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Listeria monocytogenes Brain Abscess: Controversial Issues for the Treatment--Two Cases and Literature Review.

1. Introduction

Listeria monocytogenes (LM) is a facultative intracellular Gram-positive bacillus, widely distributed in nature and therefore found in multiple ecological sites, which can cause listeriosis, a serious foodborne bacterial infection [1]. Invasive listeriosis is classified into three forms: bacteraemia, neurolisteriosis, and maternal-neonatal infection. The incidence of listeriosis in the western hemisphere is estimated to be approximately three to six cases per 1 million population per year [2]. Epidemiological studies have identified host risk factors for bacteraemia and neurolisteriosis which include old age, innate and cellular immune deficiencies, cancer, HIV infection, cirrhosis, diabetes mellitus, alcoholism, and immunosuppressive therapies [3-6]. The most common central nervous system manifestation is meningitidis, while meningoencephalitis, rhombencephalitis, and cerebritis are less common [7]. Brain abscesses are extremely rare as they account for approximately 1-10% of CNS listerial infections and are observed in 1% of all listerial infections [8]. There are unresolved issues regarding surgical drainage of the abscess, selection of antibiotic regimen, and optimal treatment duration. We describe two cases (the first without evident immunodeficiency and the second affected by bullous pemphigoid) of brain abscess due to Listeria monocytogenes and discuss them by reviewing the literature on this topic.

2. Case Report

2.1. Case 1. A 62-year-old immunocompetent man with no significant previous medical history was hospitalized for high-grade fever, intractable hiccup, and interscapular pain. On admission, his white blood cell count was 11 x [10.sup.9]/L (normal range 4.50-10.80 [10.sup.3] mmc), his C-reactive protein (CRP) was elevated at 4.30 mg/dl (normal range 0.00-0.75 mg/dl), while his chest radiograph, abdomen ultrasound, and echocardiography were normal. A computed tomography (CT) scan of the brain revealed a diffuse abnormal pattern (presence of a specific inflammatory material) with hypodense lesions located in the trigonum of lateral ventricle in an underlying condition of demyelination and gliosis, suspicious for chronic ischemic vascular disease. A broad-spectrum antibiotic therapy with vancomycin and ceftriaxone was initiated. The patient became afebrile within a few days. A neurological examination found him to be alert and oriented, and he did not have a stiff neck. However, the patient had persistent hiccups and headache. Magnetic resonance imaging (MRI) showed enhancement of both trigeminal nerves and white spot lesions on the pons, cerebral peduncle, midbrain, and thalamus. He was then transferred to the Neurology Department where a lumbar puncture was carried out. His cerebrospinal fluid (CSF) was clear, WBC count was 50 cells/[micro]l, 100% lymphocytes, normal glucose level (normal range 40-70 mg/dl), 103 mg/dl protein (normal range 15-45 mg/dl), and the CSF culture was negative. As a viral etiology was suspected, antibiotic therapy with vancomycin + ceftriaxone was discontinued and treatment with acyclovir and steroid was initiated. After 72 hours, a progressive deterioration of his clinical-neurological condition occurred: he became hyperpyretic and aphasic and Glasgow Coma Score (GCS) was 9. CT brain imaging showed the involvement of the subcortical left temporoparietal lobe, and he was then transferred to the Infectious Disease Department. Blood cultures were performed, and another lumbar puncture was carried out. A cerebrospinal fluid (CSF) analysis showed cloudy CSF with increased spinal column pressure, granulocytic pleocytosis (180 cells/[micro]l, with PMN 90%), normoglychorrachia, and 145 mg/dl spinal fluid protein. A combination antimicrobial therapy with ampicillin 3 g/6 h + gentamicin 80 mg/8 h was initiated; 72 hours later, fever and other systemic signs and symptoms disappeared resulting in complete recovery (GCS15). Listeria monocytogenes were isolated from the patient's blood and recognized from CSF using the molecular technique (Multiplex Real-Time PCR Meningitis/ Encephalitis Filmarray bioMerieux). The patient was treated with intravenous ampicillin for 4 weeks, with combination intravenous gentamicin for the initial 2 weeks and switched to oral trimethoprim/sulfamethoxazole 160/800 mg/8 h for 1 month. An MRI was repeated after 8 weeks of antibiotic therapy due to the persistence of fluent aphasia. MR imaging showed a ring-enhancing lesion in the left frontotemporoparietal lobe, consistent with a brain abscess with significant perilesional edema (Figure 1). Surgical excision of the lesion was performed. Molecular identification of the pus using polymerase chain reaction (PCR) identified DNA of Listeria monocytogenes. The patient was represcribed intravenous ampicillin + gentamicin for 4 weeks, and therapy was then switched to oral trimethoprim/sulfamethoxazole 160/800 mg/12h for further 4 weeks. Patient's condition has improved progressively and with a complete recovery of linguistic abilities.

