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Listeria septicaemia following insertion of a dynamic hip screw: A case report and literature review
CASE REPORT – OPEN ACCESS International Journal of Surgery Case Reports 3 (2012) 448–450
Contents lists available at SciVerse ScienceDirect
International Journal of Surgery Case Reports journal homepage: www.elsevier.com/locate/ijscr
Listeria septicaemia following insertion of a dynamic hip screw: A case report and literature review Shafiq Arif Shahban a,∗ , Natarajan Manjula b , Shabih Siddiqui b a b
Academic FY2, Leicester Royal Infirmary, Leicester, LE1 5WW, UK Kettering General Hospital, NN16 8UZ, UK
a r t i c l e
i n f o
Article history: Received 22 February 2012 Received in revised form 1 May 2012 Accepted 25 May 2012 Available online 1 June 2012 Keywords: Listeria Septicaemia Listerosis Dynamic hip screw Immunosuppression Orthopaedic surgery Rheumatoid arthritis
a b s t r a c t INTRODUCTION: Listeria monocytogenes is a food borne bacterial pathogen which is rarely encountered in the United Kingdom. This rare and potentially life threatening infection has a high mortality rate and therefore requires early antimicrobial intervention. PRESENTATION OF CASE: A case report of a patient who developed Listeria septicaemia following insertion of a dynamic hip screw is described. This 84 year old immunocompromised lady had a mechanical fall at home, from which she sustained a left neck of femur fracture. She had a background of rheumatoid arthritis, and for the last 10 years had been taking 5 mg prednisolone daily. After early surgical intervention with a dynamic hip screw, she developed Listeria septicaemia, following which she was treated successfully with ampicillin and gentamicin. DISCUSSION: Infection with unusual pathogens is not uncommon amongst immunocompromised patients. Regardless of the cause, this cohort of patients’ requires increased post operative surveillance to ensure that such a complication does not go unnoticed. CONCLUSION: This case report demonstrates the importance of having a low threshold for investigation in immunocompromised patients whilst also stressing the significance of early diagnosis and intervention. © 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
1. Introduction Orthopaedic surgery contributes largely to the development of post operative infections, and, especially amongst immunocompromised geriatric patients, the risk of developing sepsis with unusual organisms, as in this case, should always be considered. The rationale behind this report is to stress the importance of always being mindful of the possibility of infection in immunosuppressed patients. Similarly this report demonstrates how early appropriate intervention can lead to a more favourable outcome. 2. Presentation of case Mrs A, an 84-year-old lady, presented to the emergency department following a simple mechanical fall at home. She presented with pain over her hip, and a pelvic X-ray demonstrated a left intertrochanteric fracture of the femur. The following day she was taken to theatre where she had dynamic hip screw inserted on that side. There were no complications pre or peri-operatively, and nothing untoward was highlighted intra-operatively. Prophylactic intravenous Cefuroxime antibiotics were given pre and post
∗ Corresponding author at: 11 Mercer Street, Dresden, Stoke-on-Trent, ST3 4ET, UK. Tel.: +44 07795175150. E-mail address: shafi[email protected] (S.A. Shahban).
