Reactions 2001, p244 - 30 Mar 2024 1

Multiple drugs S

Listeria monocytogenes meningitis and lack of efficacy

A 74-year-old woman developed listeria monocytogenes meningitis during treatment with certolizumab-pegol and prednisone
for rheumatoid arthritis. Additionally, she exhibited a lack of efficacy during treatment with ampicillin, cefepime, ceftriaxone and
vancomycin for listeria monocytogenes meningitis and streptococcus pneumoniae meningitis and unspecified vasopressors
for septic shock [routes, dosages, durations of treatments to reaction onset and outcome not stated].
The woman, who had history of rheumatoid arthritis, receiving prednisone and certolizumab-pegol [certolizumab]. She presented
to the emergency department with comatose, headache and fever the day prior. She was intubated on arrival and was found to be in
septic shock, which required three unspecified vasopressors.She was empirically treated with vancomycin, cefepime, ampicillin
and aciclovir [acyclovir]. Her dexamethasone [Decadron] was stopped.She had haemodynamic instability. She had been receiving
apixaban for atrial fibrillation. On day 2 of admission, her blood cultures resulted positive for Listeria monocytogenes and she also
diagnosed with meningitis. However, aetiology of shock and meningitis was presumed to be listeria. It was reported that, she
developed listeria monocytogenes meningitis due to her immunocomprised state during treatment with prednisone
and certolizumab-pegol.
Therefore, the woman’s antibacterials [antibiotics] were narrowed to cefepime and ampicillin. Eventually, her shock was
improving; however, the course was complicated by acute renal failure, which required continuous renal replacement therapy
(CRRT). On day 3, she underwent lumbar puncture due to persistent encephalopathy and fevers. Her CSF PCR was positive for
streptococcus pneumoniae and listeria monocytogenes with lymphocytic predominance. She was initiated on vancomycin
and ceftriaxone [Rocephin] in addition to ampicillin. Her shock resolved; but, she remained neurologically comatose only
withdrawing to pain. MRI brain showed meningitis and ventriculitis. She received levetiracetam for seizures. On day 18, lumbar
puncture was repeated due to lack of improvement in mental status. Despite ampicillin, cefepime, ceftriaxone and vancomycin,
her repeat MRI and MRA brain showing persistent meningitis and ventriculitis with pus (lack of efficacy). Eventually, she underwent
tracheostomy, and goals of care discussions were pursued with family.
Mendpara R, et al. Double Trouble: Dual Pathogen Bacterial Meningitis. American Journal of Respiratory and Critical Care Medicine 207: A3539, May 2023. Available from:
URL: https://doi.org/10.1164/ajrccm-conference.2023.207.1_MeetingAbstracts.A3539 [abstract] 803849519