Craig Baldwin is 65 years old and resides in Aurora, Colorado. He was born and raised in Illinois, went to college in Missouri, and has spent his adult life in Colorado, working as an aeronautical engineer for 40 years. He is widowed and has one son, Stanley, and a daughter named Sarah. Craig enjoyed good health prior to his Listeria illness. Around August 1, 2011, Craig made some dietary changes – he wanted to be healthy. He began a gluten free diet and began eating cantaloupe for breakfast almost every day. Beginning July 31, 2011, Craig’s purchase history from King Soopers includes purchases of processed—i.e. cut up or sliced—cantaloupe on at least 7 occasions.
On September 21st, Craig returned to the dermatology clinic to report that he had gone to work that morning but was shaking so badly that he was unable to hold a pencil or type.
In fact, Craig’s symptoms had been present for almost 2 weeks. As he recalls:
For 2 weeks prior to going into the hospital I worked in a constantly fatigued condition that I attributed to the steroids I was taking for Pemphigus. Finally I could no longer function at work and noticed my handwriting and signature were nearly impossible to read. I left work at noon on September 21 for my appointment with Dr. Huff.
Although the rash did seem to be better with his treatment, Craig said he was considering a leave of absence from his work and thought that his tremulousness might be an anxiety attack. He was not tremulous at this office visit and was afebrile with no evidence of a secondary infection. The prednisone was changed to a single 60 mg dose in the AM. The remainder of the treatment protocol was continued unchanged. Craig was also seen by Dr. Quintana for complaints of constipation. A physical examination disclosed internal and external hemorrhoids and weight loss. Treatment recommendations included Metamucil, fluids, dietary fiber and a 2-week hold on calcium supplements until the constipation resolved, then slow resumption of the calcium supplement as tolerated.
University of Colorado Hospital (UCH) – Emergency Department – September 22, 2011:
The night of September 21 was miserable. “I spent the night in my recliner,” Craig recalls, “since I did not think I could get out of bed once I got in. On my trips to the bathroom I was staggering around like a drunk.” By 6 AM, Craig thought he was in trouble. He called his sister, who is a nurse, who rushed to his house and then took him to the University of Colorado Hospital ER. He was suffering from total body fatigue with decreased coordination. At the ER, he explained that the symptoms had been generally progressive over the last week but reported feeling fatigue for the better part of a month. He denied any other symptoms, particularly focal weakness, numbness or tingling.
The emergency department physician reviewed Craig’s medical history, medications, and most recent illness course secondary to the pemphigus foliaceous. Craig’s vital signs revealed mild hypertension (130/99 to 149/92), heart rates 112 to 77, and no fever. An EKG was normal. Chest x-rays were negative. The doctor’s impression was “unclear etiology at this time but no evidence of lung infiltrates, infection, CHF, anemia, GI bleed or neurologic injury.” Craig was discharged home and instructed to follow with his regular doctor.
Back at home, things worsened quickly. At approximately 2:00 PM, Craig developed the onset of significant right-sided weakness associated with slowed and slurred speech. He returned to the ED at UCH, where he was examined by Dowin Boatright, MD. Craig denied nausea/vomiting but reported a headache. Nothing aggravated or relieved the symptoms.
A brain CT without contrast was performed and followed by CT brain and neck angiograms. There were three mass lesions in the left frontal, right corpus callosum and left cerebellum. The primary consideration was a neoplasm such as astrocytoma. The findings were atypical for an acute infarct and there was no intracranial hemorrhage. There was no evidence of aneurysm or dissection in the cervical or intracranial arterial vasculature.
Neurologist Wayne Moldovan, MD found Craig awake, alert, and oriented but did not know the month. The neurological exam revealed normal coordination and strength (5/5) in the left upper and lower extremities, weakness and 2/5 strength in right upper and lower extremity. Tremors were evident in the right upper extremity and there was poor finger to nose with pass pointing. Pitting edema (2+) of the mid-tibia was noted (left greater than right). There was mild facial asymmetry with subtle right facial weakness/droop and slow, intermittently slurred speech (dysarthria).
Dr. Moldovan’s assessment was progressive weakness over the last several days with acute change in strength and slurred speech. Given the patient’s weakness and dysarthria, the initial concern was TIA vs stroke, but the suspicion for an ischemic event lessened since the CT angiogram did not show any evidence of thrombus. The differential diagnoses included central nervous system (CNS) malignancy vs arteriovenous malformation vs hematoma. The plan was to obtain an MRI of the brain with and without contrast in the morning to better characterize the hypodensity seen on the CT as well as to definitively rule out an infarct.
