TBA (16S145)

Double Trouble: Pneumocystis Pneumonia and Listeria Meningitis in a patient treated with Infliximab for Ulcerative Colitis

Author(s)

Power, D[1]., Jackson, L[1]., Murphy, O[1]., McCarthy, J[1]., Horgan, M[2].

Department(s)/Institutions

1. Department of Gastroenterology, Bon Secour Hospital, College Road., Cork 2. Department of Infectious Disease, Cork University Hospital., Wilton, Cork

Introduction

Anti-TNF-α therapy is associated with an increased risk of opportunistic infection in patients with Inflammatory Bowel Disease.We present the rare case of a patient with concomitant Listeria monocytogenes meningitis and Pneumocystis carinii pneumonia (PCP) following one infliximab infusion for Ulcerative Colitis (UC).

Aims/Background

A 55-year-old female with a 3-year history of UC, maintained on 5-aminosalycilic acid, presented with an acute episode of colitis which was confirmed endoscopically. The patient was started on IV corticosteroids and antibiotic therapy (Metronidazole and Ciprofloxacin). Following poor clinical response, she was commenced on Infliximab (5mg/kg) after usual pre-screening investigations. The patient experience a significant clinical improvement and was discharged home on a tapering corticosteroid dose. Pre-assessment for the second Infliximab infusion revealed new onset fatigue, lower back pain and ataxia. Raised CRP [149.5] and ESR [32] were demonstrated on routine pre-Infliximab bloods. The patient was admitted acutely for septic screen which was initally negative - with normal chest radiography, MRI Spine, urine and blood cultures. The patient subsequently deteriorated, developing headache with meningism over the next 24 hours. Lumbar puncture and MRI Brain showed evidence of severe bacterial meningitis [CSF WCC: 1917/μL, Blood Glucose <0.3mmol/L, Protein 1,854g/dL] - with CSF cultures positive for Listeria Monocytogenes. An extended course of IV Amoxicillin (2mg q4h) was commenced to good clinical response. 2 weeks into admission the patient developed new onset dry cough. CT Thorax revealed ground glass opacification of the right upper lobes. Bronchoalveolar lavage confirmed the diagnosis of Pneumocystis Pneumonia. Treatment was instigated with Dapsone (100mg OD) and corticosteroids for concomitant infections and the patient experienced a successful clinical outcome.

Conclusions

This is the first case report in the literature of concomitant L.Monocytogenes meningitis and PCP in IBD. This case highlights the risk of significant opportunistic infection in patients on anti-TNF-α therapy[1]. Prophylactic TMP/SMX has been suggested to minimise PCP risk in those individuals on >3 immunosupprressive agents with IBD[2]. Similarly, dietary avoidance of high risk foods for L.Monocytogenes has been suggested for patients commenced on Infliximab[3]. Careful monitoring of patients on immunomodulatory therapy in IBD is required to enable early recognition and decreased mortality.