Abstracts of the 51st Annual Conference of the Italian Society of Neurology
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ABSTRACTS
Abstracts of the 51st Annual Conference of the Italian Society of Neurology CASE REPORTS LISTERIA MONOCYTOGENES RHOMBENCEPHALITIS: A CHALLENGING DIAGNOSIS S. M. Angelocola, M. Acciarri, R. Angeloni, P. Cardinali, F. Forconesi, I. Paolino, E. Pucci Neurology Unit, "A. Murri" Hospital (Fermo) Neurolisteriosis may manifest in humans as meningitis, meningoencephalitis, and rhombencephalitis. Compared to other pathogens, Listeria Monocytogenes (Lm) has a brainstem predilection. Contrary to the more common meningitis, Lm rhombencephalitis occurs rarely and mostly in healthy and immunocompetent people. We describe the case of a 71-year-old immunocompetent woman previously in good health. About a week before hospital admission, the patient experienced nausea, vomiting and diarrhea. Subsequently, dysarthria associated with mild binocular diplopia appeared. At the time of admission, neurological examination showed dysarthria and right sixth and seventh cranial nerve palsy. The meningeal irritation signs were negative and body temperature was 36°C. She then performed a brain MRI with gadolinium, showing an extensive and clear-cut FLAIR signal alteration, affecting the pontine and mesencephalic tegmentus, without contrast enhancement; there was also a small focal diffusion signal alteration located in the midbrain-pons, on the right. The thiamine dosage, serum electrolytes and inflammatory markers were in range. During the hospitalization, she experienced worsening of vigilance and left hemiparesis. Because of the previous history of gastrointestinal infection, we made the suspiction of a post-infective Bickerstaff rhombencephalitis. The patient underwent a lumbar puncture that showed a mild mononuclear pleiocytosis with a little increase in proteins; virological tests were negative; the cultural exam didn’t show bacterial growth. We then made a therapeutic attempt with steroids and a cycle of in vein immunoglobulins, without satisfactory results. There was a progressive further clinical worsening with fever appearence. We then started empirical antibiotic treatment with ceftriaxone and decided to repeat a brain RMN, which showed progression of the FLAIR hyperintense lesion with widespread involvement of the midbrain and basal ganglia. Finally, we repeated a CSF examination with evidence of negative culture test but positive film-array PCR for Listeria. Blood cultures showed the presence of Lm. Specific antibiotic treatment was then started but the clinical picture was very poor and the patient died after a few days. Our attempt is to hilight the importance of considering a possible infectious nature of brainstem lesions even in presence of non enhancing MRI alterations, negative CSF cultures and without systemic and laboratory signs of infection. If Listerial infection is not considered or ruled out with specific tests, late diagnosis and thereby late initiation of target antibiotic treatment will allow the disease to run its devastating natural course. The administration of corticosteroids or i.v. immunoglobulins wo
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