Chest x-rays were ordered to evaluate for primary sources of metastases. Admission orders included IV decadron to decrease the surrounding intracranial fluid and Keppra for seizure prevention. Craig’s PR therapy of Prednisone and CellCept were placed on hold.
September 23, 2011:
A brain MRI found three parenchymal lesions. Given their thin, irregular peripheral enhancement and restricted diffusion, the differentials included multifocal glioblastoma, multifocal infection, demyelination, and CNS lymphoma.
Craig complained of worsening right-sided weakness and difficulty sleeping. He was evaluated by attending neurologist, Jennifer Simpson, MD who confirmed short term memory deficits, motor speech disorder (dysarthria), right facial droop and right-sided weakness. Dr. Simpson’s impression was that the multiple lesions in the brain and Craig’s subsequent right hemiparesis and dysarthria were associated with an infection. She added that he was at high risk for opportunistic infection given significant immunosuppression with CellCept (MMF) and prednisone for treatment of the PF. A lumbar puncture was ordered for cerebrospinal fluid (CSF) studies, fungal, bacterial, and viral cultures. A discussion was scheduled with dermatology for assistance in managing the PF since CellCept (MMF), prednisone and topical steroid ointments had to be abruptly discontinued.
Despite the evidence of an infectious etiology, a CT scan of the chest was performed to further investigate for the presence of a primary malignancy as a cause of Craig’s brain lesions and stroke. The finding was remarkable for a “moderate burden of pulmonary thromboembolism, likely acute, involving the right middle and lower lobes and their segmental and subsegmental arteries.”
CSF analysis from the lumbar puncture showed an elevated protein level and leukocytosis with an elevated WBC count—generally associated with bacterial infections of the central nervous system.
Dr. Nancy Madinger, an infectious disease specialist, next assessed Craig. She thought the multifocal brain masses and CSF neutrophilic pleocytosis in an immunocompromised patient were very concerning for lymphoma associated with MMF use. She concurred with the Vancomycin treatment and ordered a neurosurgical consult for a possible brain biopsy.
September 24, 2011:
On this date, blood cultures grew gram positive rods. Another infectious disease specialist, Taylor Washburn, MD, and neurologist Emily Lampe, MD, concluded that the gram positive rods were highly suggestive for Listeria or Nocardia. Intravenous antibiotic therapy (Vancomycin and meropenem) were continued, pending final “speciation.”
September 25, 2011:
Craig was alert and oriented with some persistent short-term memory deficits, and was understandably very teary and emotional about his condition when his doctors checked him. The lab called to report that the blood cultures were growing Listeria.
At this point, Dr. Washburn was certain that Craig was bacteremic with Listeria and that the CNS lesions were also Listeria in an immunocompromised patient. She discontinued vancomycin and meropenem and narrowed the antibiotic therapy to ampicillin which was likely needed for 4-8 weeks. Note was made that the prior discontinuation of the prednisone and immunosuppressant therapy (MMF/CellCept) was done in order to enable a maximum immune response to the Listeria bacteremia.
September 26, 2011:
Craig developed worsening weakness of the right upper and lower extremities. A physical exam revealed no finger or shoulder movement to command in the right arm, and although he was able to wiggle his toes on the right, Craig could make no other purposeful movement. These findings increased the concern for brain edema, increasing size of the brain lesions, or less likely, bleeding. The brain MRI showed “progression of the multifocal process in the brain. The previously described 3 lesions had increased in size and there were 2 new small lesions as well as new hemorrhagic regions within these lesions—consistent with abscesses (vs masses) from Listeria, although the findings were non-specific.”
September 27, 2011:
The MRI findings were reviewed by Craig’s medical team. Ampicillin and Bactrim were continued and Gentamycin was added. The doctors knew they had to get Craig’s brain infection under control if he was to have any chance of survival. Dr. Simpson discontinued the heparin drip in light of the CNS hemorrhage evident on the MRI. A neurosurgery consult was requested to determine the need for aspiration of the brain lesions.
PT therapist, Carla Potvin, reported clonus of the right foot for the first time. She added that Craig appeared more fatigued and reported feeling restless. Pulmonologist Matthew Moles, MD, was asked to advise on how best to handle anticoagulation for treatment of pulmonary embolism (PE) in the setting of hemorrhagic brain lesions secondary to Listeria. Dr. Moles noted that Craig’s lower extremity ultrasounds were negative for DVT and his risk of complications from PE were low (1%), while his risk of further cerebral bleeding exceeded any benefit in the use of anticoagulation. He recommended repeating the lower extremity ultrasound to exclude DVT, placing Craig on subcutaneous heparin for DVT prophylaxis, and continuing this method of treatment for 3 months.
