompetent persons with mild constitutional symptoms such as gastroenteritis. Indications for antibiotic therapy include CNS infection, bacteremia, and endocarditis. First-line standard of care treatment for listeriosis remains a standard regimen of ampicillin or penicillin G (usually in combination with gentamicin for synergistic properties).⁶ Second-line treatment may be initiated with macrolides, fluoroquinolones, trimethoprim-sulfamethoxazole, or vancomycin.⁷

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