Case 1 (the son)
A 16-year old boy presented to the pediatric emergency department with a 1 week history of rhinitis and general malaise and reduced appetite, and mild watery diarrhea with abdominal pain for the last 4 days. On the day of admission he had developed fever, vomited once, and complained of bilateral lower limb pain. His father was also ill with fever and diarrhea. Both had been at a camping site in Germany 1 week previously. A third person (grandfather) did not fall ill.
The boy is generally in good health. He is known to have alpha thalassemia (heterozygote) and glucose-6-phosphate dehydrogenase deficiency (G6PD). He suffered from malaria in May 2006 and August 2014 after vacations in Kenya, his country of origin. Currently, he did not take any regular medication. There was no significant travel history in the preceding 6 months.
On presentation he was unwell, core body temperature measured 39 °C. His heart rate was 111/beats per min, his blood pressure was 124/63 mmHg. He was tender in his right and left iliac fossae with rebound tenderness noted on the right. The remaining physical examination was unremarkable apart from bilateral tender thighs.
Peripheral blood white cell count (WCC) was 8.65 × 109/l, C-reactive protein (CRP) was 34 mg/l (<10 mg/l) and Procalcitonin level was 0.929 ng/ml, (<0.1 ng/ml). Liver and renal parameters were unremarkable. Creatinine kinase was 272 U/l (<270 U/l). Blood cultures were taken and he was admitted to the ward for intravenous rehydration with a presumed diagnosis of viral gastroenteritis. One day after admission, he remained unwell with high fever and crampy abdominal pain. Appendicitis was considered but this was ruled out following surgical assessment. A second set of blood cultures was taken. His CRP increased to 175 mg/l and WCC decreased (min. 3.08 × 109/l). On day 3 of admission, the second set of blood cultures yielded Gram-positive rods. A rapid identification using MALDI-TOF mass spectrometry directly from the positive blood culture vials revealed Listeria monocytogenes (time to positivity 20 h and 36 min.; see microbiology results below for details). Further diagnostic tests (stool cultures for Shigella, Salmonella and Campylobacter and PCR for Adeno- and Rotavirus) were all negative. Due to the MALDI-TOF results, treatment with Amoxicillin i.v (25 mg/kg qid) and Amikacin (15 mg/kg qd) was initiated and the patient recovered rapidly within three days without any sequelae. Amoxicillin i.v. was continued for a total of 10 days and Amikacin was discontinued after 5 days.
Case 2 (the father)
The day following the son’s admission to hospital, his 46-year old father presented to the emergency room with a 3-day history of heavy watery diarrhea (10–20 times a day), vomiting, weakness, joint and muscle pain, and distinct headache. On one occasion his temperature measured >38 °C. Previously he was healthy, did not take regular medication, and drank no alcohol.
At presentation, the patient was febrile (core body temperature 39.8 °C) with a heart rate of 95 bpm and blood pressure reading 100/65 mmHg. Clinical examination revealed bilateral conjunctivitis and hyperactive bowel sounds. Laboratory analysis showed a left-shift of neutrophils (65%, norm 5–15%), an elevated CRP of 214 mg/l (<10 mg/L) and a creatinine level of 117 μmol/l (range 49–97 μmol/l).
As he had travelled to Kenya a few months previously, malaria was excluded. After drawing blood cultures, antibiotic therapy with ceftriaxone 2 g IV per day and metronidazole 500 mg PO three times a day was commenced as empiric therapy for sepsis due to infectious diarrhea.
The following day a blood culture flagged positive and Gram staining revealed Gram-positive rods. Again, the rapid identification directly from the positive blood culture vials using MALDI-TOF mass spectrometry showed Listeria monocytogenes (see microbiology results below for details). Further diagnostic tests (stool cultures for Shigella, Salmonella and Campylobacter and C.difficile- and Norovirus-PCR) were negative. According to the MALDI-TOF findings, the antibiotic therapy was changed to amoxicillin 2 g every 4 h IV and gentamicin 80 mg every 8 h IV (1 mg/kg tid). The latter was stopped after 5 days as the patient’s condition improved. Meningitis was ruled out following a normal cerebrospinal fluid analysis. On day nine, the diarrhea significantly improved and the patient was discharged home in good condition with oral sulfamethoxazole/trimethoprim 800/160 mg 2 tablets every 8 h (5 mg/kg trimethoprim component tid) to complete a 14 day course of antibiotic treatment.
Further detailed history revealed that both, father and son, had eaten suspect not-well tasting cheese and ham sandwiches at the camping site about a few days before presentation. No one else in the family and, as far as we know, nobody else at the camping site developed illness. No other unusual food was eaten. Unfortunately, the sandwiches as the suspected source of infection could not be retrieved retrospectively.