Ramesh Kumar, MD, a neurosurgeon agreed that the MRI findings were peculiar for Listeria infection; and that, therefore, biopsy of the lesions should be performed to further evaluate the lesions.
September 28, 2011:
As part of the preoperative evaluation for biopsy of the brain for definitive diagnosis of the brain lesions, Craig was transported to radiology for MRI of the brain with Gadolinium. The image quality was limited to motion artifact. The multiple brain lesions were unchanged and stable. The ventricles and sulci were without significant change and remained normal. At that time, seven fiducial markers were placed overlying the left scalp in preparation for biopsy needle placement.
Craig was transported to the OR for stereotactic needle biopsy and drainage of a left posterior frontal abscess using streotactic guidance. Purulent material was obtained from the lateral wall of the target lesion/cyst and the middle portion of the cyst, and was sent for STAT gram stain as well as aerobic, anaerobic, fungal cultures and histology. There was no unusual bleeding.
Gram stain of the biopsy specimens showed gram positive rods (GPR) and gram positive cocci (GPC). There was some question as to whether the GPC represented a contaminate or superinfection. Nevertheless, vancomycin was started for GPC coverage.
A CT scan of the brain was performed postoperatively and compared with the prior MRI’s. There were surgical changes in the left frontal lobe, a few gas pockets along the biopsy tract, and a few hyper-dense foci that likely represented blood product. No large hemorrhage was visualized. The right occipital lesion was not visible. The other four lesions were unchanged, but had progressed when compared to the September 22nd CT scan.
September 29, 2011:
The breadth and severity of Craig’s medical status was provided in the neurosurgery ICU note and included the following:
Pemphigus Foliaceus – currently on clobetasol and denoside
Brain abscesses – embolic in nature and associated with listeria infection/bacteremia
Sepsis – blood cultures have only grown listeria. Continued on coverage for listeria (ampicillin/bactrim) as well as broad spectrum coverage for unknowns. Blood cultures repeated.
Possible endocarditis – new embolic changes seen on CT scan. TTE (transthoracic echocardiogram) was ordered.
Cerebral edema – total fluids were decreased and a steroid (Decadron) burst with decreased taper was planned.
Intracerebral hemorrhage – likely due to septic thromboemboli vs vasculitis
Hyponatremia – 2% sodium chloride drip changed to a 3% drip at 30-60 ml/hr with q 4 hr sodium checks and a goal of serum sodium between 120-130.
Anemia – plan to transfuse only if hematocrit <30
Pulmonary emboli – currently treated with subcutaneous heparin. Inferior vena cava (IVC) filter planned given the risks of bleeding with heparin.
On September 29, Craig was resting in bed, with his daughter and sister in the room with him, when the neurologist arrived to reevaluate. Craig was “alert with slight speech slurring.” His vital signs showed moderate hypertension, normal heart rate, no fever. Hydralazine was continued with the goal of maintaining systolic blood pressures between 90 and 140 mm Hg. Decadron and Keppra were continued for treatment of brain edema and seizure prevention.
The finding of gram positive cocci in the brain lesion biopsy sample was unclear but infectious disease specialist, James Colbert, MD, agreed with coverage for MRSA with vancomycin until the brain biopsy sample was “speciated.” He continued the antibiotic regimen for treatment of Listeriosis (ampicillin, bactrim and gentamicin), but discontinued voriconazole and cefepime since there was no evidence of fungal infection. A triple lumen left arm PICC line was inserted under fluoroscopic guidance for long-term IV access.
September 30, 2011 – October 3, 2011:
Cultures of the brain lesion were positive for Listeria monocytogenes.
Craig was reevaluated by the various members of the treatment team. He was awake and alert but slow to respond. A motor exam revealed that he could wiggle right toes but had no movement of the right upper extremity. Craig expressed frustration about his current condition and “dislikes his head turban” but denied pain or headaches. The plan was to remove the head dressing for an hour then redress. Lasix was ordered to reduce cerebral edema and improve declining urinary output.
Shortly before 5:00 PM, Craig was transported to the interventional radiology lab for placement of the inferior vena cava (IVC) filter under conscious sedation. The right internal jugular vein was found to be widely patent. IVC venogram was performed with no evidence of problems or intraluminal thrombus. The CBC showed a drop in hemoglobin and hematocrit levels and a blood transfusion with two units was ordered.