2.2. Case 2. A 72-year-old man with a history of bullous pemphigoid treated with a monoclonal antibody was admitted to another hospital due to a balance disorder. A neurological examination identified a left hemiplegia with no sensory deficits. An immediate CT brain scan showed a ring-enhancing cortical-subcortical lesion on the right frontal-parietal hemisphere. In view of the CTscan findings, gadolinium MRI of the brain was performed. MRI showed a caudal extension of the lesion with irregular enhancement and a necrotic region (Figure 2). Blood cultures were collected before initiating antimicrobial therapy. A few days later, his blood cultures grew Listeria monocytogenes. Based on organism sensitivity, intravenous therapy with ampicillin 3 g/6 h +gentamicin 80 mg/8 h +vancomycin 1 g/12h was initiated. Steroid therapy was also administered due to the associated moderate mass effect. The patient was then transferred to our Infectious Diseases Department for further workup and management. Forty-eight hours after the initiation of target therapy, the patient was afebrile. Twenty days later, he showed progressive clinical and neurologic deterioration characterized by visual hallucinations, frontal symptoms with disinhibition, and persistent hemiplegia. An MRI brain scan showed a substantial increase in lesion size, and new lesions appeared on splenium of corpus callosum and right temporal lobe with a significant mass effect on the right lateral ventricle. Trimethoprim/sulfamethoxazole 160/800 mg/8 h was added. The patient underwent a surgical biopsy of the lesion. Molecular identification of the brain tissue using PCR identified Listeria monocytogenes DNA. At the follow-up appointment five weeks later, additional imaging studies were performed which showed a considerable reduction in the size and enhancement of the lesions. Ampicillin, gentamicin, and vancomycin therapy was stopped while trimethoprim/sulfamethoxazole therapy was continued. The patient's neurological condition improved. An MRI brain scan performed after 8 weeks of antibiotic therapy, showed significant improvement, with noticeable decrease in the amount of vasogenic edema. Trimethoprim/sulfamethoxazole therapy was discontinued, and the patient was discharged. A year after the listeria brain abscess diagnosis, the patient does not show any significant neurologic deficits and is able to carry out all activities of daily living.

3. Discussion

Listeria monocytogenes can invade tissues that are normally resistant to infection, such as the CNS, a gravid uterus, or a fetus. This bacterium reaches the CNS due to hematogenous spread from the gastrointestinal tract [9]. The epithelium of the choroid plexus enables LM to gain access to CNS and causes a meningitides infection. On the other hand, LM may reach the brain parenchyma via the cerebral capillary endothelium, a single layer of brain microvascular endothelial cells characterized by tight junctions. It has been reported that LM-infected macrophages may pass through endothelial cells via the middle cerebral artery resulting in cerebritis which leads to brain abscess formation [10-13].