operatively, as per trust guidelines. Post operative wound care included the intraoperative use of a sterile dressing followed by compression bandaging. The wound was checked and the dressing changed at 24 hour intervals – throughout which nothing untoward was noted. Past medical history of note included a 10 year history of rheumatoid arthritis, for which she had continued to take 5 mg prednisolone once a day, previous cataract surgery, cholecystectomy and the insertion of cannulated screws in the right hip. Six days following the procedure, Mrs A was progressing satisfactorily with physiotherapy and mobilising independently with a pulpit frame. Incidentally, it was noted that she developed a lowgrade fever of 38.0◦ and was later reviewed by the senior house officer. Biochemically, it was noted that she had a C-reactive protein of 86 and a mildly elevated white cell count of 12.2. Blood cultures were also sent for microscopy, culture and sensitivity. A chest X-ray at that time was normal and the urine result demonstrated a mixed growth. The operative wound was clean, dry, non erythematous and non tender and therefore a wound swab was not indicated. The following day the C-reactive protein increased to 117, but soon fell (the next day) to 104 and continued to fall, similarly the white cell count fell to 8.9, and she had been apyrexial (37.8◦ ) – paracetamol was given pro re nata for analgesic benefit. After 24 hours of incubation, both blood culture bottles grew gram positive rods, and after discussing this with the microbiology
2210-2612/$ – see front matter © 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijscr.2012.05.012
CASE REPORT – OPEN ACCESS S.A. Shahban et al. / International Journal of Surgery Case Reports 3 (2012) 448–450
team, given the background of long-term steroids, the patient was commenced on intravenous Ampicillin 2 g 4 hourly to cover for Listeria. The isolate was subsequently identified as Listeria monocytogenes (confirmed by Colindale), and found to be sensitive to Ampicillin and Gentamicin. A two week course of ampicillin (2 g intravenous 4-hourly for 10 days, and then 2 g intravenous 6hourly for 4 days) and one week course of gentamicin (dosed at 5 mg/kg, with daily monitoring of gentamicin level) was commenced. Upon examination of the patient, there were no signs to suggest meningism and a lumbar puncture was not indicated. The Health Protection Agency was notified, who then proceeded to investigate for potential sources. This lady lived at home alone and cooked her own meals. There was no history of any recent travel and no history of previous infection(s) which required hospital admission. It was concluded that this episode of Listeria septicaemia was community acquired, however no source was identified. After completion of the two week course of antimicrobial therapy, the patient was discharged with a 1-week course of amoxicillin antibiotic therapy (1 g three times a day), and at that point she was seen to be mobilising independently with a Zimmer frame, with regular paracetamol. At the routine four week follow up clinic, Mrs A was mobilising independently without any aids, and had not reported any history of a fever, wound pain or any such untoward symptoms. She had excellent, pain-free range of movement of the affected hip, and follow up radiographs were satisfactory.
3. Discussion This case report documents the journey of a patient who had been on long term steroids and then acquired Listeria septicaemia following major orthopaedic surgery. The primary objective of this case report is to demonstrate the importance of being vigilant when treating septicaemia in elderly immunocompromised patients. To add to the side-effects of steroids, increasing age leads to a decline in the immune response, which brings about changes to the lymphocyte-macrophage-system and ultimately our body’s ability to fight infection.1 Listeria monocytogenes is a gram-positive facultative anaerobic bacterium which is relatively uncommon in the United Kingdom,2 with most cases having identifiable food sources.1 This bacterium tends to cause infection in high risk individuals, including the immunosuppressed, pregnant women, foetuses, neonates and elderly patients. Listeria septicaemia has a mortality rate between 11 and 60%,1 is a medical emergency and if not treated immediately can lead to death through meningoencephalitis.3 Okada et al. studied the antimicrobial susceptibility of 201 strains of Listeria monocytogenes and found that they were all susceptible to ampicillin.3 With explicit reference to Listeria monocytogenes, Naper et al. found that in rats depleted of natural killer cells, specifically Ly49 receptor bearing cells, there was a greater bacterial load found within the spleen. Conversely, in rats with a high number of Ly49 expressing natural killer cells, resistance to Listeria species was considerably higher4 – indicating its role in defence against this organism, which is likely to have been lost in the case of Mrs A. Listeria monocytogenes, through phagocytosis, is taken up initially into dendritic cells.5 The intracellular pathogen then enters into the host cells and then into the cytoplasm; and through actin polymerisation, is able to pass from cell-to-cell,6 therefore allowing for the development of Listeria septicaemia. An alternative treatment regime to that documented in this report includes trimethoprim and sulfamethozaxole, which has been documented by Fernández Guerrero et al. to yield results similar to those which
