Earline Mages always says when you talk to her – “This is Earline Mages from Farmer’s Branch Texas.”
“She will never be that person she was before September 7, 2011” Frank Mages
Ms. Earline Mages is a 76-year-old woman who has been healthy and active throughout her life. Her medical history is significant only for hypothyroidism, hypertension, and elevated cholesterol. Ms. Mages had never suffered a major illness until she became acutely ill after consuming food products contaminated with Listeria monocytogenes in the fall of 2011. The causal link between Earline Mages’ Listeria infection and contaminated cantaloupe grown at the Jensen Farms facility is clear. In August 2011, Ms. Mages consumed Jensen Farms/Frontera cantaloupe purchased on several occasions at Kroger located on Valwood Parkway in Dallas, Texas.
A. Onset of Ms. Mages’ Listeriosis
Ms. Mages was enjoying her usual state of good health until she developed a severe headache with nausea and vomiting on September 7, 2011. Her symptoms were severe enough to alarm her family, and so they took her to the ER at Baylor Regional Medical Center at Plano, Texas. A head CT showed no intracranial abnormality. Since she also had a mild cough, a chest x-ray was done, but this showed no evidence of pulmonary disease. Between about 9 AM and 2 PM, she was observed and treated with IV fluids and medications for her symptoms. She was released to the care of her family and sent home with instructions to return if she did not continue to feel improved.
Unfortunately, Ms. Mages did not feel better, and in fact her symptoms worsened over the course of the next few hours at home. After doing poorly overnight and then spiking a fever, her family called 911 around noon on September 8, 2011. The Farmers Branch Fire Department arrived at her home to find her sitting in a chair and complaining of dizziness, nausea, and continued headache. Their first impression was that she had suffered a stroke, however because of a temperature of 104.6ºF, a urinary tract infection was suspected. Ms. Mages’ vital signs were otherwise stable, with a blood pressure of 114/80. Her oxygen saturation, however, was only 86% on room air, but it came up to 96% with supplemental oxygen. Her blood glucose was elevated at 193.
After arrival at the ER, family members reported that Ms. Mages had been weak and not feeling well ever since she came back from the hospital the day before. She had now developed confusion and was delayed on responding to questions on her own. She reported that she had pain in her belly around the umbilicus, with some shortness of breath but no chest pain. The EMT placed a cold pack on her neck and she was moved to a stretcher for transport. Their initial impression of stroke ruled out, they notified Baylor Medical Center that they were en route to the emergency department with Ms. Mages, where they arrived at 1:40 PM.
Upon arrival at the ER, a right PICC line was placed in the superior vena cava, and a chest x-ray was done to confirm placement and check Ms. Mages’ lungs. The x-ray revealed a change in her lungs from the imaging the day before, with diffuse increased interstitial markings consistent with interstitial edema versus interstitial infection. There were patchy bibasilar opacities suspicious for atelectasis, early pneumonia, or early air space edema.
Dr. Sayantani Lahiri was the attending physician, and he admitted Ms. Mages to the hospital with a diagnosis of pneumonia, hypoxia, and possible early sepsis. He reviewed the progression of symptoms that Ms. Mages had experienced since she was seen the day before in the ER. This involved worsening coughing, continued vomiting, and spiking a fever and chills. Her negative medical history was noted, with notable exceptions of hypertension, thyroid disease, and high cholesterol. Dr. Lahiri noted that she had always been a nonsmoker and non-drinker and was independent of all activities of daily living in her own home.
Ms. Mages’ fever came down to 102.5ºF in the ER, and her vital signs remained stable. Her lungs sounded coarse to auscultation, her abdomen was nontender without rebound, and there were audible bowel tones. Her white count had been 6.7 the day before, and it was now 16. Dr. Lahiri thought that Ms. Mages probably had severe community-acquired pneumonia. After consulting with Pulmonary Medicine, he decided to treat her with aggressive IV fluids and continue her home medications. For DVT prophylaxis, he started Lovenox. He ordered lab studies for urine and serum osmolality, in order to rule out SIADH of acute disease versus dehydration. Levaquin and Rocephin were started while in the ER, but Pulmonary Medicine soon changed the Rocephin over to Meropenem to cover anaerobes, because Ms. Mages suspected she might have aspirated while at home the day before.
Dr. Jason Clark came in for a Pulmonary Medicine Consultation on request of Dr. Lahiri at about 5 PM. for Ms. Mages’ diagnoses of pneumonia and hypoxemia and respiratory failure. He continued oxygen by non-rebreather mask, which held her oxygen levels around 98%. He noted that she had been confused that morning, but she was alert and oriented to his exam. Her nausea and vomiting had resolved, but she continued to have some mild burning pain in the mid epigastric area, as well as pain in both shoulders.
