Diaphragmatic Pacing for Chronic Hypercapnic Respiratory Failure in a Patient with Listeria Meningoencephalitis

Case Diagnosis: Chronic Hypercapnic Respiratory Failure Secondary to Listeria Meningoencephalitis

Case Description or Program Description: A 60-year-old with osteoporosis and anxiety/depression presented with three days of headaches and dysphagia. MRI showed multiple ring-enhancing lesions in the left medulla, left CN V, left midbrain, and left parietal leptomeninges, later expanding to the cerebrum, cerebellum, brainstem, and cervical spinal cord (C2-C7).
On hospital day 2, they developed respiratory failure requiring intubation and full-body paralysis. A biopsy confirmed listeria meningoencephalitis. They received 10 weeks of IV antibiotics, with gradual strength improvement to 3/5 in the BLE and RUE but 0/5 in the LUE. They were weaned to a trach collar during the day but required nocturnal ventilator support due to hypercapnia and apnea.
Admitted to acute rehabilitation, they showed mobility gains but persistent nocturnal hypercapnia (pCO2 and end-tidal CO2 >60) and failed pressure support due to apnea. A diaphragmatic pacer was placed, with amplitude and pulse width adjusted to achieve tidal volumes of 550 mL and minute ventilation of 8 L/min. Using the pacer, they tolerated ~3 nights off the ventilator before developing hypercapnia but did not experience apnea. They are now trialing BiPAP via facemask with a capped trach, with good tolerance.

Setting: Acute Rehabilitation

Assessment/Results: A 60-year-old with chronic nocturnal apnea and hypercapnia secondary to listeria meningoencephalitis had great improvement with diaphragmatic pacing.

Discussion (relevance): Listeria meningoencephalitis is rare in immunocompetent adults, with variable recovery outcomes. Brainstem lesions affecting the central respiratory center can lead to prolonged ventilator dependence. Despite improved strength and daytime respiration, this patient had persistent central sleep apnea and hypercapnia, which improved with diaphragmatic pacing.

Conclusions: Diaphragmatic pacing may be an effective treatment for central sleep apnea and hypercapnia in patients with brainstem lesions, even after antibiotic therapy and functional recovery.