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CASE REPORT  
Year : 2013  |  Volume : 5  |  Issue : 1  |  Page : 31-33
Listeriosis infection of an abdominal aortic aneurysm in a diabetic patient


1 Department of Vascular Surgery, University Hospital of Patras, Patras, Greece
2 Department of Radiology, University Hospital of Patras, Patras, Greece
3 Department of Internal Medicine, University Hospital of Patras, Patras, Greece

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Date of Web Publication14-Feb-2013
 

   Abstract 

A rare case of an abdominal aortic aneurysm (AAA) infected by Listeria monocytogenes in a 72-year-old male diabetic farmer, is reported. Our patient had a history of a recent pneumonia that could have been caused by Listeria too. Aneurysm infection was manifested by fever and abdominal and back pain, which prompted investigation with CT scanning that revealed a 4.9 cm AAA with typical signs of infection. He underwent urgent AAA repair with aortobifemoral bypass grafting and had an uneventful course. Aneurysm content microbiology revealed Listeria monocytogenes and following a 9-week course of antibiotics our patient remains asymptomatic 11 months later.

Keywords: Infected aneurysm, Listeria, Pneumonia

How to cite this article:
Papadoulas SI, Kakkos SK, Kraniotis PA, Manousi ME, Marangos MN, Tsolakis IA. Listeriosis infection of an abdominal aortic aneurysm in a diabetic patient. J Global Infect Dis 2013;5:31-3

How to cite this URL:
Papadoulas SI, Kakkos SK, Kraniotis PA, Manousi ME, Marangos MN, Tsolakis IA. Listeriosis infection of an abdominal aortic aneurysm in a diabetic patient. J Global Infect Dis [serial online] 2013 [cited 2020 Jan 27];5:31-3. Available from: http://www.jgid.org/text.asp?2013/5/1/31/107173



   Introduction Top


Listeria monocytogenes can rarely infect atherosclerotic abdominal aortic aneurysms (AAA) in nonimmunocompromised patients. [1],[2] In contrast to Listerial meningitis and bacteraemia, where over 90% of patients have immunosuppression due to neoplasia or other reasons, it has been suggested that patients with Listerial endocarditis and infected arteries must have other types of deficiencies predisposing to infection. [2] Herein, we present a case of AAA infected by Listeria monocytogenes following a recent pneumonia, the first to our knowledge, which could have been caused by the same pathogen. Pulmonary Listeriosis is extremely rare with a handful of cases being reported. [3],[4] Additionally, no more than two dozen cases of infected AAA caused by Listeria monocytogenes have been reported in the English literature.


   Case Report Top


A 72-year-old male hospitalized at an outside facility 2 months ago with lower-left lobe pneumonia treated with moxifloxacin for 12 days, and continuing symptoms of malaise, loss of appetite and weight loss, was referred to the emergency department with a symptomatic 4.9 cm AAA on CT scanning causing severe continuous lower abdominal and back pain requiring opiates and recurrent fever, up to 38.5°C. The latter symptom had started 12 days ago, although it had subsided 3 days later after receiving ciprofloxacin. Past medical history included COPD, hypertension, hyperlipidaemia, diabetes mellitus, and hyperuricemia. He was on formoterol and tiotropium inhalers, valsartan/hydrochlorothiazide, barnidipine, moxonidine, ezetimibe/simvastatin, sitagliptin/metformin, and allopurinol. He was an ex-smoker, while his occupation was sheep and goat keeper and slaughterer and he reported to consume raw dairy products, including home-made cheese made from unpasteurized milk. On presentation, he was hemodynamically stable, afebrile, while a tender AAA was noted. Leukocytosis (WBC 16,650/mm 3 with a left shift) and raised CRP (29 mg/ dL, reference value <0.8 mg/dL) were found. Blood cultures were negative. He underwent an abdominal CTA with contrast ([Figure 1]a-c and [Figure 2]a-b) with a 16 × MDCT scanner (Lightspeed 16, GE, Milwaukee, WI, USA). The nonenhanced scan revealed an infrarenal AAA with a maximum diameter of 4.9 cm, in the axial plane, aortic wall calcifications, some of them apparently discontinuous, and subtle periaortic fat stranding. The contrast-enhanced CT scan underwent multiplanar reformat using the maximum intensity projection (MIP) algorithm. The aortic wall was markedly irregular, with the presence of multiple contrast-filled saccular outpouchings. There was also evidence of periaortic soft-tissue attenuation mass and/or luminal thrombus. The abnormalities extended distally up to the level of the aortic bifurcation, and the proximal part of the right common iliac arteries. There was no evidence of contrast extravasation or hematoma in the retroperitoneal space. There was no evidence of gas in the region. The abdominal CT scan was otherwise unremarkable.
Figure 1: Unenhanced (a), arterial (b), parenchymal (c) axial CT. (a) There is periaortic fat stranding (white arrowheads). The fat plane between aorta and the duodenum is indistinct (white arrows). (b) The aortic lumen is irregular (black asterisk) with an internal flap (white arrow). (c) There is enhancement of the aortic wall (white arrowheads)