Infectious disease specialist, Dr. Washburn reviewed the culture results and continued the ampicillin and Bactrim. She discontinued the vancomycin after the pathologist from the micro lab informed her that the gram positive cocci (GPC) seen in the initial brain biopsy lesion were actually evidence of partially treated gram positive rods (GPR) and that no other organisms were growing in the culture.
With respect to the decreased urinary output and the suspicion of acute kidney injury, Dr. Washburn agreed that acute kidney injury (AKI) and resulting renal insufficiency could occur secondary to any one of the antibiotics. She recommended a hold on the gentamicin since the patient was well-covered on ampicillin and Bactrim. To further evaluate renal function, she placed a Foley urinary catheter.
Antibiotic therapy was continued for treatment of intracranial abscesses secondary to Listeria. The IVC filter was being monitored and subcutaneous heparin was continued. There had been no seizure activity and Keppra was continued. Craig was tolerating, as well as anyone could, a modified diet of pureed food.
Neurosurgeons Derrick Sun and Robert Neumann, MD, along with infectious disease specialist Dr. Washburn, were in to reevaluate Craig on October 3rd. Serum sodium and chloride levels were low at 131 and 100, which prompted a return of the sodium chloride drip to a higher infusion rate (30 ml/hour). Renal function studies (BUN and creatinine) were also normal following the hold on gentamicin.
Dr. Washburn maintained the hold on gentamicin and ordered liver function testing to investigate for any evidence of hepatic toxicity. Dr. Neumann increased the salt tabs in an effort to get Craig off the 3% sodium chloride drip and continued serial sodium checks.
October 4, 2011:
Craig was seen by infectious disease physician Kristine Erlandson, MD. The extent of his brain injury was evident even as he improved. He was described as alert, oriented, and his speech less garbled. There was some slight movement of the right fingers, right toes and right knee. Craig was able to get himself to the edge of the bed with moderate assistance. Sitting balance deficits were noted. But he fatigued easily and was unable to attempt standing. His right upper extremity remained flaccid.
October 5, 2011:
Craig was more fully awake, asking for breakfast and following commands. Blood pressures continued to be mildly elevated. Dr. Neumann reviewed the lab results and ordered another blood transfusion for treatment of anemia. The results of the cortisol stim test for adrenal insufficiency were positive. Treatment with ampicillin and Bactrim for Listeria bacteremia and brain abscesses continued. The length of treatment would be determined by repeat brain imaging as dictated by the primary treatment team.
October 6-7, 2011:
Physiatrist, David Stone, MD from the department of Rehabilitation/Physical Medicine arrived on the Neuro Intensive Care Unit to evaluate Craig for acute inpatient rehab. The need for rehab was evident given Craig’s multiple brain abscesses, dysarthria, right hemiparesis and decreased mobility.
Dr. Stone’s history reflected the prior normalcy of Craig’s life: Craig lived alone in a one-level home in Aurora, CO. There was a flight of stairs to the basement and three steps outside of the front door. His daughter had moved there temporarily to assist with his needs. Prior to hospitalization, Craig was driving and working as an aeronautical engineer. He was independent for bowel and bladder function, ADL’s, self care and mobility. In contrast, Craig now required at least moderate assist for ADL’s and self-care; moderate-max assistance with two persons for mobility and transfers. A Foley catheter remained in place.
Negative findings in Dr. Stone’s examination included flat affect, slurred speech, 2+ lower extremity edema, right facial weakness, dysphagia, weakness, tremors, and minimal movement of the right upper extremity and lower extremities. DTR’s (deep tendon reflexes) were 2+ throughout on the right and left with no clonus.
Dr. Stone indicated that Craig would benefit from 3 hours of PT/OT per day and required 24 hour RN supervision and daily medical management for ongoing medical and rehab issues. Estimated length of stay was 3-4 weeks.
University of Colorado Hospital – Rehabilitation Unit – October 7-9, 2011:
Craig was transferred to the Acute Rehabilitation Unit at University of Colorado Hospital, where he was admitted to the service of physical medicine and rehabilitation specialist, William Sullivan, MD. Dr. Sullivan’s assessment was “64 year old male with history of pemphigus in immunosuppression therapy, now with right hemiparesis and dysarthria due to multiple intracranial ring enhancing lesions caused by culture confirmed listeria in the blood and brain biopsy lesions.” He indicated that he would be working closely with the infectious disease and neurosurgery/neurology teams to coordinate essential and specialized care, with the goal of improving function, independence, and returning the patient home.
