Richard Benell is 76-years-old, and lives with his wife of many years, Carol, in Colorado Springs, Colorado. Richard has never had a major illness or surgery in his adult life, and has always been active and healthy. Very recently, he was diagnosed with acid reflux and a tendency toward Type II diabetes. He worked as an electrician until retirement several years ago.
Richard and Carol frequently purchase groceries at the King Soopers location on Centennial Boulevard in Colorado Springs. At that location, on multiple occasions in the first half of August 2011, they purchased a cantaloupe, grown and packed by Jensen Farms, that was contaminated by Listeria monocytogenes. Richard and Carol ate the fruit on several occasions over the course of the weeks that followed those purchases.
Beginning in the latter half of August, Richard just did not feel well. Carol recalls that he was sleeping more than usual during the day, and not sleeping well at night. Toward the end of the month he began feeling worse each day, his appetite decreasing, and losing weight. This is an image of Richard on September 1, losing weight and looking tired.
The true severity of Richard’s health problems began to become clearer on approximately September 6, 2011, when, in addition to his other symptoms, he began to run a high fever. This persisted, along with intermittent spells of feeling very cold, for the next several days. Also, he became even weaker than he had been in previous weeks, had a persistent headache, and, as Carol recalls, developed confusion, muscle pain, and had a difficult time walking.
By September 8, Carol had become very worried about her husband’s condition and called 9-1-1. The Colorado Springs Fire Department dispatched an ambulance, and emergency medical personnel found Richard sitting upright in a chair in his living room. He explained to the EMT’s that, for the past three days, he had been having fever and chills, body aches, increased fatigue, excessive urination, and increased blood sugar levels. He reported that he was a diabetic, but that his condition was well-controlled with the right diet and exercise. Carol added that Richard had also been having “uncontrollable tremors.” After an exam to insure his stability, the EMTs took Richard to the emergency department at Penrose St. Francis Hospital.
At Penrose, Richard saw Dr. Sooch in the emergency department, who noted that Richard’s temperature measured 103°F. Dr. Sooch initially thought that Richard had pneumonia, but a chest x-ray rule that out. Lab tests showed that Richard was hyperglycemic with low platelets. Dr. Sooch decided that Richard should be admitted to the hospital
Once Richard was admitted and in his hospital room, Francis Joseph, MD, performed the admission history and physical exam, noting that Richard’s chief complaints were persistent fever and chills. Dr. Joseph also recorded a history of intermittent, episodic rigors, and diffuse aches and pains all over Richard’s body. Follow-up lab tests, done on Dr. Joseph’s orders, confirmed that Richard’s platelets were low, and that his glucose was high. In addition, his urine was positive for glucose and protein. Dr. Joseph decided to observe him and await the blood and urine cultures that were collected in the ER.
On September 10, 2011, an infectious disease specialist saw Richard because the blood sample that had been collected in the ER was growing gram-positive rods. Peter Brookmeyer, MD, was unable to confirm that the gram-positive rods were evidence of infection, at this point, but nevertheless ordered antibiotic coverage for Listeria, starting Mr. Benell on Vancomycin and Unasyn intravenously. Dr. Brookmeyer made special note of the recent Listeria outbreak in the state of Colorado, which caused him to be suspicious for this pathogen.
September 10 blood test results continued to show that Richard’s platelets were low, which further validated Dr. Brookmeyer’s concern for a septic-type illness due, possibly, to Listeria infection.
Dr. Joseph rounded later in the day, and Richard reported that he was actually feeling better, but still had chills. Dr. Joseph was watching Richard’s elevated blood sugars, and also noted that lab tests earlier in the day showed that Richard had become hyponatremic—i.e. deficient in sodium. He felt that this could have been caused by a combination of hypovolemia, hyponatremia, and early ascites syndrome.
The next day, September 11, the pathogen previously suspected by the presence of gram-positive rods was confirmed as Listeria monocytogenes. Nevertheless, Richard did not have a fever at this point and was up and walking unassisted in the hallway when Dr. Joseph next came to see him. Richard’s vital signs were stable, but liver function tests were now abnormal, and blood tests continued to show that Richard was thrombocytopenic (low platelets) and hyponatremic. In consultation with Dr. Brookmeyer, Dr. Joseph changed Richard’s antibiotic to high dose ampicillin intravenously.
Richard continued to be thrombocytopenic, and suffering from severe abdominal pain, until September 13. In fact, his physicians were concerned that the abnormal liver function with accompanying abdominal pain represented acute hepatitis. Ultrasounds and a CT scan failed to show any processes of that nature, however, and the discomfort ultimately resolved without any invasive treatment.
When Dr. Joseph rounded on September 13, he found Richard to be relatively comfortable and taking food and fluids orally. His blood sugars continued to be high, however, and so he was started on the diabetic medication Lantus. By this point, Richard’s platelet count had begun to rise, and his liver function was still abnormal but trending back to normal. Dr. Joseph felt that Richard could be discharged home, as long as intravenous ampicillin could be continued. His discharge diagnoses were:
- Fever secondary to Listeria sepsis.
