Case Reports © 1991 S. Karger AG, Basel 0378-7346/91/0313-0179S2.75/0
Gynecol Obstet Invest 1991;31:179-181
Maternal-Fetal Listeriosis: 2 Case Reports Jens Svarea, Lars Franch Andersena, Jens Langhoff-Roosa, Hans Madsena, Brita Bruunb a Department of Obstetrics and Gynecology, Rigshospitalet, University of Copenhagen, and bStatens Seruminstitut, Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark
Key Words. Perinatal listeriosis • Preterm labor • Neonatal infection
Introduction Listeria monocytogenes has a special predilection for pregnant women and their fetuses, probably because of depressed cell-mediated immunity during pregnancy [13]. Approximately half of the cases of listeriosis have been reported to occur in pregnant women and neonates [2, 4], Listeriosis in pregnancy may cause spontaneous abortion, fetal death, preterm delivery and neonatal septicemia/meningitis with a high mortality [1,4, 5]. Since promptly instituted antibiotic therapy appears to be cru cial for the prognosis of the fetus or neonate, it is impor tant to be aware of listeriosis as a differential diagnosis in pregnant women with fever of unknown origin and preterm labor. We therefore report 2 cases of maternal listeriosis resulting in preterm delivery and severe neo natal disease.
Case Reports Case 1. A 28-year-old gravida II, para II was hospitalized at 32 weeks of gestation because of pyrexia, influenza-like symptoms and preterm labor. Uterine tenderness was not found. Cultures from the
urine and cervix showed no growth of L. monocytogenes. Blood culturing was not done. Tocolytic therapy with ritodrine infusion was instituted, as were betamethasone injections for fetal lung mat uration. Preterm labor was arrested but recurred 2 days later. Re instituted tocolytic therapy was unsuccessful and a 2,470 g male infant with Apgar scores 9 at 1 min and 10 at 5 min was delivered vaginally. Because of mild signs of respiratory distress and petechia, cul tures of umbilical cord blood and cerebrospinal fluid were taken from the infant, and intravenous treatment with ampicillin and gen tamicin was started. L. monocytogenes was grown from the blood and cerebrospinal fluid. The infant required artificial ventilation and suffered from convulsions and one episode of cardiac arrest. An ultrasonic scan of the brain showed intraventricular hemorrhage. Treatment with ampicillin and gentamicin continued for 3 and 2 weeks, respectively. The infant was discharged from the hospital, slightly hypotonic, at 5 weeks of age, but was readmitted 6 weeks later because of hydrocephalus. A cerebral CT scan at this time showed grossly dilated ventricles, necessitating establishment of a ventriculo-peritoneal shunt. At 3 months of age the infant appeared moderately retarded with reduced muscular tone. The mother was given antibiotics for 7 days because of postpar tum fever and she became afebrile after 1 day of treatment. Cultures of urine and cervix taken 8 days after delivery were negative for L. monocytogenes. Case 2. A 25-year-old gravida II, para I was hospitalized at 34 weeks of gestation because of pyrexia, influenza-like symptoms and preterm labor. Uterine tenderness was not found. Tocolytic therapy
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Abstract. Two cases of maternal-fetal infection with Listeria monocytogenes are reported. Both women were admitted with influenza-like symptoms and preterm labor at 32 and 34 weeks of gestation, respectively. The infants were delivered within a few days of onset of maternal symptoms. One infant was seriously ill with meningitis and subsequently developed hydrocephalus. The other infant suffered from septicemia, but had no sequelae. It is recom mended always to consider the diagnosis listeriosis in pregnant women with fever of unknown origin and preterm labor.