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Figure 2: Coronal (a) and sagittal (b) thick-slab reformatted MIP, contrast-enhanced, arterial-phase image of the abdominal aorta. The aortic lumen is irregular, with saccular outpouchings. There is soft tissue attenuation (white asterisk) around the aortic lumen, representing the asymmetrically thickened, inflamed aortic wall

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Based on the clinical picture, the history of an infectious disease (pneumonia) and CT findings, an infected AAA was suspected. Our patient was started meropenem 1gr TID and vancomycin 1gr BID and underwent urgent AAA repair with typical aortobifemoral bypass grafting using a 16 × 8 mm bifurcated e-PTFE graft (Advanta SST, Atrium Medical Corp, Hudson, NH, USA). Operative findings included an infrarenal AAA extending to the aortic bifurcation. The right common iliac artery was pulseless. The left common iliac artery had a whitish color. The intestine was adhered densely on the aneurysm. A small amount of dirty fluid inside the luminal thrombus was sent for culture along with aneurysmal wall samples and thrombus material for common bacteria, mycobacterium, and Brucella pathogens. Periaortic tissue and aortic wall were sent for histological examination. A part of the presumably infected aneurysmal sac was excised. The culture of the dirty fluid was positive for Listeria monocytogenes, sensitive to ampicillin, penicillin, vancomycin, teicoplanin, erythromycin, chloramphenicol, and ofloxacin. Additionally, a multisensitive Staphylococcus epidermidis was isolated. Histology showed acute sac inflammation. Postoperative course was uneventful and on postoperative day 10, our patient was transferred to his regional hospital to complete a further 4-week course of intravenous antibiotics (meropenem 2gr TID and vancomycin 1gr BID) and an additional 4-week course of oral antibiotics (trimethoprime/sulfomethoxazole 800/160 mg BID) as an outpatient. Eleven months later our patient remains asymptomatic.


   Discussion Top


A rare case of an AAA infected by Listeria monocytogens is reported. Fewer than two dozen cases of infected arterial aneurysms caused by Listeria monocytogenes have been reported in the English Literature. [2],[5] We assume that patient's pneumonia was due to the same pathogen, and we could not find in the literature similar cases of AAAs infected as a result of inoculation from a remote source.

