Life-threatening Listeria meningitis : need for revision of South African acute bacterial meningitis treatment guidelines

BACKGROUND: The recent listeriosis outbreak in South Africa (SA) received widespread attention in the media. More than 1 000 laboratoryconfirmed cases of listeriosis occurred during an 18-month period, with a case fatality rate of 28%. Acute bacterial meningitis due to listeriosis was extremely rare at Steve Biko Academic Hospital in Pretoria until 2017/18, when we saw two very sick adults with this condition during the listeriosis outbreak. OBJECTIVES: To describe the presentation, treatment and outcome of these patients to raise awareness of this potentially fatal but treatable infection that does not respond to empirical third-generation cephalosporins. CASE REPORTS: Case 1: A 60-year-old man collapsed at home after being discharged from hospital for treatment of Listeria meningitis. On readmission he had neck stiffness and a depressed level of consciousness with right-sided hemiparesis. A computed tomography (CT) scan of the brain showed possible subarachnoid haemorrhage, but on CT angio- and venograms, extensive thrombosis of the superior sagittal, right transverse and bilateral sigmoid sinuses extending into the right internal jugular vein was noted. Patient 2: A 55-year-old HIV-positive hypertensive man on highly active antiretroviral therapy and antihypertensives visited the emergency department complaining of a newonset headache. He was discharged on pain medication, but was readmitted the next day with a depressed level of consciousness, neck stiffness, low-grade fever and generalised tonic-clonic convulsions. A lumbar puncture revealed active cerebrospinal fluid that was culturepositive for L. monocytogenes. The patients received ampicillin and gentamicin for 3 weeks; the cerebral venous thrombosis was treated with unfractionated heparin. In both cases, the course of the disease was complicated. The first patient remained confused and suffered from psychotic episodes for 5 weeks. He was finally discharged after 6 weeks in hospital and continued to improve to the extent that he was able to return to work. The second patient needed intubation and ventilation and was treated in the intensive care unit. He improved over the next week and was finally discharged home with no residual neurological sequelae. CONCLUSIONS: Our two cases demonstrate that the listeriosis outbreak should change the way we view bacterial meningitis in SA: according to the National Institute for Communicable Diseases, empirical treatment for meningitis should include ampicillin and gentamicin in all adult patients with features of meningitis. There may be a need for an updated meningitis treatment guideline in SA.http://www.samj.org.zapm2020NeurologyRadiolog