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Listeria monocytogenes Meningoencephalitis During the Treatment With Rituximab and Mycophenolate Mofetil in a Patient With Pediatric-onset Systemic Lupus Erythematosus
Meningoencefalitis por Listeria monocytogenes durante el tratamiento con rituximab y micofenolato de mofetilo en una paciente con lupus eritematoso sistémico de inicio pediátrico
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"albertosifuentesg@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0015" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Carlos Antonio" "apellidos" => "Guillén Astete" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "Irene" "apellidos" => "Amil Casas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "María Luz" "apellidos" => "Gámir Gámir" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Reumatología, Hospital Universitario Ramón y Cajal, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0015" ] 1 => array:3 [ "entidad" => "Centro de Salud Benita de Ávila, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Meningoencefalitis por <span class="elsevierStyleItalic">Listeria monocytogenes</span> durante el tratamiento con rituximab y micofenolato de mofetilo en una paciente con lupus eritematoso sistémico de inicio pediátrico" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We have pointedly read the excellent review of cases of central nervous system (CNS) due to <span class="elsevierStyleItalic">Listeria monocytogenes</span> (<span class="elsevierStyleItalic">L. monocytogenes</span>) infection in patients with systemic lupus erythematosu (SLE published by Horta-Baas et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>) and would like to describe an additional case of meningoencephalitis in pediatric onset SLE (pSLE) during treatment with rituximab and mycophenolate mofetil (MMF).</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 12 year old girl from Ecuador, residing in Spain since the age of 4, with a history of uncomplicated hydrocephalus was diagnosed with pSLE in August 2008 at the age of 10, based on fever, anemia, oral ulcers, finger vasculitis, joint pain, pericarditis, pneumonitis, positive ANA and anti-DNA antibodies. She was initially treated with prednisone 2<span class="elsevierStyleHsp" style=""></span>mg/kg/day in a descending dose and hydroxicloroquine 200<span class="elsevierStyleHsp" style=""></span>mg/day with a good response but later developed type IV nephritis, pericarditis, constitutional symptoms, neurologic involvement (headache and psychiatric alterations) and type B insulin resistance syndrome (hyperinsulinism, hypoglycemia, acantosis nigricans and polycystic ovaries). She received 3 monthly boluses of cyclophosphamide (500<span class="elsevierStyleHsp" style=""></span>mg/m<span class="elsevierStyleSup">2</span> iv) between February and April 2009 without improvement and therefore was treated with rituximab (375<span class="elsevierStyleHsp" style=""></span>mg/m<span class="elsevierStyleSup">2</span>/week iv 4 doses) starting in May and, since July, with MMF (1.5<span class="elsevierStyleHsp" style=""></span>g/day) plus prednisone 35<span class="elsevierStyleHsp" style=""></span>mg/day, with renal function and disease activity improvement (ΔSLEDAI 18→6), administering a new cycle in October. She underwent an oophorectomy in November because the increase in size of annexal masses carried a high risk of complications or malignity, the latter excluded by histopathological analysis. During this internment the patient presented bacteremia associated to a urinary catheter caused by <span class="elsevierStyleItalic">Candida parasilopsis</span> and a relapse in lupus activity, being treated with 3 boluses of methylprednisolone (30<span class="elsevierStyleHsp" style=""></span>mg/kg iv) and increasing oral prednisone to 45<span class="elsevierStyleHsp" style=""></span>mg/day (1<span class="elsevierStyleHsp" style=""></span>mg/kg/day). A month after this episode she came to the emergency room due to fever, forceful vomiting which had lasted for 12<span class="elsevierStyleHsp" style=""></span>h, with no prior symptoms. At the time she was using the same dose of MMF and prednisone 35<span class="elsevierStyleHsp" style=""></span>mg/day, but