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Listerial rhombencephalitis in an immunocompetent young adult
International Journal of Infectious Diseases (2009) 13, e65—e67
http://intl.elsevierhealth.com/journals/ijid
CASE REPORT
Listerial rhombencephalitis in an immunocompetent young adult ¨ nal Kayaaslan a, Esragu ¨khan Go ¨zel a, Bircan U ¨l Akıncı a,*, S¸ule Bilen b, Mustafa Go Deniz Erdem c, Mustafa Aydın C ¸evik a, Hu ¨rrem Bodur a a
Ankara Numune Education and Research Hospital, Clinic of Infectious Diseases and Clinical Microbiology, Ankara, Turkey Ankara Numune Education and Research Hospital, Clinic of Neurology, Ankara, Turkey c Ankara Numune Education and Research Hospital, Clinic of Anesthesiology and Reanimation, Ankara, Turkey b
Received 23 February 2008; received in revised form 31 May 2008; accepted 19 June 2008 Corresponding Editor: Craig Lee
KEYWORDS Listeria; Rhombencephalitis
Summary Listeria monocytogenes is a common cause of central nervous system infections, especially in immunosuppressed patients, infants and elderly people. Listerial rhombencephalitis is a rare and severe infection of the brainstem that is reported to have high mortality and frequent serious sequelae for survivors. We report the case of a 19-year-old healthy male who presented with listerial brainstem infection due to Listeria monocytogenes. # 2008 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
Case report A 19-year-old healthy male was admitted to our emergency room with chills, trembling, fever, nausea, vomiting, headache, diplopia and unsteady gait for two days previously. There was no history of underlying disease or other predisposing factors for listeriosis. At the time of admission, his temperature was 38.5 8C and his mental status was normal. He had left peripheral type facial paralysis, right-sided horizontal nystagmus, right-sided cerebellar ataxia, bilateral hypoactive deep tendon reflexes and hypoesthesia on the right side of the face. Neck stiffness was not detected. Laboratory values were as follows: white blood cell (WBC) * Corresponding author. Ankara Numune Education and Research Hospital, Clinic of Infectious Diseases and Clinical Microbiology, Samanpazarı 06100, Ankara, Turkey. Tel.: +90 3122878183; fax: +90 312 312 6876. E-mail address: [email protected] (E. Akıncı).
count 10.6 109/L (79% neutrophils), erythrocyte sedimentation rate (ESR) 36 mm/h and C-reactive protein (CRP) 6.9 mg/dl. A computed tomography (CT) scan of the brain was normal. Cerebrospinal fluid (CSF) examination revealed a leukocyte count of 130/mm3 (90% lymphocytes, 10% neutrophils), a protein concentration of 45 mg/dl and a glucose concentration of 71 mg/dl (blood glucose: 151 mg/dl). Cultures and Gram staining of the CSF were negative for bacteria and fungi. The patient was hospitalized with a preliminary diagnosis of viral meningoencephalitis. After taking blood cultures, treatment with intravenous acyclovir 10 mg/kg every 8 hours was introduced. Ceftriaxone 2 g every 12 hours was also added in case of the possibility of bacterial etiology. On the 2nd day of hospitalization, his condition worsened. Strabismus, dysphagia and dysarthria developed. Neurological examination revealed asymmetrical palsies of the 6th, 7th, 9th and 10th cranial nerves. Cranial diffusion magnetic resonance imaging (MRI) showed gross brainstem involvement. On the 3rd day, penicillin G 4 million units every 6 hours was
1201-9712/$36.00 # 2008 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijid.2008.06.026
¨ . Kayaaslan et al. B.U
e66
Discussion
Figure 1 Cranial diffusion MRI showing abscess formation in the left posterior side of the pons.