On September 9, 2011, Dr. Lahiri continued to manage Ms. Mage’s hospital care. She reported that she was feeling better that morning, and her temperature was down to 99ºF. Her lungs continued to sound coarse, and Dr. Clark continued to follow her from a pulmonary standpoint. She continued her on her current antibiotic regimen and IV fluid hydration. Dr. Clark also restricted free water out of concern for hyponatremia and SIADH.
On September 10, 2011, Dr. Lahiri came in and noted that Ms. Mages was feeling so much better that she was ready to get up and out of bed. Her exam was benign except for coarse lung sounds, and her vital signs were stable. Dr. Lahiri continued her antibiotic regimen and Dr. Clark continued to follow her progress. He planned to stop the Meropenem if the cultures remained negative and to change the Levaquin to oral delivery. He was happy to see that her hypoxemia was resolving so well that he was able to wean her oxygen from the non-rebreather mask to oxygen by nasal cannula at 3 liters/min.
Dr. Lahiri came in on September 11, 2011, reporting an alarm value from the laboratory that one out of four of Ms. Mages’ blood cultures was coming up positive. Repeat cultures were ordered with identification of the organism to follow.
On September 12, 2011, Dr. Lahiri came back in and reported that the blood culture positive result had been identified as Listeria monocytogenes. He consulted with Infectious Disease specialist Dr. Lauren V. Hobratsch, who advised changing the antibiotic regimen to high dose ampicillin with synergistic gentamicin. Dr. Hobratsch came in for a consultation and stated that the case was being reported to the Dallas County Health Department, with final identification of Listeria to be confirmed by their laboratory.
Dr. Hobratsch came in for an Infectious Disease Consultation by request of Dr. Lahiri for Ms. Mages’ diagnoses of Listeria monocytogenes, sepsis/bacteremia. She ordered serial blood cultures and a lumbar puncture for cerebrospinal fluid culture. Antibiotics were to be administered via PICC line. If there was evidence of meningitis per the lumbar puncture, the antibiotics were to be administered for three weeks. Gentamicin 1 mg/kg every eight hours for synergy for 7-14 days.
On September 13, 2011, Dr. Lahiri came in to check on Ms. Mages, who continued to feel slightly better. Her lungs now sounded clear to auscultation. He noted that the hyponatremia was resolving. A chest x-ray was done that showed interval development of right basal pleural effusion with adjacent atelectasis, but her lungs were otherwise clear.
Dr. Jesse Hochman came in to do another lumbar puncture at 11:48 AM, and a cerebrospinal fluid sample was withdrawn and sent to the lab for culture and other analyses.
Dr. Hobratsch reviewed Ms. Mages’ pneumonia diagnosis, stating that she doubted it was community-acquired pneumonia. Instead, Dr. Horbratsch suspected ARDS. She advised continuing the ampicillin and gentamicin for three weeks. She ordered an MRI to rule out cerebritis.
On September 14, 2011, Ms. Mages underwent an MRI of the brain without contrast. It showed minimal scattered white matter hyperintensities likely due to minimal microvascular disease. Her vital signs were stable and her exam was unchanged. Her lungs were clear and she had no dependent edema.
Dr. Hobratsch also came in to see Ms. Mages later that afternoon to review the MRI results with her. She discussed the Listeria sepsis and noted there was no abscess noted on the MRI. She continued to recommend the current antibiotic regimen without changes. She also had a lengthy discussion with Ms. Mages’ son and daughter-in-law about her illness.
On September 15, 2011, Dr. Lahiri came in to see Ms. Mages. She was stable without current complaints except for constipation, and dietary changes were advised. On September 16, 2011, Ms. Mages continued to do well and was discharged from Baylor Regional Medical Center.
On September 16, 2011, Ms. Mages was admitted to a long-term acute care facility to continue her IV antibiotic regimen to its conclusion, as well as to continue her rehabilitation for physical mobility and self-care. Nauman Anwar, M.D, admitted her to Select Specialty Hospital. Dr. Anwar reviewed her medical history and treatment at Baylor Regional Medical Center at Plano. He reviewed the details of her Listeria monocytogenes meningitis and the deconditioning and lethargy that had followed.