Svare/Andersen/Langhoff-Roos/Madsen/Bruun
180
Discussion L. monocytogenes is an ubiquitous microorganism found in soil, on vegetation and in water. Fecal carriage of L. monocytogenes occurs in 1-15 % of the population [1, 6]. Other sites of carriage and theoretical sources of infection include the vagina/cervix and the pharynx [1, 5], However, alimentary transmission is considered the most common mode of infection, and food has been incriminated as the cause of outbreaks of listeriosis [7, 8]. During the last decade there appears to have been an increase in the incidence of listeriosis in Northern Eu rope [1, 7], the disease affecting not only pregnant women and immunocompromised persons, but also ap parently healthy persons. The symptoms of maternal listeriosis are uncharacter istic, consisting of fever, headache and muscular pain [9-11). A diagnosis of influenza is often made, as in the present cases. Symptoms and signs of fetal death, spon taneous abortion or preterm labor may occur, but signs of overt intraamniotic infection are often absent [1214], The maternal symptoms tend to disappear quickly after delivery of the fetus [4], The route of L. monocytogenes infection of the fetus and neonate is still under debate [1,4, 15]. The most common route is probably hematogenous spread of the bacteria from the gastrointestinal tract via the placenta and the umbilical vein to the fetus, but ascending infec tion from the vagina and cervix is also possible [1,4, 15]. Furthermore the fetus may be infected during delivery
by the passage of a contaminated birth canal, and infec tions due to nosocomial spread among neonates have also been reported [1,4, 15, 16], Neonatal listeriosis may occur within a few hours or days of the birth - ‘early onset disease’ - most often as septicemia or meningitis with a high mortality. ‘Late onset disease’ is seen several days or weeks postpartum and has a much better prognosis [1,4, 16], The diagnosis of listeriosis should be considered dur ing pregnancy in cases with fever of unknown origin and preterm labor. Cervical and blood cultures should be taken, and amniocentesis should be considered. Micros copy of a Gram stain of amniotic fluid offers a fairly certain diagnosis within 1 h. When the diagnosis is sus pected, treatment with intravenous ampicillin and an aminoglycoside should be started [1,5, 15, 16], as recent reports indicate that prompt maternal antibiotic treat ment can prevent fetal infection [4, 10]. Dependent on the age of gestation and the condition of the fetus, imme diate delivery should be considered [11]. The present cases serve to illustrate the importance of promptly instituted antibiotic therapy and immediate delivery in cases with high gestational ages. In the 1st case correct diagnosis and therapy were delayed, result ing in severe illness and long-term sequelae in the infant. In the 2nd case prompt antibiotic therapy and delivery took place and the infant only suffered from a relatively mild disease with no apparent sequelae.
References 1 Lamont RJ, Postlethwaite R, Macgowan AP: Listeria monocyto genes and its role in human infection. J Infect 1988;17:7-28. 2 Watts DH, Eschenbach DA: Reproductive tract infections as a cause of abortion and preterm birth. Semin Reprod Endocrinol 1988;6:203-215. 3 Weinberg ED: Pregnancy-associated depression of cell-mediated immunity. Rev Infect Dis 1984;6:814-831. 4 Larsson S: Human listeriosis in Sweden; thesis Malmö, 1978. 5 Seeliger HPR, Finger H: Listeriosis; in Remington JS, Klein JO (eds): Infectious Diseases of the Fetus and Newborn Infant. Phil adelphia, Saunders, 1983, pp 264-289. 6 Bojsen-Moller J: Human listeriosis. Diagnostic, epidemiological and clinical studies; thesis Copenhagen, 1971. 7 Editorial: Is Listeriosis often a foodbome illness. J Infect 1988; 17:1-5. 8 WHO Working Group: Foodbome listeriosis. Bull WHO 1988; 66:421-428. 9 Evans JR, Allen AC, Stinson DA, Bortolussi R, Peddle LJ: Peri natal listeriosis: Report of an outbreak. Pediatr Infect Dis 1985; 4:237-241. 10 Zervoudakis IA, Cederquist LL: Effect of Listeria monocyto-
Downloaded by: King's College London 137.73.144.138 - 12/1/2017 6:58:29 PM
with ritodrine infusion was instituted together with betamethasone injections. Cultures from the urine and cervix were taken, and amniocentesis was performed. The amniotic fluid was brownish, and on suspicion of intraamniotic infection oral treatment with pivampicillin and metronidazole was started. Tocolytic therapy was stopped and labor was stimulated with oxytocin infusion. Because of lack of progression a cesarean section was performed and a 2,640 g female infant with Apgar scores 3 at 1 min and 10 at 10 min was delivered. The amniotic fluid yielded growth of L. monocytogenes, while urine and cervical cultures were negative. Because of suspected infection, superficial swabs, blood and cerebrospinal fluid cultures were taken from the infant and intrave nous treatment with ampicillin and gentamicin was started. L. monocytogenes was grown from the blood and the tracheal swab, but not from the spinal fluid. The infant required a minimal oxygen supplementation initially, but recovery was otherwise uneventful. Antibiotics were continued for 10 days. The infant remained well and was developing normally when seen 4 months later. The mother was given antibiotics for 10 days postpartum and quickly became afebrile.