added to the antimicrobial therapy against possible Listeria monocytogenes infection. The patient deteriorated rapidly and developed tetraplegia, paralysis of the neck musculature, eyelid retraction and hypoventilation. He was transferred to the intensive care unit (ICU) and mechanical ventilation was initiated immediately. L. monocytogenes was yielded from the blood cultures on the 6th day. Thus, a diagnosis of listerial rhombencephalitis was confirmed. Gentamicin 80 mg every 8 hours was added to the penicillin G therapy. His neurological symptoms improved very slowly with antibiotic treatment. When cranial diffusion MRI was repeated two weeks later, abscess formation in the left posterior side of the pons (9 10 12 mm in size), with hemorrhagical changes and a nodular lesion in the centre of the medulla oblongata, was observed (Figure 1). On the 9th day of antibiotic therapy, intravenous dexamethasone 4 mg every six hours was added to his treatment and continued for 12 days. His neurological condition subsequently improved gradually. He was extubated on the 20th day of mechanical ventilation and discharged from the ICU on the 42nd day of admission. The patient stayed in hospital for 10 weeks and was given combined intravenous antibiotic therapy for L. monocytogenes. Follow-up cranial MRI examinations were performed every four weeks. At the followups, MRI examinations revealed a noticeable decrease in the extent of lesions, concomitant with considerable neurological improvement. After 10 weeks, most of the neurological signs had resolved. He was discharged home at the end of the 10th week of hospitalization, with oral treatment of amoxicillin 1 g every 8 hours and trimethoprim-sulfamethoxazole forte one tablet every 12 hours for the next three months. When CRP and ESR reached normal levels, the antibiotics were stopped. He had follow-up care for a year after antibiotic treatment. At the final visit, he still had mild left peripheral type facial paralysis and mild motor deficiency, but could walk without aid. He started a rehabilitation program and had an operation because of his strabismus. His cognitive function improved very well and he returned to his normal life. However, he was unable to attend to school because of his mild motor deficiency.
L. monocytogenes is a common cause of central nervous system (CNS) infections, especially in immunosuppressed patients, infants and elderly people. Listerial rhombencephalitis is a rare and severe infection of the brainstem that is reported to have high mortality and frequent serious sequelae for survivors.1 However, a study from Norway has indicated that brainstem encephalitis is relatively common (11%) in listeriosis.2 In contrast to other listerial CNS infections, the majority of listerial rhombencephalitis cases occur in previously healthy adults; no infections have been reported in infants.3—5 The disease has a characteristic biphasic course: a nonspecific prodrome of fever, headache, nausea and vomiting lasting about four days is followed by progressive asymmetrical cranial nerve palsies, cerebellar signs, hemiparesis or hypesthesia, and impairment of consciousness. The onset of neurological deficiencies is usually abrupt. The most frequent neurological sign is multiple cranial nerve deficiencies, most commonly affecting the 6th, 7th, 9th, 10th and 11th nerves. The syndrome progresses rapidly and sometimes has a fatal outcome.3,6 Respiratory failure or arrest was documented in about 40% of cases.3 Neck stiffness and deterioration in mental status occur in about half of patients with listerial rhombencephalitis. Usually, CRP and WBC are within normal ranges. Analyses of CSF often reveal mild, nonspecific abnormalities and lymphocyte predominance. These are consistent with viral meningoencephalitis and other nonbacterial brain infections, which might lead to delayed or missed diagnosis. Cultures of CSF were positive in 41% of cases and the rate of blood culture positivity (61%) is higher than CSF culture.3 Thus, repeated blood cultures are important for diagnosis. Initial CT of the brain often gives normal results and could be misleading. MRI is superior to CT for demonstrating rhombencephalitis.3,7,8 Subcortical abscesses located in the thalamus, pons and medulla are common in listerial rhombencephalitis; abscesses in these sites are exceedingly rare when due to other bacteria.1,3,6,7 The patient’s first cranial CTwas normal; thus rhombencephalitis was not considered initially in the differential diagnosis. The correct diagnosis was made from the characteristic MRI pictures and positive blood cultures for Listeria. Overall mortality is 51% for listerial brainstem encephalitis. Early adequate antibiotic treatment is of crucial importance to survival and reduction of neurological sequelae. When appropriate antibiotic treatment is initiated