449
support the evidence for ampicillin–gentamicin in treating human listerosis, and which was found to be a more cost effective.2 Paul et al. described how, of the 84 case-series that he reported, the risk factors for developing such an infection included; increasing age, immunosuppression, pregnant ladies and neonates. Additionally, he highlighted a strong correlation between the occurrences of Listeria monocytogenes in already hospitalised patients’.7 In Cornwall, England, Robins et al. published a case report of a patient who was 18-years post total hip replacement and presented with a febrile illness and severe hip pain on that side. A radiograph demonstrated an abscess around the prosthesis, which was drained and found to contain Listeria monocytogenes – despite a negative blood culture. This paper demonstrates the late presentation with this infection and again the successful treatment with ampicillin and gentamicin antibiotics.8 The Health Protection Agency have reported the figures of pregnancy associated and non-pregnancy associated cases of Listeria in England and Wales between 1983 and 2010 which show an overall decline in the number of pregnancy associated cases since the 1990s. This is thought to be due to better awareness and education of pregnant women with regards to avoiding high risk foods such as soft cheese, pate, etc. In fact, the non-pregnancy associated cases have been 4–6 times more common than pregnancy associated cases in the last two decades. In 2010 there had been a reduction in the number of Listeria cases; however, in comparison to the data published in the 1990s the absolute numbers are considerably higher.9 Gottesman-Yekutieli et al. reports a rare case of Pseudallescheria boydii infection in a prosthetic hip joint,10 where the prosthesis was found to be the source and thus necessitating removal and surgical debridement. This stresses the importance of bearing in mind the possibility of obscure pathogens in immunocompromised individuals. 4. Conclusion Elderly, immunosuppressed patients are at a higher risk of developing post-operative infection with any potential obscure or common pathogen. A low threshold for investigation in such highrisk patient groups, a high index of suspicion and early initiation of appropriate antimicrobial therapy will result in a more favourable outcome – as demonstrated in this case. Conflict of interest statement None. Funding None. Ethical approval Consent gained from patient. Patient details are anonymised within the case report. I have obtained written consent from the patient and I am happy to provide this if necessary. Signed consent form is attached. Author contributions Shafiq A. Shahban is the main author. References 1. Harris J. Listeria monocytogenes – which of your patients is not at risk? Australian Nursing Journal 2008;16(1):26–8.
CASE REPORT – OPEN ACCESS 450
S.A. Shahban et al. / International Journal of Surgery Case Reports 3 (2012) 448–450
2. Fernández Guerrero ML, Torres R, Mancebo B, et al. Antimicrobial treatment of invasive non-perinatal human listeriosis and the impact of the underlying disease on prognosis. Clinical Microbiology and Infection 2011, http://dx.doi.org/10.1111/j.1469-0691.2011.03616.x. 3. Okada Y, Okutani A, Suzuki H, et al. Antimicrobial susceptibilities of Listeria monocytogenes isolated in Japan. Journal of Veterinary Medical Science 2011 [Online ISSN: 1347-7439]. 4. Naper C, Shegarfi H, Inngjerdingen M, Rolstad B. The role of natural killer cells in the defense against Listeria monocytogenes lessons from a rat model. Journal of Innate Immunity 2011;3(3):289–97. 5. Kolb-Maurer A, Kurzai O, Goebel W, Frosch M. The role of human dendritic cells in meningococcal and listerial meningitis. International Journal of Medical Microbiology 2003;293(4):241–9.
6. Rouquette C, Berche P. The pathogenesis of infection by Listeria monocytogenes. Microbiologia 1996;12(2):245–58. 7. Paul ML, Dwyer DE, Chow C, et al. Listerosis – a review of eighty-four cases. Medical Journal of Australia 1994;160(8):489–93. 8. Robins RH, Brunton WA. Listeria infection in an old hip implant. International Orthopaedics 1992;16(3):235–6. 9. Health Protection Agency. Decrease in listerosis incidence in England and Wales in 2010. Health Protection Report 2011;5(13). 10. Gottesman-Yekutieli T, Shwartz O, Edelman A, Hendel D, Dan M. Pseudallescheria boydii infection of a prosthetic hip joint – an uncommon infection in a rare location. American Journal of the Medical Sciences 2011;342(3):250–3.