181
Maternal-Fetal Listeriosis
12
13
14
15 Spencer JAD: Perinatal listeriosis. Br Med J 1987;295:349. 16 Editorial: Perinatal listeriosis. Lancet 1980;i:911.
Received: September 13, 1990 Accepted: September 28, 1990 Jens Svare Department of Obstetrics and Gynecology Herlev Hospital Herlev Ringvej DK-2730 Herlev Hvidovre (Denmark)
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11
genes septicemia during pregnancy on the offspring. Am J Obstet Gynecol 1977;129:465-467. Halliday HL, Hirata T: Perinatal listeriosis - A review of twelve patients. Am J Obstet Gynecol 1979;133:405-410. Romero R, Winn HN, Wan M, Hobbins JC: Listeria monocyto genes chorioamnionitis and preterm labor. Am J Perinatal 1988; 5:286-288. Valkenburg MH, Essed GGM, Potters HVPJ: Perinatal listerio sis underdiagnosed as a cause of pre-term labour? Eur J Obstet Gynecol Reprod Biol 1988;27:283-288. Makar AP, Vanderheyden JS, De Schrijver D, Keersmaekers G: Perinatal listeriosis; more common than reported. Eur J Obstet Gynecol Reprod Biol 1989;31:83-91.
Gynecol Obstet Invest 1991;31:179-181
Maternal-Fetal Listeriosis: 2 Case Reports Jens Svarea, Lars Franch Andersena, Jens Langhoff-Roosa, Hans Madsena, Brita Bruunb a Department of Obstetrics and Gynecology, Rigshospitalet, University of Copenhagen, and bStatens Seruminstitut, Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark
Key Words. Perinatal listeriosis • Preterm labor • Neonatal infection
Introduction Listeria monocytogenes has a special predilection for pregnant women and their fetuses, probably because of depressed cell-mediated immunity during pregnancy [13]. Approximately half of the cases of listeriosis have been reported to occur in pregnant women and neonates [2, 4], Listeriosis in pregnancy may cause spontaneous abortion, fetal death, preterm delivery and neonatal septicemia/meningitis with a high mortality [1,4, 5]. Since promptly instituted antibiotic therapy appears to be cru cial for the prognosis of the fetus or neonate, it is impor tant to be aware of listeriosis as a differential diagnosis in pregnant women with fever of unknown origin and preterm labor. We therefore report 2 cases of maternal listeriosis resulting in preterm delivery and severe neo natal disease.