In our patient, we believe that consumption of raw dairy products caused bacteraemia and seeding of avascular AAA contents, that is, thrombus and mural calcifications, although negative blood cultures, like our case, have been previously reported. [2] We cannot prove if patient's pneumonia, which preceded the clinical manifestations of the infected AAA, was due to Listeria after hematogenous spreading, but we strongly suspect that this was the case because the patient never fully recovered. It is known that pulmonary listeriosis is extremely rare. [3],[4] Most likely both AAA infection and pneumonia were caused by the same bacteraemic episode(s) after ingestion of the pathogen and not inhalation of it. [6]

Occupational risk and diabetes as a form of immunosupression have possibly played a critical role in pathogen exposure and infection acquirement, respectively. In our area occupational exposure to Brucella sp has been reported to cause AAA infection, [7] but no such mode of Listerial AAA infection has been reported in the literature to the best of our knowledge. On the other hand, occupational infection by Listeria sp has been reported by some authors, [8] although this observation is not uniform. [9]

Clinical presentation was typical of an infected AAA, while in situ repair following a 9-week course of antibiotics proved to be safe since eleven months later our patient remains asymptomatic. In most cases where the local inflammatory findings are not severe, in situ repair, as opposed to aortic ligation and extra-anatomical repair by means of axillobifemoral bypass grafting, is indicated, [10] since its low rate of prosthesis infection outweighs the risk of stump blow-out.


   Conclusion Top


A rare case of AAA infected by Listeria monocytogens following a recent pneumonia is reported. The diagnosis of AAA infection should be considered in immunocompromised patients presenting with fever and AAA.


   Acknowledgements Top


The first two authors contributed equally.

 
   References Top

1.Haroon Y, Bhalla A, El-Tahir A. Listeria monocytogenes: A rare cause for an infected abdominal aortic aneurysm. Vasc Endovascular Surg 2011;45:773-4.  Back to cited text no. 1
    
2.Gauto AR, Cone LA, Woodard DR, Mahler RJ, Lynch RD, Stoltzman DH. Arterial infections due to Listeria monocytogenes: Report of four cases and review of world literature. Clin Infect Dis 1992;14:23-8.  Back to cited text no. 2
    
3.Ananthraman A, Israel RH, Magnussen CR. Pleural-pulmonary aspects of listeria monocytogenes infection. Respiration 1983;44:153-7.  Back to cited text no. 3
    
4.Domingo P, Serra J, Sambeat MA, Ausina V. Pneumonia due to listeria monocytogenes. Clin Infect Dis 1992;14:787-9.  Back to cited text no. 4
    
5.Clouse WD, DeWitt CC, Hagino RT, DeCaprio J, Kashyap VS. Rapidly enlarging iliac aneurysm secondary to listeria monocytogenes infection: A case report. Vasc Endovascular Surg 2003;37:145-9.  Back to cited text no. 5
    
6.Lefford MJ, Amell L, Warner S. Listeria pneumonitis: Induction of immunity after airborne infection with listeria monocytogenes. Infect Immun 1978;22:746-51.  Back to cited text no. 6
    
7.Kokkinis K, Stathopoulou S, Petrocheilou G, Makris N, Vlychou M, Evangelopoulos D, et al. Brucella spondylitis complicated by an infected abdominal aortic aneurysm and deep venous thrombosis: Case report and review of the literature. Eur J Orthop Surg Traumatol 2008;18:23-7.  Back to cited text no. 7
    
8.Kampelmacher EH, van Noorle Jansen LM. Listeriosis in humans and animals in the Netherlands (1958-1977). Zentralbl Bakteriol A 1980;246:211- 27.  Back to cited text no. 8
    
9.Art D, Andre P. Clinical and epidemiological aspects of Listeriosis in Belgium, 1985-1990. Zentralbl Bakteriol 1991;275:549-56.  Back to cited text no. 9
    
10.Yu SY, Hsieh HC, Ko PJ, Huang YK, Chu JJ, Lee CH. Surgical outcome for mycotic aortic and iliac anuerysm. World J Surg 2011;35:1671-8.  Back to cited text no. 10
    

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Correspondence Address:
Stavros K Kakkos
Department of Vascular Surgery, University Hospital of Patras, Patras
Greece
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-777X.107173

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    Abstract
   Introduction
   Case Report
   Discussion
   Conclusion
   Acknowledgements
    References
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2008 Journal of Global Infectious Diseases | Published by Wolters Kluwer - Medknow
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