early, the rate of survival is over 70%. However, neurological sequelae develop in 61% of survivors.3 The factor that most strongly correlates with survival is the timely use of appropriate antibiotics. Ampicillin or penicillin combined with gentamicin represents the first-line treatment for listerial CNS infections.1,3 Adding gentamicin to ampicillin is preferred for synergism against bacteria. We gave a penicillin G and gentamicin combination to the patient, and then continued with a trimethoprim-sulfamethoxazole and amoxicillin combination after discharge. Some reports have demonstrated that, if aminopenicillin and trimethoprim-sulfamethoxazole are given together, the same successful results are seen.7,9 If there is an allergy to penicillin, trimethoprim-sulfamethoxazole is preferred as an alternative. A recently published article shows that linezolid
Listerial rhombencephalitis in an immunocompetent young adult is another agent that can successfully treat infection of the brainstem caused by L. monocytogenes.10 Patients with rhombencephalitis should be treated with antibiotics for at least six weeks, followed by serial MRI studies.1 The role of dexamethasone in the management of listerial CNS infections is not yet well understood. It seems to be an important agent in the treatment of most CNS infections because of its potent anti-inflammatory activity and its role in controlling cerebral edema and neurological symptoms.11 Dexamethasone is not widely used in adults with listerial infections because of the frequent association of such infections with immunodeficiency. However, some recent reports have indicated that dexamethasone might be useful in treating listerial rhombencephalitis, leading to rapid regression of neurological symptoms.11,12 In this patient, the temporal relationship between the initiation of steroid treatment and subsequent clinical improvement is the most interesting aspect; after administration of dexamethasone therapy, the neurological symptoms of the patient improved more rapidly. In conclusion, early empirical treatment with appropriate antibiotics is crucial for the favorable outcome of listerial brainstem encephalitis. However, this syndrome can be misdiagnosed at an early stage of the disease. Listeria should be kept in mind, especially in immunocompetent adult patients who develop fever, asymmetrical multiple cranial nerve palsies and focal neurological symptoms localized to the brainstem. At this point, MRI is important for the early diagnosis of rhombencephalitis. Until the diagnosis is confirmed, empirical therapy, including high dose ampicillin or penicillin effective against Listeria, should be considered. Conflict of interest: No conflict of interest to declare. No fund used for our writing. No conflict of interest exists for our writing. No ethical approval needed for our writing.
e67
Acknowledgements We wish to convey our deepest regret for the loss of our outstanding scientist Dr Mustafa Aydin Cevik.
References 1. Bennett L. Listeria monocytogenes. In: Mandell GL, Bennett JE, Dolin R, editors. Principles and Practice of Infectious Diseases. 6th edition. Philadelphia: Churchill Livingstone; 2005. p. 2478—84. 2. Antal EA, Dietrichs E, Løberg EM, Melby KK, Maehlen J. Brain stem encephalitis in listeriosis. Scand J Infect Dis 2005;37:190—4. 3. Armstrong RW, Fung PC. Brainstem encephalitis (rhombencephalitis) due to Listeria monocytogenes: case report and review. Clin Infect Dis 1993;16:689—702. 4. Smiatacz T, Kowalik MM, Hlebowicz M. Prolonged dysphagia due to Listeria-rhombencephalitis with brainstem abscess and acute polyradiculoneuritis. J Infect 2006;52:e165—7. 5. Kohler J, Winkler T, Wakhloo AK. Listeria brainstem encephalitis: two own cases and literature review. Infection 1991;19:36—40. 6. Uldry PA, Kuntzer T, Bogousslavsky J, Regli F, Miklossy J, Bille J, et al. Early symptoms and outcome of Listeria monocytogenes rhombencephalitis: 14 adult cases. J Neurol 1993;240:235—42. 7. Alper G, Knepper L, Kanal E. MR findings in listerial rhombencephalitis. AJNR Am J Neuroradiol 1996;17:593—6. 8. Davies RS, Burgin M. MRI appearances of Listeria rhombencephalitis. Australas Radiol 1996;40:354—6. 9. Hof H, Nichterlein T, Kretschmar M. Management of listeriosis. Clin Microbiol Rev 1997;10:345—57. 10. Morosi S, Francisci D, Baldelli F. A case of rhombencephalitis caused by Listeria monocytogenes successfully treated with linezolid. J Infect 2006;52:e73—5. 11. Popescu GA, Saquepee M, Poisson D, Prazuck T. Treatment difficulties of a listerial rhombencephalitis in an adult patient allergic to penicillins. J Clin Pathol 2004;57:665—6. 12. Ortı´n-Castan ˜o A, Moreiro MT, Ine ´s S, de la Calle B, Rodrı´guezEncinas A. Rhombencephalitis due to Listeria monocytogenes. Probable usefulness of dexamethasone associated with antibiotic treatment. Rev Neurol 2002;34:830—2.