Open Access This article is published Open Access at sciencedirect.com. It is distributed under the IJSCR Supplemental terms and conditions, which permits unrestricted non commercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.
Contents lists available at SciVerse ScienceDirect
International Journal of Surgery Case Reports journal homepage: www.elsevier.com/locate/ijscr
Listeria septicaemia following insertion of a dynamic hip screw: A case report and literature review Shafiq Arif Shahban a,∗ , Natarajan Manjula b , Shabih Siddiqui b a b
Academic FY2, Leicester Royal Infirmary, Leicester, LE1 5WW, UK Kettering General Hospital, NN16 8UZ, UK
a r t i c l e
i n f o
Article history: Received 22 February 2012 Received in revised form 1 May 2012 Accepted 25 May 2012 Available online 1 June 2012 Keywords: Listeria Septicaemia Listerosis Dynamic hip screw Immunosuppression Orthopaedic surgery Rheumatoid arthritis
a b s t r a c t INTRODUCTION: Listeria monocytogenes is a food borne bacterial pathogen which is rarely encountered in the United Kingdom. This rare and potentially life threatening infection has a high mortality rate and therefore requires early antimicrobial intervention. PRESENTATION OF CASE: A case report of a patient who developed Listeria septicaemia following insertion of a dynamic hip screw is described. This 84 year old immunocompromised lady had a mechanical fall at home, from which she sustained a left neck of femur fracture. She had a background of rheumatoid arthritis, and for the last 10 years had been taking 5 mg prednisolone daily. After early surgical intervention with a dynamic hip screw, she developed Listeria septicaemia, following which she was treated successfully with ampicillin and gentamicin. DISCUSSION: Infection with unusual pathogens is not uncommon amongst immunocompromised patients. Regardless of the cause, this cohort of patients’ requires increased post operative surveillance to ensure that such a complication does not go unnoticed. CONCLUSION: This case report demonstrates the importance of having a low threshold for investigation in immunocompromised patients whilst also stressing the significance of early diagnosis and intervention. © 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
1. Introduction Orthopaedic surgery contributes largely to the development of post operative infections, and, especially amongst immunocompromised geriatric patients, the risk of developing sepsis with unusual organisms, as in this case, should always be considered. The rationale behind this report is to stress the importance of always being mindful of the possibility of infection in immunosuppressed patients. Similarly this report demonstrates how early appropriate intervention can lead to a more favourable outcome. 2. Presentation of case Mrs A, an 84-year-old lady, presented to the emergency department following a simple mechanical fall at home. She presented with pain over her hip, and a pelvic X-ray demonstrated a left intertrochanteric fracture of the femur. The following day she was taken to theatre where she had dynamic hip screw inserted on that side. There were no complications pre or peri-operatively, and nothing untoward was highlighted intra-operatively. Prophylactic intravenous Cefuroxime antibiotics were given pre and post
∗ Corresponding author at: 11 Mercer Street, Dresden, Stoke-on-Trent, ST3 4ET, UK. Tel.: +44 07795175150. E-mail address: shafi[email protected] (S.A. Shahban).
