Neuroimaging in Listeria Rhombencephalitis: Hydrocephalus and Parenchymal Hemorrhages as Key Findings
Year: 2025
Type: article
Study design: Case Report
Abstract: A 41-year-old man with poorly controlled type 2 diabetes presented with acute onset fever, headache, mild somnolence, and seizures for 2 days. MR imaging (MRI) of the brain revealed leptomeningeal enhancement and mild hydrocephalus [Figure 1a]. His cerebrospinal fluid (CSF) had 668 cells/mm3 (neutrophils 12% and lymphocytes 88%), increased proteins (1.76 g/L), hypoglycorrhachia (6.93 mmol/L, corresponding blood sugar 18.87 mmol/L) and a positive polymerase chain reaction for Listeria monocytogenes. He was started on intravenous ampicillin (2 g IV every 4 hours) and gentamicin (1.7 mg/kg IV every 8 hours). He became unresponsive on the seventh day [increase in hydrocephalus—Figure 1b-d] and transiently improved with external ventricular drainage (EVD). On the thirteenth day, he developed paradoxical respiration and unidirectional horizontal jerk nystagmus to the left side. A repeat MRI showed new parenchymal lesions, hemorrhages, and ependymal and leptomeningeal enhancement [Figure 1e–j]. After adding meropenem (2 g IV every 8 hours) to ampicillin and gentamicin, he completely improved.Figure 1: MRI brain on day five of the illness: Post gadolinium 3D T1W axial image (a) showing diffuse leptomeningeal enhancement (short arrow) and mild hydrocephalus (long arrow) suggestive of meningitis; axial diffusion-weighted sequence (b) showing an ovoid focus of hyperintensity (arrow) in the left middle cerebellar peduncle with corresponding low values in apparent diffusion coefficient (ADC) maps (c) indicating diffusion restriction due to acute infarct; Fluid-attenuated inversion recovery (FLAIR) axial sequences (d) on day seven showing interval increase in hydrocephalus. MRI brain on day 13 of the illness (e–j): Sagittal T2WI (e) showing hyperintense lesions in the left posterior cingulate gyrus (long arrow) and in the isthmus and splenium of corpus callosum (short arrow); axial T2W sequences (f) showing hyperintense lesions in the upper dorsal medulla (long arrow) and left flocculonodular lobe (short arrow); axial susceptibility weighted image (SWI) demonstrating areas of blooming (arrow) in the left flocculonodular lobe (g), ependymal margins of both lateral ventricles and choroid plexus (h) and, the subcortical and deep white matter of supratentorial brain parenchyma (i) indicative of parenchymal and intraventricular microbleeds; axial FLAIR post-contrast image (j) showing bilateral leptomeningeal and ependymal enhancement (progression of meningitis)The clinical course in the Listeria rhombencephalitis is usually biphasic, a flu-like prodrome followed by brainstem dysfunction including cranial nerve palsies.[1,2] Radiological abnormalities include meningeal enhancement, non-specific white matter lesions, dilated Virchow Robin spaces, brain abscess, hydrocephalus, vasculitis, and hemorrhages. Hemorrhages are rare and occur as micro-bleeds or hematomas, seen in the brainstem, cerebellum, or supratentorial locations.[3,4] High endothelial tropism of Listeria may explain vasculitis-related hemorrhages.[4] Recognizing the neuroimaging features of neurolisteriosis, like acute infarcts, hemorrhages, and hydrocephalus, help clinicians in suspecting Listeria rhombencephalitis and start early empirical antibiotics.[3,4] Patient consent The consent for publication has been obtained from the patient. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Source: Neurology India
Authors: Sayooja Sachithanandan, Adarsh Anil, Asish Vijayaraghavan, Soumya Sundaram, Sajith Sukumaran
Language: English
Subfield: Microbiology
Field: Immunology and Microbiology
Domain: Life Sciences
Open Access status: hybrid
OpenAlex ID: W4409498038