http://intl.elsevierhealth.com/journals/ijid
CASE REPORT
Listerial rhombencephalitis in an immunocompetent young adult ¨ nal Kayaaslan a, Esragu ¨khan Go ¨zel a, Bircan U ¨l Akıncı a,*, S¸ule Bilen b, Mustafa Go Deniz Erdem c, Mustafa Aydın C ¸evik a, Hu ¨rrem Bodur a a
Ankara Numune Education and Research Hospital, Clinic of Infectious Diseases and Clinical Microbiology, Ankara, Turkey Ankara Numune Education and Research Hospital, Clinic of Neurology, Ankara, Turkey c Ankara Numune Education and Research Hospital, Clinic of Anesthesiology and Reanimation, Ankara, Turkey b
Received 23 February 2008; received in revised form 31 May 2008; accepted 19 June 2008 Corresponding Editor: Craig Lee
KEYWORDS Listeria; Rhombencephalitis
Summary Listeria monocytogenes is a common cause of central nervous system infections, especially in immunosuppressed patients, infants and elderly people. Listerial rhombencephalitis is a rare and severe infection of the brainstem that is reported to have high mortality and frequent serious sequelae for survivors. We report the case of a 19-year-old healthy male who presented with listerial brainstem infection due to Listeria monocytogenes. # 2008 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
Case report A 19-year-old healthy male was admitted to our emergency room with chills, trembling, fever, nausea, vomiting, headache, diplopia and unsteady gait for two days previously. There was no history of underlying disease or other predisposing factors for listeriosis. At the time of admission, his temperature was 38.5 8C and his mental status was normal. He had left peripheral type facial paralysis, right-sided horizontal nystagmus, right-sided cerebellar ataxia, bilateral hypoactive deep tendon reflexes and hypoesthesia on the right side of the face. Neck stiffness was not detected. Laboratory values were as follows: white blood cell (WBC) * Corresponding author. Ankara Numune Education and Research Hospital, Clinic of Infectious Diseases and Clinical Microbiology, Samanpazarı 06100, Ankara, Turkey. Tel.: +90 3122878183; fax: +90 312 312 6876. E-mail address: [email protected] (E. Akıncı).
count 10.6 109/L (79% neutrophils), erythrocyte sedimentation rate (ESR) 36 mm/h and C-reactive protein (CRP) 6.9 mg/dl. A computed tomography (CT) scan of the brain was normal. Cerebrospinal fluid (CSF) examination revealed a leukocyte count of 130/mm3 (90% lymphocytes, 10% neutrophils), a protein concentration of 45 mg/dl and a glucose concentration of 71 mg/dl (blood glucose: 151 mg/dl). Cultures and Gram staining of the CSF were negative for bacteria and fungi. The patient was hospitalized with a preliminary diagnosis of viral meningoencephalitis. After taking blood cultures, treatment with intravenous acyclovir 10 mg/kg every 8 hours was introduced. Ceftriaxone 2 g every 12 hours was also added in case of the possibility of bacterial etiology. On the 2nd day of hospitalization, his condition worsened. Strabismus, dysphagia and dysarthria developed. Neurological examination revealed asymmetrical palsies of the 6th, 7th, 9th and 10th cranial nerves. Cranial diffusion magnetic resonance imaging (MRI) showed gross brainstem involvement. On the 3rd day, penicillin G 4 million units every 6 hours was
1201-9712/$36.00 # 2008 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijid.2008.06.026
¨ . Kayaaslan et al. B.U
e66
Discussion
Figure 1 Cranial diffusion MRI showing abscess formation in the left posterior side of the pons.