Furthermore, LM can use a peripheral intraneural route to invade the CNS. A recent animal study suggests that once the bacteria have gained access to the CNS via the peripheral nervous system, the infection can spread along the axons, producing additional lesions by traveling within the axons of the trigeminal nerve [14-16]. According to Bojanowski et al., once inside the CNS, the bacterium may travel along the white fiber tracts of the brain, resulting in a distinct anatomical imaging thus enabling early diagnosis [17]. The spreading of multiple listeria brain abscess within the cerebral nervous system through the intrassonal pathway justified their specific pattern and why they have more detrimental effects than bacterial brain abscess. In our case 1, MRI shows that the spreading follows the arcuate fasciculus. In case 2, the caudal extension of the lesions may also suggest that the lesion follows the projection fiber tracts.

Brain abscesses are extremely rare, accounting for approximately 1-10% of CNS listerial infections. These abscesses are generally located in the subcortical grey matter, especially in the thalamus and basal ganglia [18, 19]. Protection against LM is predominantly cell-mediated. Individuals with impaired cell-mediated immunity are at risk of developing listerial infections [20].

To the best of our knowledge, only 73 cases of brain abscess caused by L. monocytogenes were reported in the literature between 1968 and 2017. We report further two cases (Table 1) [1, 13, 17, 21-23].

Forty-eight of these patients were male (64%). The mean age of the patients was 51.9, and median age was 55 years (range 0-87 years). Fifty-nine out of 73 had one or more risk factors described in the literature for the development of neurolisteriosis (81%), 15/75 had no risk factors (19%), and in 1 case, nothing was specified. The mortality rate was 27.3%.

Blood cultures were reported for 63 cases: 50/63 were positive (79.5%).

L. monocytogenes was isolated from the CSF or brain abscesses in 31/61 patients (50.8%).

The therapeutic regimen was reported for 67/75 cases, while it is unknown in 8/75.

Twenty-seven out of 67 patients received a monotherapy regimen (40%), while a combination therapy was prescribed for 40/67 (60%) cases: a two-drug therapy was prescribed in 31 cases (50.8%) and a three-drug therapy was administered in 9 cases (14.7%).

The mortality rate in the monotherapy regimen group was 18.5% (five patients out of 27) while the group that received combination therapy showed a 20% mortality rate (eight patients out of 40). Fifty-nine out of 67 patients received a beta-lactam regimen, while 8/59 received a free beta-lactam regimen.

Considering the substantial numerical difference of the two samples, these are not comparable.

Ampicillin was the most commonly prescribed antibiotic as it was administered to 49 patients: in 21 patients, it was prescribed as monotherapy; in 23 cases, it was administered in combination with gentamicin; in 3 cases, it was administered in combination with trimethoprim/sulfamethoxazole while in 2 cases, it was administered in combination with other drugs such as vancomycin or macrolides.

There are currently no guidelines for brain abscess management. Starting from the 2010 consensus on the management and treatment of brain abscesses, we reviewed our case series [24].

Thirty-nine out of 75 patients underwent neurosurgery (52%). Four out of 31 died (13%). Thirty-four patients out of 75 (45.3%) had only been treated with medical therapy. Of these, 15/34 died (38.2%). In 2 cases, no data have been reported.

Therefore, in our case series, taking into account all of the possible bias, mortality would appear to be significantly higher in the group of patients treated exclusively with medical therapy.

In our opinion, this is a very interesting finding which requires further investigation.

However, as yet, there is no evidence concerning the appropriate duration of therapy for those patients who underwent neurosurgery.

According to a recent consensus study, antimicrobial treatment for brain abscesses should generally last 6-8 weeks and treatment for those undergoing neurosurgery should last 4-6 weeks [24].

From our literature review, the duration of therapy was known in 36/75 patients. Sixteen out of 36 received less than or equal to 6 weeks while 20/36 patients were treated for 8 weeks or more. Of the group of patients who received [less than or equal to] 6 weeks of therapy, 4/16 (25%) underwent neurosurgery, while of those belonging to the group who received [greater than or equal to] 8 weeks, 16/20 (80%) underwent neurosurgery.

A 12.5% mortality rate was observed for the first group while 0% died in the second group, thus suggesting that a combination of surgery and prolonged medical therapy has a positive impact on mortality.