The treatment plan included continuation of the antibiotic therapy for treatment of the multiple brain abscesses. The Keppra was continued for seizure prophylaxis. Intensive PT, OT and SLT were planned to assist with dysarthria and the decline in independent mobility and ADL’s. Heparin and the IVC filter were continued for management of the pulmonary embolism and prevention of further embolic problems.
Craig was initially assessed by occupational therapist, Emily Pak, who reported severe impairment with ADL’s and functional mobility skills due to poor functional endurance, decreased strength and functional balance skills. He was described as “highly motivated but quickly fatigues with activity.”
Early in the course of his rehabilitation, Craig reported restlessness, exhaustion and not sleeping well at night. The PT and OT therapist’s notes reflect that he was indeed “too tired…did not have enough strength and endurance.”
October 10, 2011:
Craig was seen in consult by the rehabilitation psychologist, Wendy Clyne, who reported that he was “scared by his deficits and how he will function in the future.” His poor appetite and difficulty eating seemed foremost in his mind since this impacted his ability to heal. Craig was also struggling with his inability to cope with his medical conditions and his current cognitive deficits. He cited lack of progress as another frustration but the therapist explained that fatigue and medications might be contributing largely to this. He reported having significant pain from the pemphigus foliaceus early on, which rendered him quite emotionally and physically fatigued even before developing the Listeria infection.
Although he had not planned an early retirement, Craig now reconsidered and decided he could tolerate giving up his job, but he was very concerned about his ability to regain function and enjoy life in the future. He also expressed fear of becoming a burden on his family. Finally, Craig spoke about how difficult and overwhelming his rehabilitative therapies seemed. Despite this, he did not want to give in or give up and was very motivated to do all that was necessary to achieve recovery.
October 10, 2011: Rehabilitation Team Rounds/Plan of Care Conference
The nursing staff reported that Craig had been sleeping poorly, for which problem he had been prescribed a sleep aid. His pain was currently being controlled with Tylenol and repositioning. His nutritional intake was poor and the registered dietician was asked to consult. Short-term goals included resolution of pain, comfort and sleep issues. Long-term goals included 100% knowledge of the names of his medications, regular bowel movements, and removal of the Foley catheter.
Occupational therapy reported that Craig required 2 person assist with showering, transfers, and upper and lower body dressing. Physical therapy reported that bed mobility and transfers (with slideboard) required a 2 person assist as well. Speech and Language Pathology therapist reported that Craig’s expressive language remained compromised by a lack of intelligibility. Craig’s thinking fluctuated between lucidity and confusion. The difficulty associated with some of the cognitive tasks overwhelmed him, and caused him to focus on how prolonged his recovery might be.
October 11, 2011:
Craig was reevaluated by dermatologist, Gina Lnapschaefer, MD. She reported much improvement in the PF over the prior two weeks. The clobetasol was discontinued on the trunk and arms with recommendations to use Vaseline twice daily on these areas and continue clobetasol only on the scalp.
The nurses reported that Craig’s mental status was “waxing and waning.” His appetite was very poor and he had lost 16% of his body weight since July. Infectious disease specialist Amie Meditz, MD, noted that Craig had not had any brain imaging since September 28. She spoke with the neurosurgeon about repeat brain imaging, as this would help determine the total length of the antibiotic therapy for treatment of the neuro-listeria infection. Until this was accomplished, she set an approximate “end-date” for ampicillin and bactrim of November 9.
Dietician Janet Andrews suspected that Craig’s poor appetite and weight loss was related to several factors: fatigue, depression, and taste acuity changes. Food preferences were elicited and Craig was educated about his energy and nutritional requirements.
October 12-16, 2011:
Treatment of the hyponatremia continued with free water restriction and adjustments in salt tabs as necessary. Dr. Meditz reported that the pemphigus foliaceus was currently “inactive” and the clobetasol was discontinued. Craig had developed a black tongue coating which she suspected was oral thrush and possibly a factor contributing to his disinterest in eating.
A CT scan of the brain was repeated on October 13th and compared to the CT dated September 29th. Findings included: “(1) resolving scattered intraparenchymal hemorrhages in the left frontal lobe, medial right parietal lobe, corpus callosum and left cerebral hemisphere; (2) persistent scattered hypodense areas, edema/encephalitis related to the listeria abscesses are in evolution with a slightly decreased mass effect – stable with no new lesions.”
Craig was reevaluated by the psychologist, Wendy Clyne, on October 15. He reported persistent fatigue and mental status fluctuations as well as frustration with the changes in his life and his slow recovery. He denied pain but demonstrated significant anxiety and inability to recognize any progress made. The therapist planned more frequent visits and antidepressant therapy (Lorazepam) was ordered.
