Bacterial Peritonitis Caused by Listeria monocytogenes: Case Report and Review of the literature

Canadian Journal of Infectious Diseases and Medical Microbiology, May 2019

Although Listeria monocytogenes has been isolated from the gastrointestinal tract, it is an infrequent cause of bacterial peritonitis. Since 1963 only 23 cases of peritonitis caused by listeria have been reported. This report describes another case in a patient with cirrhosis and chronic renal failure and presents a review of the literature. Most (16) of the previous cases were cirrhotic while six were undergoing chronic ambulatory peritoneal dialysis. Eight patients were on immunosuppressive therapy. Blood cultures were positive in fewer than half (42%) of the cases and Gram stain of peritoneal fluid was positive only twice. The peritoneal fluid protein concentration was relatively high compared with other causes of bacterial peritonitis. Ampicillin was the drug most commonly used for treatment, and the majority of patients survived the acute infection.

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Bacterial Peritonitis Caused by Listeria monocytogenes: Case Report and Review of the literature

CAN J INFECT DIS by Listeria m o n o c y t o g e n e s : jOE S DYLEWSKI 0 0 Division qfMicrobiology and Irifectious Diseases, StMary's Hospital , Montreal, Quebec Jax 514-345-3848 JS DYLEWSKI. Bacterial peritonitis caused by Listeria monocytogenes: Case report and review of the literature. Can J Infect Dis 1996;7(1):59-62. Although Listeria monoqytogenes has been isolated from the gastrointestinal tract, it is an infrequent cause of bacterial peritonitis. Since 1963 only 23 cases of peritonitis caused by listeria have been reported. This report describes another case in a patient with cirrhosis and chronic renal failure and presents a review of the literature. Most (16) of the previous cases were cirrhotic while six were undergoing chronic ambulatory peritoneal dialysis. Eight patients were on immunosuppressive therapy. Blood cultures were positive in fewer than half (42%) of the cases and Gram stain of peritoneal fluid was positive only twice. The peritoneal fluid protein concentration was relatively high compared with other causes of bacterial peritonitis. Ampicillin was the drug most commonly used for treatment, and the majority of patients survived the acute infection. Peritonite bacterienne causee par Listeria monocytogenes: rapport de cas et revue de Ia litterature RESUME : Meme si Listeria monoqytogenes a ete isole dans les voies digestives, il est rarement en cause dans Ia peritonite bacterienne. Depuis 1963, 23 cas de peritonite aListeria seulement ont ete declares . Ce rapport decrit un autre cas, chez un patient cirrhotique et insuffisant renal de longue date et presente une revue de Ia litterature. La plupart (16) des cas precedents touchaient des cirrhotiques, alors que six etaient sous dialyse peritoneale ambulatoire. Huit patients etaient sous traitement immuno-suppressif. Les hemocu ltures se sont revelees positives dans moins de Ia moitie des cas (42 %) et Ia coloration de Gram du liquide peritoneal n'a ete positive que dans deux cas. La concentration proteique du liquide peritoneal eta it relativement elevee comparativement aux autres causes bacteriennes de peritonite. L'ampicilline est le medicament le plus couramment employe et Ia majorite des patients survivent a !'infection aigue. Bacterial peritonitis; Listeria monocytogenes - L isteria monocytogenes is a Gram-positive rod that is most frequently associated with infections in neonates sepsis and/or meningitis. Only 23 cases of peritonitis caused by this organism have been reported in the English literature and in adults with impaired cell-mediated immunity. The most since 1963 ( 1-20 ). The majority of cases were described in common clinical presentation of listeria infection has been patients with cirrhosis or in those undergoing chronic ambulatory peritoneal dialysis (CAPO). A case of listeria peritonitis in a cirrhotic patient with coexisting chronic renal failure is reported along with a review of the literature. CASE PRESENTATION A 76-year-old male was admitted to hospital with a one? week history of fever and increasing weakness. Past medical history included admissions for recurrent hepatic enceph? alopathy secondary to cryptogenic cirrhosis and chronic renal failure secondary to a proliferative glomerulonephritis. He had been on hemodialysis for five months and had recovered from an episode of Staphylococcus aureus septic arthritis of the left wrist three months before this admission . On examination his temperature was 38. 