Neonatal Listeriosis: A rare but not-to-be forgotten infection

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ESPR275
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Title: Neonatal Listeriosis: A rare but not-to-be forgotten infection


History: A 22 year old Hispanic woman, , from a rural community presented to the emergency department at 29 weeks and 5 days gestation with abdominal pain, vomiting, diarrhea, fever and signs of preterm labor. The extent of prenatal care she had received was unclear, but the few available records indicated she was previously healthy, fully immunized prior to pregnancy and had normal routine infectious disease screening tests at the first prenatal visit. Shortly after arrival, the mother was started on empiric antibiotics and managed clinically for signs of sepsis. Due to non-reassuring fetal heart tracings and suspected chorioamnionitis, she soon after underwent an emergent c-section. The amniotic fluid was noted to have a green tinge with brown colored membranes on the fetal side of the placenta. The pre-term baby, with an APGAR of 5 at 1 minute of life, had significant respiratory distress requiring intubation at 4 minutes of life and was transferred to the neonatal intensive care unit (NICU) in critical condition.


Physical Exam Findings:

The infant was floppy, lethargic with poor respiratory effort. His abdomen was distended with sluggish bowel sounds and significant hepatomegaly. Skin was diffusely jaundiced and appeared to be poorly perfused with cap refill + 3 seconds. Over the next 24 hours, the infant developed significant anasarca.


Laboratory or Diagnostic Imaging: 

Abnormal laboratory findings included anemia (Hemoglobin 10.5g/dL, Hematocrit 31%), thrombocytopenia (Platelets 69 x 109L), coagulopathy (Prothrombin time 20.2 sec, Partial Thromboplastin Time 44.5 sec, INR 1.76, Fibrinogen 361 mg/dL) and transaminitis (AST 698 unit/L, ALT 83 unit/L). Blood cultures drawn at birth grew Listeria monocytogenes at 29 hours of incubation. CSF cultures were deferred due to unstable clinical status. Head ultrasound showed bilateral intraventricular hemorrhages, with a grade 4 intraparenchymal hemorrhage at the left inferior temporal lobe.


Final Diagnosis:

This patient was diagnosed with neonatal listeriosis with presumed Listeria meningitis based on overall clinical severity and abnormal neurological exam. After the diagnosis was made, the maternal social history was revisited in greater detail, to try to identify the source of the Listeria infection. It was revealed that the mother often ate queso fresco (fresh Mexican style pasteurized cheese) bought from a local vendor who came door-to-door in their migrant, farming community. Historically Listeria infection has a high association with unpasteurized dairy, however, pasteurized cheeses, can still pose a risk. The Center for Disease Control (CDC) advises expectant mothers to avoid unpasteurized cheese but to be aware that even pasteurized cheeses, such as queso fresco, are often contaminated during the cheese making process and can be associated with Listeria .[1] 


In the United States (U.S.), over the past 9 years, the CDC reports that there have been 20 major Listeria monocytogenes outbreaks. [2]  The most significant was  a large multi-state outbreak in 2011, leading to 33 deaths out of 147 infected individuals (20% mortality).[2] Although many of these outbreaks were related to soft-cheeses, deli meats are also a common source of outbreaks and are believed to be the culprit in the most recent U.S. outbreak (October 2020) in New York, Massachusetts and Florida.[2] Neonatal listeriosis occurs in approximately 8.6/100,00 live births in the U.S. with a 24 times higher risk in Hispanic women and their infants.[2,3Early onset listeriosis (diagnosed within the first 7 days of life) is typically transmitted via maternal bacteremia. Pregnant women, most often in their third trimester, can be entirely asymptomatic or present with a simple   gastroenteritis, or, in the most severe cases, like the one  presented here, with clinical features of sepsis. In a 2010 analysis of 758 Listeriosis cases in the U.S., the rate of pregnancy associated Listeriosis was 16.9%.[4] Of these pregnancy related cases, 20.3% resulted in fetal losses, including 4 post-partum neonatal deaths.[4] The most common neonatal manifestations reported were meningitis (32.9%) and sepsis (36.5%).[4] Similarly, a large global meta-analysis in 2010 estimated a rising incidence of 23,150 cases of Listeriosis worldwide with similar rates of pregnancy related infection, neonatal septicemia and neonatal meningitis.[5] Of note, 43.8% of neonates with CNS infection went on to have long term neurologic sequalae.[5]


Once diagnosed, listeriosis is traditionally treated with Ampicillin and Gentamicin for 14-21 days, with the longer length recommended with CNS involvement.[6] This particular patient developed a significant brain hemorrhage during their clinical course, ultimately leading to ventriculoperitoneal (VP) shunt which the patient still has in place to this day. Patient is now 3 years old with some neurodevelopmental delays but otherwise healthy. 


The social history, a component of patient history that is notoriously overlooked , was the key in making the diagnosis and identifying the source of infection in this case. Although many advances have been made in early prevention and the detection of Listeriosis, ,maternal and neonatal infection remains a significant public health threat. It is imperative for healthcare providers  to continue to counsel expectant mothers on avoidance of soft-cheese, both unpasteurized and pasteurized, especially in high-risk populations, such as those of Hispanic background. 


Authors/Institutions: Gretell Gomez, MD, Shamim Islam, MD, DTM&H, Department of Pediatrics , University at Buffalo and Oishei Children's Hospital, Buffalo, NY, United States


Presenter: Gretell Gomez, MD


References:

  1. Centers for Disease Control and Prevention. (2020). Listeriosis: Prevention https://www.cdc.gov/listeria/prevention.html
  2. Jackson, K., Gould, L., Hunter, J. C., Kucerova, Z., & Jackson, B. (2018). Listeriosis Outbreaks Associated with Soft Cheeses, United States, 1998–2014. Emerging Infectious Diseases, 24(6), 1116-1118. https://dx.doi.org/10.3201/eid2406.171051.
  3. Lamont, R. F., Sobel, J., Mazaki-Tovi, S., Kusanovic, J. P., Vaisbuch, E., Kim, S. K., Uldbjerg, N., & Romero, R. (2011). Listeriosis in human pregnancy: a systematic review. Journal of perinatal medicine, 39(3), 227–236. https://doi.org/10.1515/jpm.2011.035
  4. Jackson, K. A., Iwamoto, M., & Swerdlow, D. (2010). Pregnancy-associated listeriosis. Epidemiology and infection, 138(10), 1503–1509. https://doi.org/10.1017/S0950268810000294
  5. de Noordhout, C. M., Devleesschauwer, B., Angulo, F. J., Verbeke, G., Haagsma, J., Kirk, M., Havelaar, A., & Speybroeck, N. (2014). The global burden of listeriosis: a systematic review and meta-analysis. The Lancet. Infectious diseases, 14(11), 1073–1082. 90
  6. American Academy of Pediatrics. [Listeria monocytogenes Infections] David W. Kimberlin, MD, Michael T. Brady, MD, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics; 2018:[511-515]



University at Buffalo
University at Buffalo

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