A 58 yo female with
mental status changes
Aram Harijan
UNC MS3
09/26/07
1
HPI 9/10/07
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Relevant PMH of DM, SLE, Graves, TIA, UTI
Subjective fever X 1 week + intermittent shakes
Confused, slurring, dizzy X 2 days; “Talking out of her head” per
husband
Similar symptoms twice in the past; once last year and once the
year before.
Endorses urinary frequency, dark urine, lower abd pain, bilateral
shoulder pain, bilateral rib pain with deep inspiration and laughing
Denies urgency, hematuria, cough, chest pain, SOB, chills, n/v, HA,
runny nose, sore throat.
In ED, levofloxacin 500 mg IV x1, solumedrol 150 mg IV x1, tylenol
650 mg po x1
2
PMH
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DM, SLE, History of TIAs, History of UTIs,
Graves disease s/p radioablation hypothyroidism; not on meds
Restrictive lung disease 2/2 SLE
Depression
GERD
RA
Shingles
Endometrial cancer s/p total abd hysterectomy 1996
Chronic thrombocytopenia, anemia
Chronic low-grade myositis
Diastolic dysfunction
Hypertension
Mitral regurg
Osteoporosis
3
Social/Family History
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Lives with husband in Raleigh
Retired teacher/minister
No T/A/D
No history of recent travel.
One daughter.
Mother died at 50s of bone cancer
4
Medications
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Actonel 35 mg po Qweek
Albuterol 90 mcg inhaler q6hours + prn
Calcium carbonate 1.25 GM
Multivitamins + Vit D
Furosemide 40 mg po qd
Hydrocodone-APAP 5/325 BID
Hydroxychloroquine 200 mg QD
Omeprazole 20 mg QD
Ponaris nasal emollient
Prednisone 20 mg QD
Systane 0.3-0.4 % eye drop
5
ROS
•Mostly negative except
per HPI
•Neck: No stiffness
•Endocrine: Often feels
cold.
PE
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Vitals: 39.3 P 137 RR 40 BP 143/90 O2
sat 95% RA
General: AAF lying in bed in NAD
Eyes:PERRL, EOMI, no photophobia
+Proptosis
Neck:Negative Brudzinski +Thyromegaly
CV: RRR, No murmurs, rubs. +Chest
wall TTP bilaterally
Pulm:+decreased breath sounds in LLL
Skin: No lesions
Psych:Alert and oriented X3, labile
affect, slow to answer questions
Extremeties: 1+ edema LE bilaterally
6
Laboratory 9/11/07
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Glucose 130
WBC 9.3
Hemoglobin 13.7
Platelets 85
UCx pending
BCx pending
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Sputum culture:
oropharyngeal flora
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No LP
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Urinalysis
 1+ LE
 +nitrites
 2+ protein
 2+ blood
 30 WBCs
 7 RBCs
 many bacteria
7
Imaging
• CXR
• Diminished lung volumes
with bibasilar atelectasis
and left pleural effusion
• LLL pneumonia versus
atelectasis
•MRA of head
•Nonspecific white
matter focal flare signal
abnormality and
cerebral volume loss
•Normal circle of Wilis
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Discussion
When I approach a
child, he inspires
me two
sentiments;
tenderness for
what he is, and
respect for what he
may become.
-Louis Pasteur
9
Further workup
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C3 120
C4 < 8 (as in the past)
CRP 27
ESR 120
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T4, total 4.6 (L)
T4, free 0.68 (L)
TSH, 0.32 (L)
T3, free 1.8 (L)
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Urine culture 9/12
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E. Coli
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Blood culture 9/13
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Blood culture: L. monocytogenes
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Mental Status Changes
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Non-ID causes
 Vascular: TIA, vascular
dementia, HF, dehydration
 Infection
 Neoplasm: paraneoplastic,
mass effect, lymphomas,
metastatic cancer
 Drugs (withdrawl, toxicity)
 Inflammatory: vasculitides
 Congenital: IEOM
 Autoimmune
 Trauma: IC bleeds
 Endocrine/Metabolic: DM, +/thyroid, lung/liver/kidney
failure.