Dr. Anwar continued to monitor Ms. Mages’ progress on a daily basis during her stay at Select Specialty Hospital of Dallas. She had a questionable low-grade fever on admit, but this quickly resolved and she stabilized. She was continued on her home medication for high blood pressure and cholesterol, as well as the antibiotic therapy with ampicillin and gentamicin. She was started on physical therapy and occupational therapy right away.
Over the next several days, Ms. Mages remained stable. She was weak, but she was working hard with PT to stay ambulatory. She remained afebrile with stable vital signs. She remained ambulatory and used a walker as needed. On September 18th, she had some generalized pain and thought she had a low-grade fever, but this quickly resolved and she continued to be stable after that time.
On September 23, 2011, Baylor Regional Medical Center reported that the Dallas Health Department had finalized their report about the positive blood cultures, which were confirmed to be Listeria monocytogenes.
On September 28, 2011, Dr. Tina Torten was asked to come in for an Infectious Disease Consultation for assessment of the continued antibiotic treatment for Listeria monocytogenes sepsis bacteremia with meningitis, most probably related to a community outbreak. She discussed the concern that her Listeria infection being associated with recent outbreak of Listeria in Colorado. Ms. Mages reported that she in fact had consumed cantaloupe that she purchased from the same area of distribution.
Dr. Torten stated, “I believe she was seen by infectious disease in Baylor Plano, where she was admitted. I believe the organism was sent for genetic sequencing and according to the patient, she did receive a call from the Centers of Disease Control through her son inquiring about the locality of purchase of the cantaloupe and this is likely related to the outbreak.”
Dr. Torten reviewed the history of illness and treatment, beginning with her ER admits at Baylor. She noted the positive blood cultures, as well as a spinal tap that was done that revealed over 300 cells with 70% lymphocytes and elevated protein. “I believe the cerebrospinal fluid itself did not grow the organism; however, it was certainly significant for meningitis.” She called to speak with ID specialist Dr. Hobratsch, and received extensive information from her.
Ms. Mages reported that she was currently feeling well, without coughing or diarrhea, and she was anxious to go home and be with her dog. Her recent lab results had been normal with a creatinine of 0.76, a normal white count, and a normal platelet counts. A Gentamicin trough had been ordered but was not yet available.
Dr. Torten concurred with the diagnoses and management to date, and she concurred that Ms. Mages should continue the ampicillin high-dose for three weeks supplemented by every 8-hour gentamicin. She felt the gentamicin could be stopped within a couple of days. She did not recommend reversion to an oral regimen at that time, as she felt that Ms. Mages still needed to be on the high-dose of ampicillin, which was planned through 10/3/11. She ordered blood cultures to document clearance of the bacteremia, follow her labs, and wanted to check a 2-D echo to evaluate her valves, and change her peripherally inserted central catheter line in view of some erythema noted at the insertion site.
The PICC line was removed on September 29, 2011 and antibiotics resumed through a peripheral vein. Ms. Mages continues to do well, and Dr. Anwar continued to monitor her daily progress.
Over the next couple of days, Ms. Mages was prepared to be discharged from the hospital. Pulmonary Medicine came in for a review of the case, noting her pneumonia to be resolved and that her lungs were clear. On October 3, 2011, her antibiotics were discharged per Infectious Disease. Dr. Anwar discharged her at 6:30 PM to go home, where she planned to have a friend stay at night for a little while until she was accustomed to being alone again.
On October 4, 2011, Atlas Home Health Care Services came to see Ms. Mages in her home, finding her alert, oriented, and independent of all activities. She had a friend staying at night for the moment. A plan was made for weekly skilled nursing visits, as well as PT and OT several times a week to help her keep her mobility up and herself care needs met. PT would also work on endurance, gait training, and strengthening. Her sons remained attentive and readily available if their mother needed them.
On October 11, 2011, Ms. Mages presented to see Dr. Haq Mahenaaz for a follow-up visit for her Listeria monocytogenes meningitis and prolonged hospitalization and rehab stay. Since going home, she reported that she continued to feel weak. Home health nursing was coming in and PT was ongoing in her home. Dr. Mahenaaz reviewed the details of her illness and treatment, noting that she had been given Xanax for the anxiety that resulted from her illness. This was working well for her and she requested a renewal. Overall, she was doing well with only some mild heartburn, and he advised Prilosec for that. He did lab work that showed she was stable and not anemic.
