Systemic lupus erythematosus (SLE) cerebritis versus Listeria monocytogenes meningoencephalitis in a patient with systemic lupus erythematosus on chronic corticosteroid therapy: The diagnostic importance of cerebrospinal fluid (CSF) of lactic acid levels

BACKGROUND: Listeria monocytogenes is a motile, aerobic, Gram-positive intracellular bacillus that causes enteritis, meningitis, meningoencephalitis, or subacute bacterial endocarditis. Patients with impaired T-lymphocyte function/cell-mediated immunity are predisposed to intracellular pathogens, e.g., L. monocytogenes. In adults, infection by L. monocytogenes of the central nervous system (CNS) clinically manifests as either acute bacterial meningitis or meningoencephalitis. In patients with systemic lupus erythematosus (SLE) presenting with headache and fever, SLE cerebritis must be differentiated from acute bacterial meningitis by lumbar puncture and cerebrospinal fluid (CSF) analysis. Neuropathogenic viruses are the most common causes of meningoencephalitis. The most rapid and accurate way to differentiate bacterial meningoencephalitis from nonbacterial meningoencephalitis is CSF lactic acid levels. METHODS: We present a patient receiving chronic corticosteroid therapy and manifesting SLE and severe L. monocytogenes meningoencephalitis. An early diagnosis of L. meningoencephalitis was achieved by demonstrating a very highly elevated level of lactic acid in his CSF, days before CSF and blood cultures tested positive for L. monocytogenes. RESULTS AND CONCLUSION: In this patient, the highly elevated levels of lactic acid in his CSF ruled out both viral meningoencephalitis and SLE cerebritis. The case was complicated by communicating hydrocephalus, and the patient later underwent placement of a shunt. He completed 6 weeks of meningeal dosed ampicillin.