Case Reports Case 1. A 28-year-old gravida II, para II was hospitalized at 32 weeks of gestation because of pyrexia, influenza-like symptoms and preterm labor. Uterine tenderness was not found. Cultures from the
urine and cervix showed no growth of L. monocytogenes. Blood culturing was not done. Tocolytic therapy with ritodrine infusion was instituted, as were betamethasone injections for fetal lung mat uration. Preterm labor was arrested but recurred 2 days later. Re instituted tocolytic therapy was unsuccessful and a 2,470 g male infant with Apgar scores 9 at 1 min and 10 at 5 min was delivered vaginally. Because of mild signs of respiratory distress and petechia, cul tures of umbilical cord blood and cerebrospinal fluid were taken from the infant, and intravenous treatment with ampicillin and gen tamicin was started. L. monocytogenes was grown from the blood and cerebrospinal fluid. The infant required artificial ventilation and suffered from convulsions and one episode of cardiac arrest. An ultrasonic scan of the brain showed intraventricular hemorrhage. Treatment with ampicillin and gentamicin continued for 3 and 2 weeks, respectively. The infant was discharged from the hospital, slightly hypotonic, at 5 weeks of age, but was readmitted 6 weeks later because of hydrocephalus. A cerebral CT scan at this time showed grossly dilated ventricles, necessitating establishment of a ventriculo-peritoneal shunt. At 3 months of age the infant appeared moderately retarded with reduced muscular tone. The mother was given antibiotics for 7 days because of postpar tum fever and she became afebrile after 1 day of treatment. Cultures of urine and cervix taken 8 days after delivery were negative for L. monocytogenes. Case 2. A 25-year-old gravida II, para I was hospitalized at 34 weeks of gestation because of pyrexia, influenza-like symptoms and preterm labor. Uterine tenderness was not found. Tocolytic therapy
Downloaded by: King's College London 137.73.144.138 - 12/1/2017 6:58:29 PM
Abstract. Two cases of maternal-fetal infection with Listeria monocytogenes are reported. Both women were admitted with influenza-like symptoms and preterm labor at 32 and 34 weeks of gestation, respectively. The infants were delivered within a few days of onset of maternal symptoms. One infant was seriously ill with meningitis and subsequently developed hydrocephalus. The other infant suffered from septicemia, but had no sequelae. It is recom mended always to consider the diagnosis listeriosis in pregnant women with fever of unknown origin and preterm labor.
Svare/Andersen/Langhoff-Roos/Madsen/Bruun
180
Discussion L. monocytogenes is an ubiquitous microorganism found in soil, on vegetation and in water. Fecal carriage of L. monocytogenes occurs in 1-15 % of the population [1, 6]. Other sites of carriage and theoretical sources of infection include the vagina/cervix and the pharynx [1, 5], However, alimentary transmission is considered the most common mode of infection, and food has been incriminated as the cause of outbreaks of listeriosis [7, 8]. During the last decade there appears to have been an increase in the incidence of listeriosis in Northern Eu rope [1, 7], the disease affecting not only pregnant women and immunocompromised persons, but also ap parently healthy persons. The symptoms of maternal listeriosis are uncharacter istic, consisting of fever, headache and muscular pain [9-11). A diagnosis of influenza is often made, as in the present cases. Symptoms and signs of fetal death, spon taneous abortion or preterm labor may occur, but signs of overt intraamniotic infection are often absent [1214], The maternal symptoms tend to disappear quickly after delivery of the fetus [4], The route of L. monocytogenes infection of the fetus and neonate is still under debate [1,4, 15]. The most common route is probably hematogenous spread of the bacteria from the gastrointestinal tract via the placenta and the umbilical vein to the fetus, but ascending infec tion from the vagina and cervix is also possible [1,4, 15]. Furthermore the fetus may be infected during delivery
by the passage of a contaminated birth canal, and infec tions due to nosocomial spread among neonates have also been reported [1,4, 15, 16], Neonatal listeriosis may occur within a few hours or days of the birth - ‘early onset disease’ - most often as septicemia or meningitis with a high mortality. ‘Late onset disease’ is seen several days or weeks postpartum and has a much better prognosis [1,4, 16], The diagnosis of listeriosis should be considered dur ing pregnancy in cases with fever of unknown origin and preterm labor. Cervical and blood cultures should be taken, and amniocentesis should be considered. Micros copy of a Gram stain of amniotic fluid offers a fairly certain diagnosis within 1 h. When the diagnosis is sus pected, treatment with intravenous ampicillin and an aminoglycoside should be started [1,5, 15, 16], as recent reports indicate that prompt maternal antibiotic treat ment can prevent fetal infection [4, 10]. Dependent on the age of gestation and the condition of the fetus, imme diate delivery should be considered [11]. The present cases serve to illustrate the importance of promptly instituted antibiotic therapy and immediate delivery in cases with high gestational ages. In the 1st case correct diagnosis and therapy were delayed, result ing in severe illness and long-term sequelae in the infant. In the 2nd case prompt antibiotic therapy and delivery took place and the infant only suffered from a relatively mild disease with no apparent sequelae.