operatively, as per trust guidelines. Post operative wound care included the intraoperative use of a sterile dressing followed by compression bandaging. The wound was checked and the dressing changed at 24 hour intervals – throughout which nothing untoward was noted. Past medical history of note included a 10 year history of rheumatoid arthritis, for which she had continued to take 5 mg prednisolone once a day, previous cataract surgery, cholecystectomy and the insertion of cannulated screws in the right hip. Six days following the procedure, Mrs A was progressing satisfactorily with physiotherapy and mobilising independently with a pulpit frame. Incidentally, it was noted that she developed a lowgrade fever of 38.0◦ and was later reviewed by the senior house officer. Biochemically, it was noted that she had a C-reactive protein of 86 and a mildly elevated white cell count of 12.2. Blood cultures were also sent for microscopy, culture and sensitivity. A chest X-ray at that time was normal and the urine result demonstrated a mixed growth. The operative wound was clean, dry, non erythematous and non tender and therefore a wound swab was not indicated. The following day the C-reactive protein increased to 117, but soon fell (the next day) to 104 and continued to fall, similarly the white cell count fell to 8.9, and she had been apyrexial (37.8◦ ) – paracetamol was given pro re nata for analgesic benefit. After 24 hours of incubation, both blood culture bottles grew gram positive rods, and after discussing this with the microbiology
2210-2612/$ – see front matter © 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijscr.2012.05.012
CASE REPORT – OPEN ACCESS S.A. Shahban et al. / International Journal of Surgery Case Reports 3 (2012) 448–450
team, given the background of long-term steroids, the patient was commenced on intravenous Ampicillin 2 g 4 hourly to cover for Listeria. The isolate was subsequently identified as Listeria monocytogenes (confirmed by Colindale), and found to be sensitive to Ampicillin and Gentamicin. A two week course of ampicillin (2 g intravenous 4-hourly for 10 days, and then 2 g intravenous 6hourly for 4 days) and one week course of gentamicin (dosed at 5 mg/kg, with daily monitoring of gentamicin level) was commenced. Upon examination of the patient, there were no signs to suggest meningism and a lumbar puncture was not indicated. The Health Protection Agency was notified, who then proceeded to investigate for potential sources. This lady lived at home alone and cooked her own meals. There was no history of any recent travel and no history of previous infection(s) which required hospital admission. It was concluded that this episode of Listeria septicaemia was community acquired, however no source was identified. After completion of the two week course of antimicrobial therapy, the patient was discharged with a 1-week course of amoxicillin antibiotic therapy (1 g three times a day), and at that point she was seen to be mobilising independently with a Zimmer frame, with regular paracetamol. At the routine four week follow up clinic, Mrs A was mobilising independently without any aids, and had not reported any history of a fever, wound pain or any such untoward symptoms. She had excellent, pain-free range of movement of the affected hip, and follow up radiographs were satisfactory.
3. Discussion This case report documents the journey of a patient who had been on long term steroids and then acquired Listeria septicaemia following major orthopaedic surgery. The primary objective of this case report is to demonstrate the importance of being vigilant when treating septicaemia in elderly immunocompromised patients. To add to the side-effects of steroids, increasing age leads to a decline in the immune response, which brings about changes to the lymphocyte-macrophage-system and ultimately our body’s ability to fight infection.1 Listeria monocytogenes is a gram-positive facultative anaerobic bacterium which is relatively uncommon in the United Kingdom,2 with most cases having identifiable food sources.1 This bacterium tends to cause infection in high risk individuals, including the immunosuppressed, pregnant women, foetuses, neonates and elderly patients. Listeria septicaemia has a mortality rate between 11 and 60%,1 is a medical emergency and if not treated immediately can lead to death through meningoencephalitis.3 Okada et al. studied the antimicrobial susceptibility of 201 strains of Listeria monocytogenes and found that they were all susceptible to ampicillin.3 With explicit reference to Listeria monocytogenes, Naper et al. found that in rats depleted of natural killer cells, specifically Ly49 receptor bearing cells, there was a greater bacterial load found within the spleen. Conversely, in rats with a high number of Ly49 expressing natural killer cells, resistance to Listeria species was considerably higher4 – indicating its role in defence against this organism, which is likely to have been lost in the case of Mrs A. Listeria monocytogenes, through phagocytosis, is taken up initially into dendritic cells.5 The intracellular pathogen then enters into the host cells and then into the cytoplasm; and through actin polymerisation, is able to pass from cell-to-cell,6 therefore allowing for the development of Listeria septicaemia. An alternative treatment regime to that documented in this report includes trimethoprim and sulfamethozaxole, which has been documented by Fernández Guerrero et al. to yield results similar to those which