added to the antimicrobial therapy against possible Listeria monocytogenes infection. The patient deteriorated rapidly and developed tetraplegia, paralysis of the neck musculature, eyelid retraction and hypoventilation. He was transferred to the intensive care unit (ICU) and mechanical ventilation was initiated immediately. L. monocytogenes was yielded from the blood cultures on the 6th day. Thus, a diagnosis of listerial rhombencephalitis was confirmed. Gentamicin 80 mg every 8 hours was added to the penicillin G therapy. His neurological symptoms improved very slowly with antibiotic treatment. When cranial diffusion MRI was repeated two weeks later, abscess formation in the left posterior side of the pons (9 10 12 mm in size), with hemorrhagical changes and a nodular lesion in the centre of the medulla oblongata, was observed (Figure 1). On the 9th day of antibiotic therapy, intravenous dexamethasone 4 mg every six hours was added to his treatment and continued for 12 days. His neurological condition subsequently improved gradually. He was extubated on the 20th day of mechanical ventilation and discharged from the ICU on the 42nd day of admission. The patient stayed in hospital for 10 weeks and was given combined intravenous antibiotic therapy for L. monocytogenes. Follow-up cranial MRI examinations were performed every four weeks. At the followups, MRI examinations revealed a noticeable decrease in the extent of lesions, concomitant with considerable neurological improvement. After 10 weeks, most of the neurological signs had resolved. He was discharged home at the end of the 10th week of hospitalization, with oral treatment of amoxicillin 1 g every 8 hours and trimethoprim-sulfamethoxazole forte one tablet every 12 hours for the next three months. When CRP and ESR reached normal levels, the antibiotics were stopped. He had follow-up care for a year after antibiotic treatment. At the final visit, he still had mild left peripheral type facial paralysis and mild motor deficiency, but could walk without aid. He started a rehabilitation program and had an operation because of his strabismus. His cognitive function improved very well and he returned to his normal life. However, he was unable to attend to school because of his mild motor deficiency.
L. monocytogenes is a common cause of central nervous system (CNS) infections, especially in immunosuppressed patients, infants and elderly people. Listerial rhombencephalitis is a rare and severe infection of the brainstem that is reported to have high mortality and frequent serious sequelae for survivors.1 However, a study from Norway has indicated that brainstem encephalitis is relatively common (11%) in listeriosis.2 In contrast to other listerial CNS infections, the majority of listerial rhombencephalitis cases occur in previously healthy adults; no infections have been reported in infants.3—5 The disease has a characteristic biphasic course: a nonspecific prodrome of fever, headache, nausea and vomiting lasting about four days is followed by progressive asymmetrical cranial nerve palsies, cerebellar signs, hemiparesis or hypesthesia, and impairment of consciousness. The onset of neurological deficiencies is usually abrupt. The most frequent neurological sign is multiple cranial nerve deficiencies, most commonly affecting the 6th, 7th, 9th, 10th and 11th nerves. The syndrome progresses rapidly and sometimes has a fatal outcome.3,6 Respiratory failure or arrest was documented in about 40% of cases.3 Neck stiffness and deterioration in mental status occur in about half of patients with listerial rhombencephalitis. Usually, CRP and WBC are within normal ranges. Analyses of CSF often reveal mild, nonspecific abnormalities and lymphocyte predominance. These are consistent with viral meningoencephalitis and other nonbacterial brain infections, which might lead to delayed or missed diagnosis. Cultures of CSF were positive in 41% of cases and the rate of blood culture positivity (61%) is higher than CSF culture.3 Thus, repeated blood cultures are important for diagnosis. Initial CT of the brain often gives normal results and could be misleading. MRI is superior to CT for demonstrating rhombencephalitis.3,7,8 Subcortical abscesses located in the thalamus, pons and medulla are common in listerial rhombencephalitis; abscesses in these sites are exceedingly rare when due to other bacteria.1,3,6,7 The patient’s first cranial CTwas normal; thus rhombencephalitis was not considered initially in the differential diagnosis. The correct diagnosis was made from the characteristic MRI pictures and positive blood cultures for Listeria. Overall mortality is 51% for listerial brainstem encephalitis. Early adequate antibiotic treatment is of crucial importance to survival and reduction of neurological sequelae. When appropriate antibiotic treatment is initiated