We believe that it is essential to carry out this review as brain abscesses are rare, and there are no definitive guidelines on the optimal management, type, and duration of therapy. LM infection should also be suspected in immunocompetent patients, and new molecular biology techniques play key roles in the early diagnosis of this rare pathology.

4. Conclusions

In our literature review, we found that listeria brain abscess is not related to advanced age and that it is related to high mortality (27.3%).

Diagnosis should not be suspected only in immunocompromised patients as it was found in 20% of patients who had no risk factor.

Blood cultures were positive in more than 80% of cases. Most patients received a beta-lactam regimen, and mortality appears to be lower in patients treated with combination regimens.

This result looks certainly very interesting and should be explored with dedicated studies (i.e., sharp difference in mortality between the group undergoing neurosurgery and the group that only received medical therapy). Furthermore, the specific pattern of brain diffusion, reported and highlighted in our two clinical cases, should be considered when this diagnosis is hypothesized.

Conflicts of Interest

The authors declare that there are no conflicts of interest regarding the publication of this article.


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Beatrice Tiri (iD), (1) Giulia Priante, (1) Lavinia Maria Saraca, (1) Lucia Assunta Martella, (2) Stefano Cappanera, (2) and Daniela Francisci (1)

(1) Infectious Diseases Clinic, Department of Medicine, University of Perugia, Perugia, Italy

(2) Infectious Diseases Clinic, Department of Medicine, "S. Maria" Hospital, Terni, Italy

Correspondence should be addressed to Beatrice Tiri;

Received 12 March 2018; Revised 11 June 2018; Accepted 8 July 2018; Published 24 July 2018

Academic Editor: Tomoyuki Shibata

Caption: Figure 1: MR image showing the evolution of the ring-enhancing lesion in the left fronto-temporoparietal lobe in a brain abscess with significant perilesional edema.

Caption: Figure 2: MR image showing a caudal extension of the lesion with irregular enhancement with irregular enhancement and a necrotic region (FLAIR/long TR).
Table 1: Seventy-three cases of brain abscess caused by Listeria
monocytogenes reported in the literature between 1968 and 2017
(we described two other cases).

        Age/        Underlying                brain
N.       sex         diseases         Blood   abscess

1       70/M        Myasthenia          +        -
                    gravis in
2       57/F       Cirrhosis; DM        +        +
3       60/M      DM; rheumatoid        -        +
4       52/M        OLT in HCC          +        +
                   secondary to
                 hepatitis C and
5       56/F     Primary biliary        +        +
                 cirrhosis; OLT;
6       42/M           None             +        +
7       47/F           SLE;             -        +
8       16/F           SLE;             +        -
9       81/M     Myelodys plastic       +        +
                 syndrome; basal
                    cell skin
                 prostate cancer
10      52/F           DM,              +        -
11      81/F            DM             NR        +