maintained important lupus activity (SLEDAI 10). Upon examination she was hypotensive, with pus coming out of the subclavian catheter insertion site, a reduced consciousness level (Glasgow 13), meningeal irritation signs and asymmetric bilateral paresia of the VI pair. Blood tests showed hemoglobin 10.8<span class="elsevierStyleHsp" style=""></span>g/dl, leukocytes 20.100/mm<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> (neutrophils 94.5%), C reactive protein 103<span class="elsevierStyleHsp" style=""></span>mg/dl and procalcitonin 12<span class="elsevierStyleHsp" style=""></span>ng/dl. Cerebrospinal fluid (CSF) analysis showed pleocytosis (200/mm,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> 80% mononuclear and 20% polymorphonuclear), hypoglucorrachia (2<span class="elsevierStyleHsp" style=""></span>mg/dl), hyperproteinorrachia (1.07<span class="elsevierStyleHsp" style=""></span>g/l) and a Gram stain that was negative for microorganisms. She was hospitalized, receiving empirical treatment with cephotaxim, vancomycin and iv steroids (methylprednisolone 50<span class="elsevierStyleHsp" style=""></span>mg/day). <span class="elsevierStyleItalic">Staphylococcus epidermidis</span> was isolated in the subclavian catheter and <span class="elsevierStyleItalic">Staphylococcus aureus</span> in a blood culture, while the CSF culture was positive for <span class="elsevierStyleItalic">L. monocytogenes</span>. The diagnosis of rhomb encephalitis was proposed, due to the neurologic focalization, but the cranial magnetic resonance image (MRI) did not demonstrate compatible alterations on the brain stem or cranial nerves. Antibiotics were changed to gentamycin for 7 days plus ampicillin for 4 weeks, afterward receiving amoxicyllin for two weeks after discharge. Vancomycin was maintained for coverage of catheter associated infection. The patient's consciousness level improved 24<span class="elsevierStyleHsp" style=""></span>h after hospitalization, but the oculomotor affection took longer, until the fourth week. MMF was suspended definitely, but the patient required 3 additional cycles of rituximab in May 2010, January and June 2011 for control of nephritis. She later presented other infectious complications, including herpes zoster and subdural empiema due to <span class="elsevierStyleItalic">Streptococcus pneumoniae</span>, dying as a consequence of the latter in January 2012.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The mean age of the 26 patients in the series of CNS infection due to <span class="elsevierStyleItalic">L. monocytogenes</span> in SLE by Horta-Baas et al. was 33.5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>11.8 years.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The only pediatric case corresponded to a patient of 16 years of age previously treated with steroids, azathioprine and methotrexate, who presented meningitis with a confusional state, bilateral diplopia, nistagmus, VII cranial nerve paralysis and weakness of the upper right extremity.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Alterations in consciousness appear in 75% of cases of meningitis de to <span class="elsevierStyleItalic">L. monocytogenes</span> and the focal neurologic signs appear in 35%–40%, with the term “meningoencephalitis” being more adequate.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Cranial neuropathies most commonly seen affect cranial nerves <span class="elsevierStyleSmallCaps">III</span>, <span class="elsevierStyleSmallCaps">VI</span>, <span class="elsevierStyleSmallCaps">VII</span>, <span class="elsevierStyleSmallCaps">X</span> and <span class="elsevierStyleSmallCaps">XI</span>,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> but there appearance forces the clinician to consider the possibility of rhombencephalitis.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Regarding immunosuppressive treatment of the patients in the series by Horta-Baas et al., five cases had previously received MMF but none rituximab.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Four cases of meningitis/encephalitis due to <span class="elsevierStyleItalic">L. monocytogenes</span> associated to rituximab have been published, all of them in adult patients with an underlying hematologic malignant process.