October 17, 2011:
Matthew Griffith, MD, a hospitalist from medicine services, reviewed the results of the coagulation panel. It was his impression that the acute increase in the clotting tendency of Craig’s blood most likely was associated with the initiation of fluconazole for treatment of thrush, in the setting of poor oral intake. But since Craig had no evidence or symptoms of bleeding in his brain and no new focal neurological deficits, Dr. Griffith concluded that there was no indication to reverse the coagulopathy or re-image the brain.
October 18 – 25, 2011:
Craig found gratification in the small victories he made in rehabilitation. Progress notes by Wendy Clyne reported a change in Craig’s level of optimism. He was very pleased with his ability to supinate and pronate his right wrist during PT. He talked about the anger he felt about developing the neuro-Listeria infection and confided that he had been trying to take better care of himself by eating healthier foods and fruits such as cantaloupe. The irony has become a lasting part of Craig’s life.
The Rehabilitation Team met on October 24th. Nursing reported bowel incontinence requiring total assist. The Foley catheter remained in place. His oral intake was poor but he was drinking 100% of Ensure with meals. He was able to name 75% of his medications. Short and long-term goals were bowel and bladder continence.
OT reported that Craig required set-up cues for hygiene, moderate assist for bathing, showering and upper body dressing, and maximum assist for bathroom transfers and lower body dressing. Short-term goals: minimum to moderate assist for ADL’s. Long-term goals: stand-by assist to modified independence for ADL’s.
With respect to his cognitive level of function, Craig was aware of his fluctuating deficit awareness and was working on thought processing and executive functions. Short-term goals included improved performance in executive functions and thought processing cognitive tasks with 75% accuracy. Long term goal was to independently implement compensatory strategies to perform higher level cognitive tasks with 90% accuracy.
In consult with Wendy Clyne, Craig described his various therapies as tortuous but was able to identify improvements; was pleased at having a stronger voice and thinking more clearly; and was more able to use his arms. Although he was eager to go home, Craig remained quite concerned about his ability to function at home and this was a great source of his anxiety.
October 26 -31, 2011:
Anticoagulation therapy was placed on hold in preparation for removal of the IVC filter on October 26th. The procedure was accomplished under conscious sedation with ultrasound guidance.
The Rehabilitation team met on Halloween Day. The nursing staff reported that Craig was bowel continent and regulated. The Foley catheter was removed. His various skin tears were healing. He was sleeping fair to well on Trazodone. His nutritional and fluid intake was fair—he was eating 50% of his meals. Craig was able to name his medications and was using his reminder log to verify with the staff before administration. Short-term goals were urinary continence, improved intake, and eating 75% of meals. Long-term goals included independent bowel and bladder management and independence with medications.
Occupational therapy reported slow and steady progress toward these goals. Craig was able to stand at the sink for hygiene and grooming with contact guard assist (CGA) minimal assist. Minimal assist was required for bathing, showering, bathroom transfers and upper body dressing. Lower body dressing still required maximum assist. Short-term goals: stand-by assist and CGA assist for ADL’s. Long-term goals: stand-by assist-modified independence for ADL’s.
The physical therapist reported that Craig was working hard throughout PT and had made significant gains. The speech and language therapist reported that Craig continued to require support cognitively for organization of tasks on his mind that limited his mental focus.
Craig’s cognition was unchanged. He continued to have fluctuating deficit awareness and was working on thought processing and executive functions.
November 1 – 15, 2011:
The rehabilitation team met to discuss Craig’s clinical status and progress in the various therapies. His neurological status was stable but with some persistent right hemiparesis and dysarthria, secondary to listeria infection. There had been no embolic events and the patient was considered to be adequately anticoagulated on Coumadin. His weight was 183 lbs. Craig’s anxiety, sleeping difficulty and oral intake were much improved, and a discharge date was set for November 15th.
Dr. Morroni ordered repeat MRI of the brain to assess the brain abscesses prior to the anticipated discontinuation of ampicillin on the 19th. The brain MRI with and without contrast was performed on the 8th and compared with the CT scan of October 31st and the MRI of September 26th. Findings: “no new lesions or acute infarct; decreased size and surrounding edema of the 3 enhancing abscesses, which may represent central collapse of the lesions. There is a focus of hemorrhage along the posterior right subinsular cortex likely indicative of maturation. This accumulation of blood product since September represents some increased susceptibility to infection.”
Dr. Morroni reviewed the results of the MRI and noted improvement of the abscesses, but not resolution. Thus, he ordered continuation of the ampicillin until complete resolution of the abscess cavities—possibly 3-4 weeks.