12      74/F            DM              +       NR

13      32/F            LAC             +       NR

14      72/M           None             -        +
15      52/M       Inflammatory         +        -
                 myositis treated
                with prednisolone
                 and azathioprine
16      70/M        Alcoholism          +        +
17      56/M           AIDS             +        -
18      49/M     Rheumatic fever,       +        -
                  alcoholism, DM
19      64/M     DM, aortic valve       +        -
20      71/M      DM, rheumatic         +        -
                   heart disease
21      56/M           AIDS             +        -
22      70/F      Cirrhosis, DM,        +       ND
                   heart failure
23      25/F        Ulcerative         NR       NR
24      87/M           None             +        +
25      63/M           None             +        -
26      24/M           None             +        -
27      53/F           None             +        -
28      63/F           None             -        -
29      43/F           None             -        -
30      39/M           None            NR        -
31      54/F           None            NR       NR
32      1 +            None            NR       NR
33      70/M           NONE             -        +
34      53/M        Cirrhosis,          +        -
35      85/M            DM              +        -
36      43/M          OSAS,             +        -
37       0/M         Pronatis           +        -
38      63/M            MM              +        -
39      61/M            DM             NR       NR
40      60/M            HIV            NR        +
41      68/M         Leukemia          NR       NR
42      NR/M           None            NR       NR
43       2/M            NR             NR        +
44      49/M          Renal             +        +
45      16/M            ALL             +        +
46      20/M            ALL             +        +
47       6/F            ALL             +        +
48      46/F        Ulcerative          +        +
49      58/F            SLE             +        -
50      58/F      Immunoblastic         +        -
51      65/M            DM             +        NR
52      19/M         Juvenile          NR        +
                     of Fallot
53      55/M     Renal transplant       +        -
54      45/M     Renal transplant       +        -
55      60/F        Rheumatoid          +        -
56      66/F       AML, Crohn's         +        +
57      47/M           AIDS             +        -
58      54/F        Sarcoidosis         +        -
59      23/F            ITP             +        -
60      58/M            MM              +        -
61      55/M       Glioblastoma         -        +
62      51/M         Cardiac            +        +
63      37/M         Cardiac            +        +
64      56/F     Primary biliary        +       +
65      50/M        Sarcoidosis         -        +
66      51/F         Crohn's            -        +
67      50/M         Cardiac            -       +
                  transplant, DM
68      75/M           None                     ND
69      77/M            CLL             -       NR
70      58/M            CLL             -        +
71      Child           ALL            NR       NR
72      68/F       Breast cancer        +       ND
73      47/F     Evans syndrome,        +        -
                      SLE, DM
Case    62/M           None             +        +
Case    72/M         Bullous            +        +
2                   pemphigoid

            Surgery/                                   Duration
N.            type              Antibiotic            of therapy