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> Infection with <span class="elsevierStyleItalic">L. monocytogenes</span> in pSLE is rare, found in the literature only in a 5 year old patient with type IV lupus nephritis, neurologic alterations and antiphospholipid syndrome who developed bacteremia due to <span class="elsevierStyleItalic">L. monocytogenes</span>, treated and solved with ampicillin.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> One aspect that is also interesting in our patient is the subsequent appearance of other severe neurologic infections after the administration of rituximab.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Sifuentes Giraldo WA, Guillén Astete CA, Amil Casas I, Gámir Gámir ML. Meningoencefalitis por <span class="elsevierStyleItalic">Listeria monocytogenes</span> durante el tratamiento con rituximab y micofenolato de mofetilo en una paciente con lupus eritematoso sistémico de inicio pediátrico. Reumatol Clin. 2015;11:125–126.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Central nervous system infection by <span class="elsevierStyleItalic">Listeria monocytogenes</span> in patients with systemic lupus erythematosus: analysis of 26 cases, including the report of a new case" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "G. Horta-Baas" 1 => "O. Guerrero-Soto" 2 => "L. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 10 | 9 | 19 |
| 2024 October | 40 | 18 | 58 |
| 2024 September | 50 | 17 | 67 |
| 2024 August | 52 | 42 | 94 |
| 2024 July | 45 | 25 | 70 |
| 2024 June | 52 | 32 | 84 |
| 2024 May | 50 | 39 | 89 |
| 2024 April | 57 | 22 | 79 |
| 2024 March | 44 | 30 | 74 |
| 2024 February | 38 | 25 | 63 |
| 2024 January | 46 | 23 | 69 |
| 2023 December | 27 | 28 | 55 |
| 2023 November | 41 | 30 | 71 |
| 2023 October | 41 | 35 | 76 |
| 2023 September | 55 | 34 | 89 |
| 2023 August | 39 | 15 | 54 |
| 2023 July | 35 | 31 | 66 |
| 2023 June | 36 | 24 | 60 |
| 2023 May | 50 | 35 | 85 |
| 2023 April | 27 | 11 | 38 |
| 2023 March | 33 | 18 | 51 |
| 2023 February | 46 | 27 | 73 |
| 2023 January | 32 | 23 | 55 |
| 2022 December | 52 | 31 | 83 |
| 2022 November | 60 | 28 | 88 |
| 2022 October | 53 | 23 | 76 |
| 2022 September | 46 | 36 | 82 |
| 2022 August | 39 | 33 | 72 |
| 2022 July | 34 | 35 | 69 |
| 2022 June | 44 | 31 | 75 |
| 2022 May | 31 | 47 | 78 |
| 2022 April | 43 | 48 | 91 |
| 2022 March | 43 | 40 | 83 |
| 2022 February | 42 | 30 | 72 |
| 2022 January | 37 | 32 | 69 |
| 2021 December | 24 | 37 | 61 |
| 2021 November | 31 | 37 | 68 |
| 2021 October | 69 | 47 | 116 |
| 2021 September | 45 | 46 | 91 |
| 2021 August | 48 | 39 | 87 |
| 2021 July | 38 | 34 | 72 |
| 2021 June | 42 | 46 | 88 |
| 2021 May | 51 | 36 | 87 |
| 2021 April | 73 | 67 | 140 |
| 2021 March | 52 | 26 | 78 |
| 2021 February | 42 | 23 | 65 |
| 2021 January | 33 | 28 | 61 |
| 2020 December | 40 | 18 | 58 |
| 2020 November | 26 | 20 | 46 |
| 2020 October | 13 | 14 | 27 |
| 2020 September | 43 | 27 | 70 |
| 2020 August | 19 | 13 | 32 |
| 2020 July | 19 | 9 | 28 |
| 2020 June | 33 | 26 | 59 |
| 2020 May | 46 | 14 | 60 |
| 2020 April | 34 | 18 | 52 |
| 2020 March | 22 | 21 | 43 |
| 2018 May | 2 | 1 | 3 |
| 2018 April | 37 | 7 | 44 |
| 2018 March | 49 | 8 | 57 |
| 2018 February | 29 | 1 | 30 |
| 2018 January | 27 | 4 | 31 |
| 2017 December | 33 | 4 | 37 |
| 2017 November | 39 | 11 | 50 |
| 2017 October | 66 | 6 | 72 |
| 2017 September | 29 | 7 | 36 |
| 2017 August | 40 | 8 | 48 |
| 2017 July | 37 | 12 | 49 |
| 2017 June | 50 | 15 | 65 |
| 2017 May | 46 | 17 | 63 |
| 2017 April | 39 | 9 | 48 |
| 2017 March | 31 | 20 | 51 |
| 2017 February | 38 | 8 | 46 |
| 2017 January | 29 | 5 | 34 |
| 2016 December | 73 | 17 | 90 |
| 2016 November | 51 | 6 | 57 |
| 2016 October | 61 | 11 | 72 |
| 2016 September | 59 | 7 | 66 |
| 2016 August | 64 | 7 | 71 |
| 2016 July | 27 | 4 | 31 |
| 2015 December | 2 | 0 | 2 |
| 2015 November | 1 | 17 | 18 |
| 2015 October | 1 | 19 | 20 |
| 2015 September | 2 | 0 | 2 |
| 2015 August | 1 | 0 | 1 |
| 2015 July | 28 | 10 | 38 |
| 2015 June | 47 | 8 | 55 |
| 2015 May | 68 | 28 | 96 |
| 2015 April | 117 | 31 | 148 |
| 2015 March | 55 | 15 | 70 |
| 2015 February | 9 | 4 | 13 |
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