References 1 Lamont RJ, Postlethwaite R, Macgowan AP: Listeria monocyto genes and its role in human infection. J Infect 1988;17:7-28. 2 Watts DH, Eschenbach DA: Reproductive tract infections as a cause of abortion and preterm birth. Semin Reprod Endocrinol 1988;6:203-215. 3 Weinberg ED: Pregnancy-associated depression of cell-mediated immunity. Rev Infect Dis 1984;6:814-831. 4 Larsson S: Human listeriosis in Sweden; thesis Malmö, 1978. 5 Seeliger HPR, Finger H: Listeriosis; in Remington JS, Klein JO (eds): Infectious Diseases of the Fetus and Newborn Infant. Phil adelphia, Saunders, 1983, pp 264-289. 6 Bojsen-Moller J: Human listeriosis. Diagnostic, epidemiological and clinical studies; thesis Copenhagen, 1971. 7 Editorial: Is Listeriosis often a foodbome illness. J Infect 1988; 17:1-5. 8 WHO Working Group: Foodbome listeriosis. Bull WHO 1988; 66:421-428. 9 Evans JR, Allen AC, Stinson DA, Bortolussi R, Peddle LJ: Peri natal listeriosis: Report of an outbreak. Pediatr Infect Dis 1985; 4:237-241. 10 Zervoudakis IA, Cederquist LL: Effect of Listeria monocyto-
Downloaded by: King's College London 137.73.144.138 - 12/1/2017 6:58:29 PM
with ritodrine infusion was instituted together with betamethasone injections. Cultures from the urine and cervix were taken, and amniocentesis was performed. The amniotic fluid was brownish, and on suspicion of intraamniotic infection oral treatment with pivampicillin and metronidazole was started. Tocolytic therapy was stopped and labor was stimulated with oxytocin infusion. Because of lack of progression a cesarean section was performed and a 2,640 g female infant with Apgar scores 3 at 1 min and 10 at 10 min was delivered. The amniotic fluid yielded growth of L. monocytogenes, while urine and cervical cultures were negative. Because of suspected infection, superficial swabs, blood and cerebrospinal fluid cultures were taken from the infant and intrave nous treatment with ampicillin and gentamicin was started. L. monocytogenes was grown from the blood and the tracheal swab, but not from the spinal fluid. The infant required a minimal oxygen supplementation initially, but recovery was otherwise uneventful. Antibiotics were continued for 10 days. The infant remained well and was developing normally when seen 4 months later. The mother was given antibiotics for 10 days postpartum and quickly became afebrile.
181
Maternal-Fetal Listeriosis
12
13
14
15 Spencer JAD: Perinatal listeriosis. Br Med J 1987;295:349. 16 Editorial: Perinatal listeriosis. Lancet 1980;i:911.
Received: September 13, 1990 Accepted: September 28, 1990 Jens Svare Department of Obstetrics and Gynecology Herlev Hospital Herlev Ringvej DK-2730 Herlev Hvidovre (Denmark)
Downloaded by: King's College London 137.73.144.138 - 12/1/2017 6:58:29 PM
11
genes septicemia during pregnancy on the offspring. Am J Obstet Gynecol 1977;129:465-467. Halliday HL, Hirata T: Perinatal listeriosis - A review of twelve patients. Am J Obstet Gynecol 1979;133:405-410. Romero R, Winn HN, Wan M, Hobbins JC: Listeria monocyto genes chorioamnionitis and preterm labor. Am J Perinatal 1988; 5:286-288. Valkenburg MH, Essed GGM, Potters HVPJ: Perinatal listerio sis underdiagnosed as a cause of pre-term labour? Eur J Obstet Gynecol Reprod Biol 1988;27:283-288. Makar AP, Vanderheyden JS, De Schrijver D, Keersmaekers G: Perinatal listeriosis; more common than reported. Eur J Obstet Gynecol Reprod Biol 1989;31:83-91.
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