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ID causes
 Septic encephalitis: UTI, pneumo,
sepsis, bacterial peritonitis
 Brain:“-itis”, empyema, abscess
 Treatable aseptic: HSV, VZV
 EBV, CMV, measles,
mumps, viruses named after
places, Arboviruses, Rabies
 HIV: toxo, tb, syphilis,
lymphomas, crypto, asper,
norcardia,
 Parasites: cysticercosis
 Bacterial: S. pneumo, N.
meningitidis, H. influenzae,
enteric GNR, L.
monocytogenes.
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Listeria monocytogenes
GPR
 Intracellular
 Tumbling
motility
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Narrow zone of hemolysis on sheep blood agar
and the production of acid from glucose, maltose,
L-rhamnose, and -methyl-D-mannoside but not
from D-xylose. Somatic (o) and flagella (H)
antigens. Serotypes 1/2a, 1/2b, 4b.
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Intracellular = Think cell-mediated
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Internalin - phagocytosis
Listeriolysin O,
phospholipases - escape
phagosome
Flagella - cell to cell
movement
Not eliminated by
antibodies
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Food-borne epidemics
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1985 LA : 142 cases; 48 deaths or still
births (20 fetus, 10 neonates, 18 nonpreg)
France 1992 : 279 cases; 63 deaths
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Epidemiology - Invasive listeriosis
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CSF or blood culture
Dx.
3-5 per million in US
Most sporadic
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Epidemiology - Perinatal listeriosis
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9 birth
complications /
100k
20% fatal or
result in
stillbirth
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Clinical presentation - Pregnancy
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Pregnancy-associated listeriosis
 Most detected in 3rd trimester
 1/2-2/3 experience mild illness fever, myalgia, malaise,
backache, +/- diarrhea, abd pain,
n/v
 Bacteremia -> transplantal spread
-> chorioamnionitis, premature, IU
demise, newborn disease
(meningitis <1 months)
Neonates: early granulomatosis
infantisepticum (<1 wk), late meningitis
(>1 wk)
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Refresher
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Clin. presentation - Immunocompromised
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Most common - bacteremic infection without focus
 Febrile, appear extremely ill
 Myalgia, n/v, diarrhea
2nd MC - CNS infection
 Meningitis MC: acute or subacute
 Fever, HA, altered level of consciousness
 CSF: pleocytosis, ^ protein, nml glucose. Gram positive 25%.
 Rarely monocytosis
 Meningoencephalitis, cerebritis, various abscesses.
 Fever, ataxia, seizures, personality changes, coma
 Nuchal rigidity rare in nonmeningitic inf.
 BCx > LP
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Clin Present. Continued
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Endocarditis
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Prosthetic/damaged valves
Predilection for left side of heart
Systemic embolization often present
Focal infections
Acute diarrheal syndrome in
immunocompetent.
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Treatment
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Immunocompetent
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Immunosuppressed + meningitis
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Amp (2 g IV q4h) or pen G (15-20m unit IV divided in six
doses qd) X 2-3 wk p defervescence
Amp + gentamicin (1.3 mg/kg IV q8h) X 4-6 wks
Neonatal: amp X 2-3 wks
Pregnant: amp X 2 wk; erythromycin for pen
allergy
No cephalosporins
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Prevention
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No unpasteurized milk or products
No soft cheese
Reheat food until steam
Don’t eat cold meat
Don’t eat mush food
Food industry standards and regulations
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Epilogue
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Progressive improvements in mentation
MMSE 30 on day 5 hospitalization
Currently @ SNF for completion of ABX tx
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References
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Harrison’s Principles
of Internal Medicine
16th Ed. Chapter 123.
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Book available online via
the UNC-CH Libraries
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Search PubMed
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Listeria Meningitis
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Case Reports
Reviews
Differential Diagnosis
Drug Therapy
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