During the month of October 2011, Atlas Home Health continued to provide PT and skilled nursing services several times a week for Ms. Mages. On October 31, 2011, she returned to see Dr. Mahenaaz’ colleague, Jill Studley, MD. She was brought in by her daughter-in-law, and she reported that she was taking all her home medications as directed and was still getting PT and home health nursing care. Her exam that day was unremarkable and her blood pressure under good control with Lisinopril. She reported that she was sometimes having problems with her balance. She did report that she was using Xanax for anxiety as needed, and was cautioned about the risk of falls while using it. Her lab work was again within normal range.
During the month of November 2011, Ms. Mages continued to receive visits from Atlas Home Health personnel for PT and skilled nursing. She was discharged from these services on November 30, 2011.
D. More Follow-up
On December 7, 2011, Ms. Mages returned to see Dr. Studley in her office. She again reported that she was having some problems with balance. She felt that the PT was not really helping through the home, and that is why she let them go. She had a physical therapist she wanted to see who was closer to her home. She had not sustained any falls, and she was using a walker. She denied vertigo but reported the feeling that when she moved her head, the symptoms got worse. She felt very dizzy when she turned her head. She reported no further panic attacks. Dr. Studley recommended vestibular rehab and made a referral for her to be seen.
On December 12, 2012 Ms. Mages was seen at Dallas Medical Center for a physical therapy evaluation due to her complaints of imbalance. Over the next several weeks, Ms. Mages received five PT sessions.
On January 9, 2012, Ms. Mages presented to the office of Michael Paul Kellam, M.D. for a consultation on referral from Dr. Studley. During his interview, he noted that it was difficult to direct in her history due to pressured speech and somewhat non-linear presentation. He reviewed her history of food poisoning illness from Listeria monocytogenes, with subsequent hospital admission, antibiotic therapy, and rehab.
Ms. Mages reported that she began noticing symptoms of poor balance after her discharge from inpatient rehab. Currently she still noted problems with poor balance and coordination. She found this is much worse if she turned her head quickly, although she did not describe vertigo with it. She was using a walker for balance at all times unless she was inside her house where she could hold onto furniture to maintain her balance. She reported there was no associated nausea, headache, diplopia or dysphagia. She did report several prior episodes of vertigo since 1958, but these had been highly sporadic in occurrence and was never seen for this or given a specific diagnosis or treatment for it. It had last been noted three years earlier .
After a full history and exam, Dr. Kellam diagnosed Ms. Mages with vestibular neuropathy. He felt that her symptoms were almost certainly the result of vestibular dysfunction secondary to the antibiotic gentamicin. He did not think it was likely to have been a direct result of the meningitis.
Dr. Kellam discussed the treatment for vestibular neuropathy, and explained that he knew of no specific treatment for it. He further explained that her exam showed no evidence of cerebellar dysfunction. He felt that she should see a specialist to confirm the diagnosis, and so he made a referral for her to see Dr. Lunde, ENT, for vestibular testing.
On February 1, 2012, Ms. Mages presented to the Dallas Ear Institute, where Yoav Hahn saw her, M.D. He again reviewed her history and the preliminary diagnosis made by Dr. Kellam a few weeks earlier. She continued to have the balance problem, and she especially had difficulty in dark rooms. He diagnosed her with dizziness and sensorineural hearing loss, and he advised her to start Cawthorne exercises, as well as to see an ophthalmologist.
On February 17, 2012, Ms. Mages presented to the Dallas Ear Institute to see Stephanie Cox, Au.D, CCC/A, Clinical Doctor of Audiology. The purpose for the visit was a consultation for vestibular evoked myogenic potential (VEMP) and video nystagmography (VNG) evaluations. The results were consistent with symmetrical responses between ears (asymmetry ratio: 1%), suggesting normal saccular function bilaterally. VNG: Caloric testing revealed a right unilateral peripheral vestibular weakness (36%). Central, positional and positioning testing was unremarkable.
Dr. Cox reported her findings in a letter to Dr. Hahn of the same date. She commented, “It was recommended that Mrs. Mages follow-up with you regarding today’s test results.”
Ms. Mages’ life is much different from before eating the tainted fruit. Her sons Mark and Frank see a remarkable woman changed. Mark has observed his mom post-Listeria as:
She continues to struggle with her balance. She now uses a cane or a walker for stability and has nearly stopped driving all together.
Frank has seen her change from a “picture of health for someone her age” to someone who has lost “her confidence both for driving and simple walking. She has been forced to abandon several of her regular activities. She no longer is able to cook and deliver funeral meals to the church and is no longer able to drive to see her brothers.”
Although hard to admit, Ms. Mages now needs to ask for help when she was independent in the past. She does not like asking people to drive her places. She misses taking care of her house and her yard by herself. She finds it “depressing to not be able to do the things I used to do.”