- Degenerative joint disease.
- History of transient ischemic attack.
- History of hearing loss.
- Gastro-esophageal reflux disease.
At discharge, Richard was cautioned to follow a strict medication regimen due to his severe Listeria infection. His medications included Lantus, Lisinopril, and Ampicillin. He was also advised to follow-up with Dr. Brookmeyer one week post-discharge, and to see his primary physician Douglas Swanson, MD, in two days.
The day after discharge, September 14, Richard had a central line placed in his right arm to accommodate the continuous Ampicillin treatment he was going to need for the next few weeks. His lab test results were trending back to normal. (WBC 4.6, Hgb 10.8L, Hct 30.9L, Platelets 125L, AST 71H, ALT 100H, Alk Phos 236H, Albumin 3.0L. Blood culture – NO GROWTH (collected 9/11/2011)). Carol recalls that the task of carrying around a large backpack full of antibiotics wherever Richard went immediately became a trying task. Home health came regularly to assist in the administration of Richard’s medication, but the task of changing the antibiotic bag and flushing the PICC line frequently fell to Carol.
A couple of days afterward, Richard began to experience pain in his right arm. On September 16, he presented to the Penrose ER again, where he saw Randolph Maul, MD. Richard reported that the pain in his right arm was worse with movement, and that he had noticed swelling in both ankles.
A chest x-ray was done, as well as CT and venous duplex Doppler studies of his right arm. The Doppler study showed a non-occlusive thrombus in the right subclavian, right axillary, and right basilica vein, adjacent to the indwelling PICC line. An ECG was normal. Dr. Maul prescribed Warfarin and Lovenox, anticoagulants, for DVT (deep venous thrombosis) prophylaxis. He also prescribed pain medications for a couple of days and sent Richard home with instructions to return if he had any warning signs of additional thrombus.
On September 20, Richard saw his primary physician, Dr. Swanson. At this point, Richard was getting continuous intravenous amoxicillin through the PICC line, managed by Dr. Brookmeyer, which was to continue for two more weeks. Dr. Swanson examined Richard and found him to be unusually weak. He affirmed the diagnosis of “potentially lethal listeria infection.” Richard also reported recent headaches, but Dr. Swanson did not think they were due to meningitis. He felt the embolus diagnosed at the ER was from the PICC line, but he also had ankle edema, which was quite significant, and no ultrasound of his legs had been done. Dr. Swanson suspected fluid overloading in the hospital, or perhaps an element of septic shock. Since the swelling did not seem to bother him, he decided they would simply continue to observe.
On September 22, Richard returned to see Dr. Brookmeyer, reporting that he felt dramatically better. They discussed the blood clot diagnosed in the ER, for which he was now on Lovenox and Coumadin, but decided not to pull out the PICC line. Richard stated that the pain that had been in the right lower quadrant of his abdomen had “pretty much resolved.” His lab test results were also continuing to improve. Finally, Dr. Brookmeyer indicated that, with this high-grade bacteremia, they would need to get test-of-cure (i.e. re-culturing the site of, or someone with, a previous infection to ensure that it has resolved) blood cultures in about a week.
On September 29, Richard again saw Dr. Swanson, to whom he also reported feeling much better, with an increased appetite and intentional weight gain. His vital signs continued to be stable and he was afebrile, though he continued to have moderate bilateral ankle edema. Dr. Swanson noted that he was getting stronger because his diet had improved. He planned to begin the process of trying to wean him down on the Lantus. He felt it might be possible that his PICC line would be removed soon, after which they would continue warfarin for about a month. At that point, risk of taking warfarin would likely be greater than the risk of the clot breaking off and floating downstream.
Richard’s next visit with Dr. Swanson occurred on October 7. The bilateral ankle edema was improving; the PICC line had been removed; and the antibiotics discontinued. Dr. Swanson expressed uncertainty why Richard had had the ankle edema, but it seemed to get better after the PICC line was removed. Because the cause of his phlebitis was no longer present, he felt they could stop the Warfarin in one more month.
Mr. Benell returned to see Dr. Brookmeyer on October 12, 2011. He reported that he felt completely back to normal. His vital signs were stable and he had remained afebrile. Blood test results from October 6 had shown “no growth,” but did show another drop in platelets. Dr. Brookmeyer felt that the Listeria bacteremia was showing no evidence of meningitis, and he was stable off the IV antibiotics for two weeks. He felt hopeful this represented a cure.
Dr. Brookmeyer felt that they could now carefully monitor for symptoms of relapse, and accordingly told Richard to call if he developed any of those, or to go immediately to the ER. Specifically, if he developed fevers, neck stiffness, weakness, fatigue or other symptoms he should contact him immediately. The low platelets were of unclear etiology but were borderline low, and he felt that they may simply be residual from the infection.