early, the rate of survival is over 70%. However, neurological sequelae develop in 61% of survivors.3 The factor that most strongly correlates with survival is the timely use of appropriate antibiotics. Ampicillin or penicillin combined with gentamicin represents the first-line treatment for listerial CNS infections.1,3 Adding gentamicin to ampicillin is preferred for synergism against bacteria. We gave a penicillin G and gentamicin combination to the patient, and then continued with a trimethoprim-sulfamethoxazole and amoxicillin combination after discharge. Some reports have demonstrated that, if aminopenicillin and trimethoprim-sulfamethoxazole are given together, the same successful results are seen.7,9 If there is an allergy to penicillin, trimethoprim-sulfamethoxazole is preferred as an alternative. A recently published article shows that linezolid
Listerial rhombencephalitis in an immunocompetent young adult is another agent that can successfully treat infection of the brainstem caused by L. monocytogenes.10 Patients with rhombencephalitis should be treated with antibiotics for at least six weeks, followed by serial MRI studies.1 The role of dexamethasone in the management of listerial CNS infections is not yet well understood. It seems to be an important agent in the treatment of most CNS infections because of its potent anti-inflammatory activity and its role in controlling cerebral edema and neurological symptoms.11 Dexamethasone is not widely used in adults with listerial infections because of the frequent association of such infections with immunodeficiency. However, some recent reports have indicated that dexamethasone might be useful in treating listerial rhombencephalitis, leading to rapid regression of neurological symptoms.11,12 In this patient, the temporal relationship between the initiation of steroid treatment and subsequent clinical improvement is the most interesting aspect; after administration of dexamethasone therapy, the neurological symptoms of the patient improved more rapidly. In conclusion, early empirical treatment with appropriate antibiotics is crucial for the favorable outcome of listerial brainstem encephalitis. However, this syndrome can be misdiagnosed at an early stage of the disease. Listeria should be kept in mind, especially in immunocompetent adult patients who develop fever, asymmetrical multiple cranial nerve palsies and focal neurological symptoms localized to the brainstem. At this point, MRI is important for the early diagnosis of rhombencephalitis. Until the diagnosis is confirmed, empirical therapy, including high dose ampicillin or penicillin effective against Listeria, should be considered. Conflict of interest: No conflict of interest to declare. No fund used for our writing. No conflict of interest exists for our writing. No ethical approval needed for our writing.
e67
Acknowledgements We wish to convey our deepest regret for the loss of our outstanding scientist Dr Mustafa Aydin Cevik.
References 1. Bennett L. Listeria monocytogenes. In: Mandell GL, Bennett JE, Dolin R, editors. Principles and Practice of Infectious Diseases. 6th edition. Philadelphia: Churchill Livingstone; 2005. p. 2478—84. 2. Antal EA, Dietrichs E, Løberg EM, Melby KK, Maehlen J. Brain stem encephalitis in listeriosis. Scand J Infect Dis 2005;37:190—4. 3. Armstrong RW, Fung PC. Brainstem encephalitis (rhombencephalitis) due to Listeria monocytogenes: case report and review. Clin Infect Dis 1993;16:689—702. 4. Smiatacz T, Kowalik MM, Hlebowicz M. Prolonged dysphagia due to Listeria-rhombencephalitis with brainstem abscess and acute polyradiculoneuritis. J Infect 2006;52:e165—7. 5. Kohler J, Winkler T, Wakhloo AK. Listeria brainstem encephalitis: two own cases and literature review. Infection 1991;19:36—40. 6. Uldry PA, Kuntzer T, Bogousslavsky J, Regli F, Miklossy J, Bille J, et al. Early symptoms and outcome of Listeria monocytogenes rhombencephalitis: 14 adult cases. J Neurol 1993;240:235—42. 7. Alper G, Knepper L, Kanal E. MR findings in listerial rhombencephalitis. AJNR Am J Neuroradiol 1996;17:593—6. 8. Davies RS, Burgin M. MRI appearances of Listeria rhombencephalitis. Australas Radiol 1996;40:354—6. 9. Hof H, Nichterlein T, Kretschmar M. Management of listeriosis. Clin Microbiol Rev 1997;10:345—57. 10. Morosi S, Francisci D, Baldelli F. A case of rhombencephalitis caused by Listeria monocytogenes successfully treated with linezolid. J Infect 2006;52:e73—5. 11. Popescu GA, Saquepee M, Poisson D, Prazuck T. Treatment difficulties of a listerial rhombencephalitis in an adult patient allergic to penicillins. J Clin Pathol 2004;57:665—6. 12. Ortı´n-Castan ˜o A, Moreiro MT, Ine ´s S, de la Calle B, Rodrı´guezEncinas A. Rhombencephalitis due to Listeria monocytogenes. Probable usefulness of dexamethasone associated with antibiotic treatment. Rev Neurol 2002;34:830—2.