The rehabilitation team met again on November 10th to discuss the discharge plan. Home health care arrangements were planned for administration of ampicillin via a continued infusion cassette. The family was scheduled for education and instruction in PICC line management. Craig was to follow with Dr. Jones in the neurology clinic. After completion of the extended antibiotic course, a repeat MRI of the brain was to be scheduled.
The rehabilitation team met for one last time on November 14th. The nursing staff reported no changes—Craig remained bowel and bladder continent. His skin was flaky but intact. OT reported that Craig had progressed to stand-by assist for hygiene, grooming, bathroom transfers and lower body dressing. Equipment recommendations included bedside commode, 4-wheeled walker and front wheeled walker.
The speech and language therapist reported that Craig continued to require support cognitively for organization of tasks that limit his focus mentally. Self-monitoring was improved but he continued to need cues for divided attention and to maintain accuracy with stress-related situations.
Life changed for more than just Craig after his hospitalization for Listeria. He needed help, and his daughter Sarah Baldwin stepped in to help her dad. Craig recalls:
My daughter was ending her job as a summer park ranger in California and came back to Aurora instead of returning to her residence in Dixon, California. She was a great help taking care of things at the house that I could not do, including paying bills and feeding the cat. I decided that since the first floor of the house was in need of a lot of deferred maintenance Sarah would be in charge of getting the work done. Since it was not certain what my condition would be upon returning home the main bathroom was redone with ADA wheelchair accessible sink, toilet and shower and a wider entry door. While the house was being redone I was recovering on the rehabilitation floor at University hospital. I do not remember a lot of my stay at the hospital.
On December 2nd an MRI of the brain was performed with and without contrast and was compared to the prior study on November 8th. Findings included “resolution of the focal hemorrhagic lesion in the right posterior insula; minimal change in the 3 hemorrhagic enhancing lesions since the last study; decreased enhancement of the large left frontal lesion; stable nodule in the right posterior cingulate; slightly smaller left cerebellar lesion; no new lesions.
Also on the 2nd Craig was seen by dermatologist, Ryan Oyer, MD. Craig indicated that he had two concerns: right hip paresthesia (numbness) and a welt on the right flank. Dr. Oyer determined that the right hip paresthesia was located in the distribution of the right lateral femoral cutaneous nerve and was likely associated with the gait belt used during PT. There was some induration in the soft tissue of the right flank, which was consistent with a small hematoma.
On December 9th, Craig saw Dr. Quintana, who reviewed his hospital/illness course and current medications. His weight was 209 lbs. His physical exam showed two areas of pemphigus foliaceus on the chest and right-sided hemiparesis. Improvement of the PF was noted and this was being followed by Dermatology at UHC.
Craig was reported to be doing well overall when he returned for follow-up with Dr. Oyer. He was walking without a cane or walker at home and exclusively with a cane when out. The right hip paresthesia was not worsening. Dr. Oyer spoke with the radiologist about the findings on the MRI of the brain. Although he thought the findings on the scans showed improvement, it was difficult to say with certainty whether there were any viable Listeria bacteria in these lesions. Accordingly, Dr. Oyer ordered continuation of the ampicillin for another month.
On December 15th, Craig saw neurologist, Jennifer Simpson, MD. Since discharge, he reported doing well. He was walking with a cane and walking up and down stairs with supervision. He needed help showering but did most of the task independently. He denied depression but admitted to anger about his situation. Craig expressed a desire to continue a formal PT/OT day-program and that he had applied to a program at Spalding Rehab Hospital.
Dr. Simpson felt that the likelihood of a seizure was small but instructed Craig to remain on the Keppra for seizure prophylaxis until he completed the ampicillin. She discussed signs and symptoms of seizure activity with Craig and his daughter and instructed her to call 911 if seizure occurred.
Spalding Rehab Hospital – Outpatient Program – December 27, 2011:
Craig was provided with a prescription for PT/OT/SLT from Dr. Quintana and underwent initial evaluations by the various therapists on December 27th. The referral diagnosis/treatment diagnoses was “L frontal lobe abscess secondary to Listeria; decreased cognition, poor endurance and motivation.” His complaints included numbness in the right thigh, right shoulder stiffness, tight gastroc soleus and hamstrings, bilateral weakness, right greater than left.
Craig was walking with and without a cane but with poor upright posture—his head down and slumped. Functional mobility assessment revealed he was independent for bed mobility and transfers but sometimes slow when getting up from a chair. He could sidestep 15 feet with a cane and close supervision, climb 12 stairs, and walk backward 10 feet with close supervision. A summary of his functional impairments included alterations in gait, high and low ADL’s, driving ability, ability to work and safety. Problem’s included range-of-motion (ROM), strength, balance, endurance, coordination.