1              ND             Ampicillin +             6 weeks
                               gentamicin;           ampicillin +
                              trimethoprim/         gentamicin for
                             sulfamethoxazole          10 days
2            Biopsy           Ampicillin +                NR
                            (a) Amoxicillin +         (a) 17 days
3              ND           (b) Trimethoprim/        (b) 20 days
                              (c) Linezolid          (c) 33 days
                             (d) Amoxicillin            (d) NR
4         Craniotomy          Ampicillin +             3 weeks
        with resection        gentamicin +           (gentamicin
         of the lesion         penicillin G            only for
                                                       2 weeks)
5            Biopsy           Ampicillin +             8 weeks
                                gentamicin           (gentamicin
                                                       only for
                                                       2 weeks)
6         Biopsy and          Ampicillin +                NR
            drainage          gentamicin +
7              ND               Ampicillin              6 weeks
8          External           Trimethoprim/            13 weeks
          ventricles        sulfamethoxazole         trimethoprim/
             device           + ampicillin        sulfamethoxazole;
                               + meropenem          ampicillin for
                                                       4 weeks;
                                                    meropenem for
                                                    5 weeks (total
                                                     of 22 weeks)
9       Craniotomy with         Ampicillin                NR
         resection of
           the lesion
10           Biopsy           Ampicillin +              6 weeks
11           Biopsy             Ampicillin              8 weeks
12             NR             Vancomycin +                NR
                              ampicillin +
13             NR             Ampicillin +             8 weeks;
                              trimethoprim/           linezolid
                            sulfamethoxazole          for 10 days
                               + linezolid
14             ND               Ampicillin                NR
15             ND               Ampicillin              6 weeks
16             ND             Ampicillin +             3-6 weeks
                              gentamicin +
17             ND             Ampicillin +           Article not
                                gentamicin             available
18             ND             Penicillin G +              NR
                             streptomycin +
19             ND             Ampicillin +            4 weeks +
                                gentamicin            ampicillin
                                                      for 2 weeks
20             ND             Ampicillin +                NR
21             ND             Ampicillin +           Article not
                                gentamicin             available
22             ND             Ampicillin +           Article not
                              trimethoprim/            available
23             ND                   NR                    NR
24             ND            Penicillin G +               NR
25             ND               Ampicillin                NR
26             ND             Ampicillin +             6 weeks,
                                gentamicin            gentamicin
                                                       only for
                                                        10 days
27             ND             Minocycline,              2 weeks
28             ND                   NR                    NR
29             ND               Ampicillin                NR
30             ND                   NR                    NR
31             ND                   NR                    NR
32             ND              Amoxicillin           Article not
33        Craniectomy           Ampicillin                NR
        and open biopsy
34             +             Penicillin G +          Article not
                               erythromycin            available
35             +                Ampicillin           Article not
36             +                    NR               Article not
37             +              Ampicillin +           Article not
                                gentamicin             available
38           Biopsy          (a) Ampicillin          (a) 5 weeks
                             (b) Linezolid +         (b) 15 weeks
39           Biopsy           Trimethoprim/            3 weeks,
                           sulfamethoxazole +        trimethoprim/
                             chloramphenicol       sulfamethoxazole
                                                      alone for
                                                       20 weeks
40      Craniotomy and       Penicillin G +               NR
        intraoperative       chloramphenicol
41             ND            Chloramphenicol              NR
42             ND                   NR                    NR
43      Craniotomy with             NR                    NR
         resection of
           the lesion
44             ND            Chloramphenicol              NR
45             ND            Penicillin G +               NR
46             ND             Ampicillin +              8 weeks
                            chloramphenicol +
47             ND              Ampicillin,                NR
48             ND              Ampicillin,             8 weeks,
                                gentamicin              4 weeks
49             ND            Penicillin G +          ARTICLE NOT
                                tobramycin             AVAILABLE
50             ND               Ampicillin              8 weeks
51            ND              Ampicillin +             4 weeks
52             ND             Vancomycin +           Article not
                                ampicillin             available
53             +                Ampicillin           Article not
54        Craniotomy            Ampicillin             10 weeks
          and drainage
55           Biopsy            Ampicillin,             8 weeks,
                               amoxicillin             24 months
56           Biopsy             Ampicillin              4 weeks
57         Craniotomy          Ampicillin,                NR
58           Biopsy           Ampicillin +                NR
59        Drainage of         Trimethoprim/            12 months
          the abscess        sulfamethoxazole
60        Craniotomy        (a) Trimethoprim/        (a) 12 weeks
          and drainage      sulfamethoxazole +       (gentamicin
                               gentamicin           only 2 weeks)
                            (b) Trimethoprim/        (b) 5 months
61           Biopsy           Amoxicillin +            12 weeks
62       Stereotactic         Ampicillin +             6 weeks,
        brain aspiration        gentamicin            gentamicin
                                                     only 2 weeks
63      Craniotomy with        penicillin G             8 weeks
         resection of
           the lesion
64          Biopsy            Ampicillin +             6 weeks
                               gentamicin             gentamicin
                                                     only 2 weeks
65         Craniotomy         Trimethoprim/          Article not
                             sulfamethoxazole          available
66           Biopsy           Ampicillin +             12 weeks
                                gentamicin           (gentamicin
                                                     not reported)
67        Biopsy and          Ampicillin +           18 weeks of
          aspiration           gentamicin            ampicillin;
                                                       14 weeks
68             +              Ampicillin +           Article not
                                gentamicin             available
69             +             Chloramphenicol         Article not
70           Biopsy           Ampicillin +              6 weeks
71             +                    NR               Article not
72           Biopsy            Ampicillin,            10 weeks,
                               amoxicillin             24 weeks
73             ND              Ampicillin,            6 weeks, NR
Case    Craniotomy with     (a) Ampicillin +         (a) 8 weeks
1        resection of          gentamicin            (gentamicin
           the lesion       (b) Trimethoprim/       only 4 weeks)
                             sulfamethoxazole         (b) 8 weeks
Case         Biopsy         (a) Ampicillin +         (a) 5 weeks
2                             gentamicin +            (b) 3 weeks
                            (b) Trimethoprim/