7?C and he appeared lethargic but ori? ented. There was no asterixis and the neck was supple. Ascites was evident. Peripheral white blood cell count was 4x 109/L. Five sets of blood cultures were obtained over a 48 h period and a peritoneal tap was performed. White blood cells in ascitic fluid totalled 46x106!L (two neutrophils and 44 lym? phocytes). On Gram stain no organisms were seen. The patient was observed for 48 h off antibiotics but did not improve. At this time the peritoneal fluid was reported as growing Es? cherichia coli and L monocytogenes. A repeat peritoneal tap was performed and the cell count in the fluid was now 28SOx106/L neutrophils and 3SOX106/L lymphocytes. Only lis ? teria was isolated from this specimen. The patient was started on intravenous ampicillin 1 g every 6 hand treated for three weeks. A repeat peritoneal tap done after 10 days of treatment was sterile. All blood cultures taken before ampicillin was started were sterile. The patient initially responded to anti? biotic therapy with resolution of fever, but two weeks after discontinuation of ampicillin he became more deeply jaun? diced and then he developed a fatal upper gastrointestinal bleed. An autopsy was not performed. LITERATURE REVIEW MEOUNE was searched using index terms ' listeria infec? tions' and 'peritonitis'. Additional cases were identified by review of the references found during the search. Twenty-three cases of listeria peritonitis have been reported in the English language literature since 1963 (Table 1). Including this case, there has been a male predominance (1S to nine) with an average age of 60 years (range 31 to 82). Sixteen patients suffered from cirrhosis and six were on CAPO. Eight patients were receiving some form of immunosuppressive therapy. Peripheral white blood cell count was greater than 1Ox109/L in only SO% of the cases. Peritoneal fluid white blood cell count ranged from 46X106 to 14,987x106/L and the mean protein concentration was 24 g/L (range 0.8 to 49.0). Blood cultures were positive in eight of 19 (42%) cases. One patient was diagnosed on the basis of a positive peritoneal biopsy done at laparoscopy. In only two cases did the Gram stain of ascitic fluid reveal Gram-positive rods. Nineteen patients received either ampicillin or amoxicillin as part of their treatment. Five deaths were reported with at least two being attributed to gastrointestinal bleeding. Three patients survived their acute infection only to succumb later to gastrointestinal bleeding. DISCUSSION Bacterial peritonitis may occur spontaneously or as the result of bowel perforation. Anaerobes and coliforms are the usual organisms isolated from cases of secondary bacterial peritonitis , while E coli, K pneumoniae and Streptococcus pneumoniae predominate in spontaneous bacterial peritoni? tis (SBP) ( 21 ). L monocytogenes is present in the gastroin? testinal tract of up to 10% of healthy individuals (1) but it has only rarely been isolated from peritoneal fluid. In only one of the cases reviewed here was perforation of the bowel thought to lead directly to listeria peritonitis ( 13 ) . Other pos? sible mechanisms include spontaneous bacteremia or translo? cation of listeria into preexisting peritoneal fluid. Endoscopy may have precipitated the bacteremia in a few cases ( 20 ) although fewer than half had positive blood cultures. Out? breaks of listeria have been associated with ingestion of con ? taminated foods ( 22 ), and organisms may transmigrate the intestinal wall into ascitic fluid or peritoneal dialysate. Bacteria in peritoneal fluid may be eradicated by host de? fences by means of opsonins and macrophages. A low pro? tein content of peritoneal fluid has correlated with an increased risk of acquiring SBP ( 23 ). This may be due to the absence of opsonins and other proteins, which then would allow a small inoculum of bacteria to multiply to numbers significant enough to produce disease ( 24 ). Over SO% of cases of SBP in one series had a peritoneal protein content of less than S.O g/L (2S). In this review of cases there was a relatively high peritoneal fluid protein content (mean 24 g/L). This dif? ference may be because host defences against listeria depend more on lymphocyte and mononuclear phagocyte function than on opsonization. The concomitant isolation of E coli in the initial para ? centesis is unusual; only one other case of listeria peritonitis ( 13 ) had additional bacteria