A 53-year-old man with past medical history of alcohol use presented to the emergency room with a 1-month history of fatigue, night sweats, high fevers, and 20-pound weight loss over 3 months. Physical exam was significant for temperature 102.9 degrees Fahrenheit, heart rate 110 beats per minute, splenomegaly, and bilateral axillary and inguinal lymphadenopathy. Initial laboratory testing was notable for sodium 129 mmol/L, hemoglobin 7.7 g/dL, aspartase transaminase (AST) 49 U/L, alanine transaminase (ALT) 50 U/L, sedimentation rate 120 mm/hr, C-reactive protein 234 mg/L, ferritin 2950 ng/mL, otherwise normal basic chemistries and normal white blood count and platelets. Computed tomography (CT) revealed splenomegaly to 14.2 cm, mediastinal and axillary lymph nodes up to 1.2 cm in diameter, and abdominal (paracaval and paraaortic) lymph nodes up to 3 cm in diameter.
Within 24 hours of admission, blood cultures returned positive for Listeria monocytogenes. Treatment was initiated with intravenous (IV) ampicillin and gentamicin. Soon after, the patient complained of a severe headache, associated with high fevers, tachycardia, and meningeal signs. Cerebrospinal fluid (CSF) revealed 1100 cells/uL with 92% granulocytes, glucose 54 mg/dL and protein 93 mg/dL. CSF cultures for bacteria, fungi and acid-fast bacteria as well as viral studies were all negative. Headache and meningeal signs improved with treatment for presumed Listeria meningitis, however the patient continued to spike high fevers daily. Further evaluation of his lymphadenopathy with CT-guided core tissue biopsy of the retroperitoneal lymph nodes revealed fibrous adipose tissue with mixed inflammatory cell proliferation. Positron emission tomography (PET) was performed to help guide further diagnostic testing, which confirmed intensely hypermetabolic lymph nodes, most notable in the axillae, mediastinum and retroperitoneum. Excisional lymph node biopsy of axillary lymph nodes revealed classic Hodgkin lymphoma. Chemotherapy was subsequently initiated with resolution of fevers.
Listeria monocytogenes, a gram-positive facultative anaerobic rod, is well-known to affect patients with known immunocompromised states. Our patient was an unusual case in whom sepsis due to Listeria monocytogenes was the initial presentation of previously undiagnosed Hodgkin lymphoma. This case also underscores the importance of excisional lymph node biopsy for the diagnosis of Hodgkin lymphoma. Although this patient’s largest lymph nodes were in the retroperitoneum, CT-guided core biopsy of these lymph nodes was not diagnostic. Excisional biopsy of the smaller axillary lymph nodes revealed the diagnosis of Hodgkin lymphoma.
Systemic listeriosis should be considered and empirically treated in patients with suspected underlying malignancy, especially if evidence of meningitis is present. Excisional lymph node biopsy should be used for diagnosis of Hodgkin lymphoma when possible.
To cite this abstract:Xu J, Boddupalli D, Apgar S. Sepsis Due to Listeria Bacteremia As Initial Presentation of Hodgkin Lymphoma. Abstract published at Hospital Medicine 2015, March 29-April 1, National Harbor, Md. Abstract 441. Journal of Hospital Medicine. 2015; 10 (suppl 2). https://www.shmabstracts.com/abstract/sepsis-due-to-listeria-bacteremia-as-initial-presentation-of-hodgkin-lymphoma/. Accessed May 27, 2019.