449
support the evidence for ampicillin–gentamicin in treating human listerosis, and which was found to be a more cost effective.2 Paul et al. described how, of the 84 case-series that he reported, the risk factors for developing such an infection included; increasing age, immunosuppression, pregnant ladies and neonates. Additionally, he highlighted a strong correlation between the occurrences of Listeria monocytogenes in already hospitalised patients’.7 In Cornwall, England, Robins et al. published a case report of a patient who was 18-years post total hip replacement and presented with a febrile illness and severe hip pain on that side. A radiograph demonstrated an abscess around the prosthesis, which was drained and found to contain Listeria monocytogenes – despite a negative blood culture. This paper demonstrates the late presentation with this infection and again the successful treatment with ampicillin and gentamicin antibiotics.8 The Health Protection Agency have reported the figures of pregnancy associated and non-pregnancy associated cases of Listeria in England and Wales between 1983 and 2010 which show an overall decline in the number of pregnancy associated cases since the 1990s. This is thought to be due to better awareness and education of pregnant women with regards to avoiding high risk foods such as soft cheese, pate, etc. In fact, the non-pregnancy associated cases have been 4–6 times more common than pregnancy associated cases in the last two decades. In 2010 there had been a reduction in the number of Listeria cases; however, in comparison to the data published in the 1990s the absolute numbers are considerably higher.9 Gottesman-Yekutieli et al. reports a rare case of Pseudallescheria boydii infection in a prosthetic hip joint,10 where the prosthesis was found to be the source and thus necessitating removal and surgical debridement. This stresses the importance of bearing in mind the possibility of obscure pathogens in immunocompromised individuals. 4. Conclusion Elderly, immunosuppressed patients are at a higher risk of developing post-operative infection with any potential obscure or common pathogen. A low threshold for investigation in such highrisk patient groups, a high index of suspicion and early initiation of appropriate antimicrobial therapy will result in a more favourable outcome – as demonstrated in this case. Conflict of interest statement None. Funding None. Ethical approval Consent gained from patient. Patient details are anonymised within the case report. I have obtained written consent from the patient and I am happy to provide this if necessary. Signed consent form is attached. Author contributions Shafiq A. Shahban is the main author. References 1. Harris J. Listeria monocytogenes – which of your patients is not at risk? Australian Nursing Journal 2008;16(1):26–8.
CASE REPORT – OPEN ACCESS 450
S.A. Shahban et al. / International Journal of Surgery Case Reports 3 (2012) 448–450
2. Fernández Guerrero ML, Torres R, Mancebo B, et al. Antimicrobial treatment of invasive non-perinatal human listeriosis and the impact of the underlying disease on prognosis. Clinical Microbiology and Infection 2011, http://dx.doi.org/10.1111/j.1469-0691.2011.03616.x. 3. Okada Y, Okutani A, Suzuki H, et al. Antimicrobial susceptibilities of Listeria monocytogenes isolated in Japan. Journal of Veterinary Medical Science 2011 [Online ISSN: 1347-7439]. 4. Naper C, Shegarfi H, Inngjerdingen M, Rolstad B. The role of natural killer cells in the defense against Listeria monocytogenes lessons from a rat model. Journal of Innate Immunity 2011;3(3):289–97. 5. Kolb-Maurer A, Kurzai O, Goebel W, Frosch M. The role of human dendritic cells in meningococcal and listerial meningitis. International Journal of Medical Microbiology 2003;293(4):241–9.
6. Rouquette C, Berche P. The pathogenesis of infection by Listeria monocytogenes. Microbiologia 1996;12(2):245–58. 7. Paul ML, Dwyer DE, Chow C, et al. Listerosis – a review of eighty-four cases. Medical Journal of Australia 1994;160(8):489–93. 8. Robins RH, Brunton WA. Listeria infection in an old hip implant. International Orthopaedics 1992;16(3):235–6. 9. Health Protection Agency. Decrease in listerosis incidence in England and Wales in 2010. Health Protection Report 2011;5(13). 10. Gottesman-Yekutieli T, Shwartz O, Edelman A, Hendel D, Dan M. Pseudallescheria boydii infection of a prosthetic hip joint – an uncommon infection in a rare location. American Journal of the Medical Sciences 2011;342(3):250–3.
Open Access This article is published Open Access at sciencedirect.com. It is distributed under the IJSCR Supplemental terms and conditions, which permits unrestricted non commercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.