isolated from the ascitic fluid. The inability to grow the E coli on the repeat tap before therapy may reflect this patient's ability to neutralize this organism. The clinical presentation of listeria peritonitis is similar to other causes of SBP in that fever, abdominal pain and change in mental status are the most common manifestations ( 18 ). Gram stain of peritoneal fluid was positive in only two cases ; however, care must be taken not to disregard a report of Gram-positive rods present on stain or culture. Peritoneal fluid should be inoculated into blood culture bottles to enhance isolation ( 26 ). Treatment should involve either penicillin or ampicillin . Combination therapy with an aminoglycoside does not appear to be a necessity. Other antibiotics that have been used successfully include trimethoprim-sulfamethoxazole and erythromycin. Vancomycin failure has been reported (1S). The duration of antibiotic therapy is not known , with most cases cured with two to three weeks of treatment. CONCLUSION Bacterial peritonitis caused by L monocytogenes remains a rare occurrence but should be considered in patients with cirrhosis or in those on CAPO who develop fever, abdominal pain and a change in mental status . ADDENDUM Since this paper was accepted for publication, an additional case of Listeria monocytogenes peritonitis has been reported in a 29-year-old female ( 27 ). Information on the character? istics of the peritoneal fluid was not not given. 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Listeria monocytogenes peritonitis . An additional case . Am J Gastroenterol 1989 ; 84 : 454 - 5 . (Lett) 9. Pascual J , Sureda A , Boixeda D. Listeria monocytogenes spontaneous peritonitis . Am J Gastroenterol 1989 ; 84 : 455 . (Lett) 10 . Curosh NA , Perednia DA . Listeria monocytogenes septic arthritis . A case report and review of the literature . Arch Intern Med 1989 ; 149 : 1207 - 8 . II. Allais JM , Cavalieri SJ , Bierman MH , Clark RB . Listeria monocytogenes peritonitis in a patient on continuous ambulatory peritoneal dialysis . Nebr Med J 1989 ; 74 : 303 - 5 . 12 . Korzets A , Andrews M , Campbell A , Feehally ) , Walls J , Prentice M. Listeria monocytogenes peritonitis complicating CAPO . Perit Diallnt 1989 ; 9 : 351 - 2 . 13. Siegfried C , Schubert TT . Secondary bacterial peritonitis due to Listeria monocytogenes after paracentesis . South Med J 1990 ; 83 : 213 - 4 . 14. al-Wali Wl , Baillod R , Hamilton-Miller JM , Kyi MS , Brumfitt W. Listeria monocytogenes peritonitis during continuous ambulatory peritoneal dialysis . Postgrad Med J 1990 ; 66 : 252 . (Lett) 15 . Dryden MS , Jones NF , Phillips I. Vancomycin therapy failure in Listeria monocytogenes peritonitis in a patient on continuous ambulatory peritoneal dialysis . J Infect Dis 1991 ; 164 : 1239 . (Lett) 16. Hart KA , Reiss-Levy EA , Trew PA . Listeria monocytogenes peritonitis associated with CAPO . Med J Aust 1991 ; 154 : 59 - 60 . 17. Lunde NM , Messana JM , Swartz RD . Unusual causes of peritonitis in patients undergoing continuous peritoneal dialysis with emphas is on Listeria monocytogenes . J Am Soc Nephrol 1992 ; 3 : 1092 - 7 . 18. Sivalingam JJ , Martin P , Fra imow HS , Yarze JC , Friedman LS . Listeria monocytogenes peritonitis; case report and literature review . Am J Gastroenterol1992; 87 : 1839 - 45 . 19. Polanco A , Giner C , Canton R , et al. Spontaneous bacterial peritonitis caused by Listeria monocytogenes: two case reports and literature review . Eur J Clin Microbial infect Dis 1992 ; 11 : 346 - 9 . 20. Nguyen MH , Yu VL . Listeria monocytogenes peritoni tis in cirrhotic patients. Value of ascitic fluid Gram stain a nd a review of literature . Dig Dis Sci 1994 ; 39 : 215 - 8 . 21. Hoefs JC , Runyon BA . Spontaneous bacterial peritonitis . Dis Mon 1985 ; 31 : 14 . 22. Schlech WF , Lavigne PM , Bortolussi R , et al. Epidemic listeriosis - evidence fo r transmission by food . N Eng! J Med 1983 ; 308 : 203 - 6 . 23. Runyon BA . Low-protein-concentration ascitic fluid is predisposed to spontaneous bacterial peritonitis . Gastroenterology 1986 ; 91 : 1343 - 6 . 24. Runyon BA . Patients with deficient ascitic fluid opsonic activity are predisposed to spontaneous bacterial peritonitis . Hepatology 1988 ; 8 : 632 - 5 . 25 . Runyon BA , Hoefs JC . 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Joe S Dylewski. Bacterial Peritonitis Caused by Listeria monocytogenes: Case Report and Review of the literature, Canadian Journal of Infectious Diseases and Medical Microbiology, DOI: 10.1155/1996/853472