N.       Outcome        References

1       Survived       Chalouhi et
                         al., 2013
2         Died          Matera et
                         al., 2012
3       Survived         Coste et
                         al., 2012
4       Survived       Choudhury et
                         al., 2013
5       Survived         Tseng et
                         al., 2013
6       Survived        Beynon et
                         al., 2013
7       Survived      Horta-Baas et
                         al., 2013
8       Survived        Perini et
                         al., 2014
9       Survived         West et
                         al., 2015
10      Survived       Al-Harabi et
                         al., 2015
11      Survived      Dejesus-Alvelo
                       et al., 2015
12      Survived        Bojanowski
                        et al. [17]
13      Survived        Fervienza
                       et al., 2016
14      Survived         Mano et
                         al., 2017
15      Survived         Onder et
                         al., 2016
16        Died           Cone et
                         al. [13]
17      Survived         Patey et
                         al., 1989
18        Died         Buchner and
19      Survived         Soto and
                       Sliman, 1992
20        Died          Eckburg et
                         al. [22]
21      Survived         Patey et
                         al., 1989
22        Died         Sivalinga et
                         al., 1992
23        Died         Larsson and
                       Linell, 1979
24        Died          Spilkin et
                         al., 1968
25        Died          Kennard et
                         al., 1979
26      Survived       Smiatacz et
                         al., 2006
27      Survived        Mrowka et
                         al., 2002
28        Died         Brun-Buisson
                       et al., 1985
29        Died         Brun-Buisson
                       et al., 1985
30        Died         Kwantes and
                        Isaac, 1971
31        Died         Larsson and
                       Linell, 1979
32      Survived        Mancini et
                         al., 1990
33      Survived        Salgado et
                         al., 1996
34      Survived        Halkin et
                         al., 1971
35        Died           Brown et
                         al., 1991
36      Survived        Douen and
                       Bourque, 1997
37      Survived       Banerji and
                        Noya, 1999
38      Survived         Leiti et
                         al. [20]
39      Survived       Sjostrom et
                         al., 1995
40        Died          Harris et
                         al., 1989
41        Died          Larsson et
                         al., 1978
42        Died          Pollock et
                         al., 1984
43      Survived        Umenai et
                         al., 1978
44        Died         Crocker and
                      Leicester, 1976
45      Survived         Dykes et
                         al., 1979
46      Survived      Hutchinson and
                        Heyn, 1983
47      Survived        Viscoli et
                         al., 1991
48      Survived     Soares-Fernandes
                       et al., 2008
49      Survived        Takano et
                         al., 1999
50      Survived        Maezawa et
                         al. [21]
51        Died            Wu et
                        al., 2010
52      Survived        Turner et
                         al., 1995
53      Survived      Lechtenberg et
                         al., 1979
54      Survived         Stam et
                         al., 1982
55      Survived        Updike et
                         al., 1990
56      Survived        Eckburg et
                         al. [22]
57        Died           Cone et
                         al. [13]
58        Died         Ackermann et
                         al., 2001
59      Survived     Treebupachatsaul
                       et al., 2006
60      Survived      Al-Khatti and
                      Al-Tawfiq, 2010
61      Survived        Ganiere et
                         al., 2006
62      Survived        Eckburg et
                         al. [22]
63         NR           Eckburg et
                         al. [22]
64      Survived         Cone et
                         al. [13]
65      Survived      Poropatich and
                      Phillips, 1992
66      Survived       Stefanovich
                       et al., 2010
67      Survived        Eckburg et
                         al. [22]
68      Survived       Mylonakis et
                         al., 1998
69         NR         Cleveland and
                       Gelfand, 1993
70      Survived         Dee and
                       Lorber, 1986
71      Survived       An tunes et
                        al., 1998
72      Survived     Limmahakhun and
                    Chayakulkeeree [1]
73      Survived     Limmahakhun and
                    Chayakulkeeree [1]
Case    Survived
Case    Survived
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Title Annotation:Case Report
Author:Tiri, Beatrice; Priante, Giulia; Saraca, Lavinia Maria; Martella, Lucia Assunta; Cappanera, Stefano;
Publication:Case Reports in Infectious Diseases
Date:Jan 1, 2018
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