PGY2 Sarah Soliman presented a case of a 80 y/o Cantonese speaking female with history of Afib, HTN and dyslipidemia was brought in by her daughter for acute encephalopathy. The patient lives alone and carries out ADLs independently. Four days prior to admission, she had an unwitnessed ground level fall, reportedly without trauma or loss of consciousness. Patient called her daughter to let her know about the fall. On the day of admission, the daughter came to the patient’s home to check on her and found her to be sleepier than usual. Upon questioning in the ED, the patient does not remember how she arrived at the hospital and no memory of the fall. Home medications include Telmisartan 80mg qday, Apixaban 5mg BID, Metoprolol tartrate 50mg qday, amlodipine 10mg qday and pravastatin 20mg qday. Denies any tobacco/alcohol/drug use.
Vitals: T 38.7, HR 106, RR 24, BP 134/73, O2 sat 97% RA
Physical Exam significant for A&Ox1, no nuchal rigidity, irregular irregulary HR, tachpneic but clear to ausculatation bilaterally, not properly following commands but otherwise no other neuro deficits noted.
CBC: WBC 7.9> Hb 13.5/Hct 39.9 <Plt 189 (MCV 92.2, RDW 13.6%)
Diff: 78.6% PMN, 14.5% lymph, 6.8% monocytes, 0% eosinophils, and 0.1% basophils
Na 136/K 3.6/Cl 97/HCO3 21/BUN 24/Cr 1.47 <Glucose 171
ALP 72>T.protein 6.1/Albumin 2.7/AST 263/ALT 180/Tbili 0.9/Dbili 0.4
Coags: PT 15.1, INR 1.2, PTT 31.1
CXR had some questioned retrocardiac patchy airspace and patient was placed on antibiotics to cover community acquire pneumonia.
Pan –scan including CT head, Chest and Abdomen/Pelvis did not reveal any acute etiologies.
On hospital day 2, the patient’s mental status worsened and became completely aphasic along with worsening fevers, tachycardia and tachypnea. She was upgraded to the MICU for closer monitoring.
Infectious workup done with the lumbar puncture showing the following results:
- Color: Xanthrochromic
- Clarity: slightly cloudy
- RBC: 23/cumm
- Nucleated cells: 485/cumm
- Segmented Neutrophils: 46%
- Lymph: 30%
- Monocytes: 11%
- Glucose: 28 mg/dL
- Protein: 365 mg/dL
- PCR panel positive for listeria monocytogenes
Treatment: Patient was started on IV ampicillin and gentamicin for a 3 week treatment and her mental status is slowly improving but has not returned to baseline as she is not able to carry out her ADLs independently.
- Listeria monocytogenes is a gram positive rod that is found in soil and decaying vegetable matter. Common foods that have been reported to cause outbreak: processed meats, fruit, hot dogs, soft cheeses and fruit.
- Clinical symptoms: gastroenteritis – watery diarrhea, bacteremia, meningitis.
- For patients coming to the hospital with acute encephalopathy with signs of meningitis and age >50 y/o, empiric antibiotics of IV CTX 2g Q12H + Vanc + ampicillin should be started even prior to obtaining LP in order to not delay care.