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Alemtuzumab/fingolimod/natalizumab Listeria monocytogenes bloodstream infection: case report

A 25-year-old woman developed Listeria monocytogenes bloodstream infection during treatment with alemtuzumab, fingolimod and natalizumab for multiple sclerosis [not all routes stated, dosages not stated]. The woman was diagnosed with relapsing-remitting multiple sclerosis in 2008. Following years, she had failed three lines of therapy with interferon (from 2008 to February 2012), interferon-β (from March to August 2012) and fingolimod (from January 2013 to 2015). From December 2015 to March 2018, she had received natalizumab. However, natalizumab was stopped due to the highrisk of progressive multifocal encephalopathy. Hence, after neurology consultation, it was decided to initiate alemtuzumab during hospitalisation. Subsequently, from 17 September 2018 to 21 September 2018, she had received treatment with alemtuzumab infusions. During or after administration of infusions, no side-effects were noted. Hence, she was discharged from hospital. Four days after the last infusion on 25 September 2018, she developed a productive cough, sore throat and high-grade fever. Her symptoms worsened, and she developed a headache, which led to hospitalisation on 28 September 2018. She had a healthy lifestyle. Her vital signs were as follows: body temperature: 38.2°C, HR: 101 beats per minute, oxygen saturation: 98% and BP: 120/70mm Hg. She was clinically stable with no evidence of neurological signs or meningeal inflammation, except for a headache. A cranial CT scan, chest X-rays and abdominal ultrasound showed no abnormalities. Her cardiac ultrasound and high-resolution chest CT were negative. Complete blood count showed mild anaemia with a WBC count of 5.830 x 103 mmc, neutrophils 85.8% and lymphocytes 2.4%. Her CRP level was 25.5 mg/dL, and the procalcitonin level was 0.05 ng/mL. Cultural and microbiological samplings were also performed. Subsequently, the woman started receiving empiric antibiotic treatment with ceftriaxone and levofloxacin. The multiplex polymerase chain reaction was performed on her positive blood cultures, which showed positive results for Listeria monocytogenes. However, serology for Listeria monocytogenes was negative. Hence, her empiric antibiotic treatment was changed to ampicillin and gentamicin. Two days later, her symptoms recovered, along with normalisation of inflammatory indexes and resolution of fever. She had received ampicillin and gentamicin for 2 weeks, and her symptoms were completely resolved. Also, her new blood cultures were negative. On 11 October 2018, she was discharged from hospital, and was prescribed with oral amoxicillin treatment till 19 October 2018. Three days after discharge from hospital, she had relapsing fever and headache, which resulted in rehospitalisation of 17 October 2018. Therefore, her therapy with gentamicin and ampicillin was re-started and continued till 05 November 2018. Subsequently, she was discharged from hospital in good condition. Based on these clinical present