Three short-term goals were identified to improve bed mobility, upright posture and forward gaze with ambulation and balance, with a target date of January 6th. Once these goals were met, long-term goals were to include more independence with the bed exercise program, supervision with high level balance programs, ability to get up from the floor independently, more functional involvement and exercise.
Occupational Therapy assessment of Craig’s self-care status revealed modified independence for eating, grooming, upper and lower body dressing, toileting and bathing. He had difficulty manipulating a fork/spoon with the right hand and was using his left hand for the razor, comb, and toothbrush. Buttoning his shirt was getting somewhat easier but he needed extra time to tie his shoes. Showering required a grab bar, distant supervision, and some additional assistance by his daughter. Craig was not driving.
Endurance was poor due to fatigue. There were deficits in visual attention, scanning, and processing speed. Functional impairments included deficits in complex and instrumental ADL’s, functional cognitive skills, and deficits in functional mobility, visual/spatial skills, activity tolerance and upper extremity functioning.
Speech and language therapist Margaret Palmer performed an initial evaluation on December 27th. Craig was noted to be alert with poor attention span and very frustrated with the decline in his cognitive and physical state and often focused on what he can no longer do. Hearing and vision were impaired as well, and he had moderate deficits in memory (both verbal and visual) and in attention/ processing. Minimal deficits were noted in executive function; she suspected some high level problem solving, organization and planning deficits.
An MRI of the brain was performed with and without contrast and was compared to the prior study on December 2nd. Findings included “decreased size and edema surrounding brain abscesses in the left posterior frontal lobe, right posterior cingulate gyrus and left cerebellum – abscesses resolved.”
The antibiotic therapy had been completed. Craig was told he would most likely be able to stop the Keppra once he completed the antibiotic therapy. Dr. Quintana indicated he would contact neurology to discuss a scheduled taper of the Keppra. Support stockings (TEDs) were ordered daily and Craig was instructed to elevate his legs, and return in four weeks. The paresthesia of the right leg was improved. No new treatment was ordered. Repeat brain imaging was planned in 3-6 months.
Spalding Rehab Hospital—Discharge Summaries – January 27, 2012:
Craig made significant gains over the course of his outpatient rehabilitation program. He was able to walk independently and without a cane except for heel to toe walking. He was provided with a home exercise program and worked this program regularly. His posture was more upright. He was much more engaging with people—commenting, answering questions in a timely fashion—and had learned techniques to calm himself to be safe and appropriate.
Craig said he wanted to go back to work part-time and would like to travel. He was currently working a few hours at a family business. The therapist reported that due to his commitment and persistence, he had shown enough change in balance, strength and coordination that he “is independent in his mobility in familiar environments and should continue his exercise programs at least 1hr/day, 5 days/week.”
When given time, he was able to complete various cognitive tasks for memory, attention, deductive reasoning and problem solving with minimal to no cues and up to 100% accuracy. When tasks were timed or speed related, Craig had more difficulty. Additional gains were seen in endurance; Craig was able to return to community events (dinners, plays, errands). Craig made great use of compensatory strategies. He was able to use his daily planning sheet, to-do list and calendar independently and functionally. His practical communication skills had also improved with increased use of eye contact, facial expressions, and the ability to converse in a more social way.
In summary of his rehabilitation, Craig states:
I started at Spalding on December 27, 2011 and was discharged on January 27, 2012. It was a day rehab program with speech, physical and occupational therapy 5 days a week for 2 weeks and then 3 days a week for 2 weeks. By the time I left Spalding I was walking without a walker or cane and was able to do most things at home. I could also drive a car again. My daughter returned to California February 12, 2012, and I went back to work on about February 20. When all this happened I originally retired on paper at the end of 2011 and even got a plaque for 40 years of service but I have returned to my job at Univair Aircraft Corporation. I am very slow to walk and have had to relearn some computer procedures due to cognitive memory loss.
My lowest point in the recovery process was when the home health speech therapist gave me a cognitive memory test and I was in the low teens percentile for people my age. I am not the smartest person in the world but I have never been in the teens on any intelligence test before. I have since improved with therapy. It was also a shock to realize that all my back vacation and sick leave would be used up at the end of 2011 and for the first time in 40 years I would not have any paycheck coming in. I have a retirement plan in place but it was a relief when Univair said I could come back when I was able.
Even three years later Craig still suffers the after-effect of Listeria – all from eating “healthy.”