Case Presentation: 84-year-old female who came to hospital with complaints of mild watery diarrhea, generalized weakness, subjective fevers and chills for 4 days. Patient has PMH hypothyroidism, chronic dysphagia, inclusion body myositis, interstitial lung disease, and pulmonary hypertension. Patient lives alone and due to increasing weakness was brought in by family for further evaluation. In ED Vitals are HR100, Temp :102.4F, RR:18 and BP:104/88. Physical Exam was unremarkable. Labs WBC 6.9k, Hb 13, hsT 1,385, CK 201, pro- BNP 32,634, BUN 36, and Cr 0.8. CXR showed pulmonary congestion. Patient was hemodynamically stable initially and admitted to the medical floor. Within hours of admission, blood pressures dropped with SBP around 80 and tachycardic HR 140s, requiring IV NSS bolus fluids. Blood cultures were obtained and started on empiric IV antibiotic regimen as well as maintenance IV fluids. Blood cultures came back positive for Gram Positive Cocci, DNA PCR positive for Listeria monocytogenes in both sets. Critical care medicine followed and admitted to Progressive Care Unit. Patient became increasingly tachypneic, tachycardic and febrile with severe back pain. A repeat ECG led the providers to discover a new onset atrial fibrillation, but Lopressor couldn’t be initiated due to increasingly low blood pressures. Cardiology followed and recommended echocardiogram which showed severely reduced EF 25-29%. CCM and ID were consulted for increasing concerns of listeria septic shock, continued on IV Ampicillin, IV fluids and closely monitored for any neurological manifestations. Patient required vasopressor support with IV norepinephrine, emergently intubated as she experienced abrupt clinical deterioration with increasing oxygen requirements and multiple organ dysfunction requiring aggressive interventions, transferred to ICU. In the interim patient’s family informed the team about patient’s habit of keeping food refrigerated for long periods of time, even past their expiry date. Palliative medicine followed and the patient’s family opted for comfort care after a lengthy discussion regarding the patient’s wishes, extubated for terminal weaning.
Discussion: Listeria monocytogenes is a gram positive, facultative, intracellular rod that usually manifests as a self-limiting gastroenteritis in the general population. But for certain groups including pregnant women, neonates, immunosuppressed patients including transplant recipients, patients with impaired cell-mediated immunity and the elderly, Listeria is responsible for a number of life-threatening pathologies which include sepsis due to listeria bacteremia, CNS infections like meningitis and meningoencephalitis, endocarditis and localized infections like pneumonia, abscesses etc. The mortality rate of listeriosis is 20%-30% especially in the elderly and immunocompromised while having a blood stream infection has a mortality of about 45%.
Conclusions: Listeria occurs widely in food products, especially meat, poultry and seafood. The above case is an example of how the elderly are more susceptible to listeria and how deadly the consequences of this disease are. Thus, highlighting the need for prompt diagnosis and management of this condition in elderly patients and populations with compromised immunity.