Case Studies

 Case 3.9 Listeria monocytogenes meningitis

A 24-year-old woman presented with a 3-week history of tiredness, a facial rash and progressive swelling of her ankles. There was no past medical or family history of note. On examination, she was pale and pyrexial (temperature 38.2°C) with a 'butterfly' rash on her face. There was gross oedema to her sacrum and her blood pressure was 180/100. Routine ward urinalysis showed haematuria (2+) and proteinuria (3+). The clinical diagnosis was nephrotic syndrome, probably due to systemic lupus erythematosus. This was supported by the laboratory results: her haemoglobin was 91g/l with a white-cell count of 3.2 x 10⁹/l and an erythrocyte sedimentation rate (ESR) of 110mm/h. C-reactive protein was normal. Her antinuclear antibody was strongly positive (titre: >1/10000) and she had serum antibodies to dsDNA (98% binding; normal <25%). There was marked complement consumption: C3 was 0.36g/l (NR 0.8-1.4) and C4 0.08g/l (NR 0.2-0.4). Her serum albumin was 27g/l with proteinuria of 7.5g per day.

Her renal lupus (see Section 9.6) was aggressively treated with high-dose methylprednisolone, azathioprine and thrice-weekly plasma exchange. However, 4 weeks later, she suddenly became unusually agitated and disorientated, with mild neck stiffness. Cerebrospinal fluid (CSF) showed a raised protein concentration of 0.85g/l (NR 0.1-0.4) with 10⁴ polymorphs/mm³. Cultures of blood and CSF grew Listeria monocytogenes. The meningitis was treated with ampicillin and her mental state rapidly returned to normal.