1052659

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VETXXX10.1177/03009858211052659

Review
Veterinary Pathology

Listeria monocytogenes at the interface between 2022, Vol. 59(2) 186­–210

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DOI: 10.1177/03009858211052659
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pathology and pathogenesis review journals.sagepub.com/home/vet

Stefano Bagatella1, Leticia Tavares-Gomes1, and Anna Oevermann1

Abstract
The bacterium Listeria monocytogenes (Lm) is widely distributed in the environment as a saprophyte, but may turn into a lethal
intracellular pathogen upon ingestion. Invasive infections occur in numerous species worldwide, but most commonly in humans
and farmed ruminants, and manifest as distinct forms. Of those, neuroinfection is remarkably threatening due to its high
mortality. Lm is widely studied not only as a pathogen but also as an essential model for intracellular infections and host-pathogen
interactions. Many aspects of its ecology and pathogenesis, however, remain unclear and are rarely addressed in its natural
hosts. This review highlights the heterogeneity and adaptability of Lm by summarizing its association with the environment,
farm animals, and disease. It also provides current knowledge on key features of the pathology and (molecular) pathogenesis
of various listeriosis forms in naturally susceptible species with a special focus on ruminants and on the neuroinvasive form
of the disease. Moreover, knowledge gaps on pathomechanisms of listerial infections and relevant unexplored topics in Lm
pathogenesis research are highlighted.

Keywords
brain diseases, foodborne diseases, listeriosis, cattle, sheep, goats, bacterial infections, zoonosis, One Health

Listeria monocytogenes (Lm) is a globally distributed bacterial innate and adaptive immune responses toward bacterial infec-
pathogen with zoonotic potential, able to cause disease (gener- tion.219,276 Noticeable features of Lm are its high resilience and
ally termed “listeriosis”) in a wide variety of domestic and wild versatility allowing it to reside as a saprophyte in various envi-
mammalian and non-mammalian species,94,203 including ronmental habitats296 and its rapid switch into a dangerous
humans, cattle, sheep, goats, dogs, cats, horses, pigs, South opportunistic and intracellular pathogen once it is in contact with
American camelids, farmed deer, and poultry.125,180,306 Species the host.103,281 Intriguingly, the bacterium causes various disease
other than humans and ruminants, however, are only sporadi- manifestations in susceptible hosts,91,250 of which central ner-
cally affected. As an animal pathogen, Lm is a cause of concern vous system (CNS) infection, known as neurolisteriosis, is par-
not only in terms of public health and food safety but also as a ticularly threatening and occurs frequently in ruminants.63,198,309
significant cause of economic losses when livestock and their Despite the advances in our understanding of Lm infection at
offspring are affected. the cellular level, its environmental and farm life cycle as well
First described in the 1920s in a human patient,83 then a few as organ targeting mechanisms during listeriosis, in particular
years later in laboratory animals202,232 and in the following CNS infection, remain to be fully deciphered. This review aims
decade in ruminants,125 the pathogenic nature of Lm has long to summarize the current knowledge and to map research gaps
been recognized. However, the bacterium has been perceived as regarding Lm epidemiology and infection in ruminants with a
an important and deadly human foodborne pathogen only fol- focus on its peculiar neuroinvasive phenotype.
lowing major outbreaks in the 1980s, even though its oral infec-
tion route was known decades prior in farm animals.60,260,261
Lm, a Heterogeneous and Multi-Skilled
Since then, surveillance in various countries has continually
ranked Lm among the most fatal foodborne pathogens despite Bacterium
the low prevalence, as the mortality rate in listeriosis is high.85,260 Lm is a member of the genus Listeria, which currently com-
In spite of rigorous, albeit unharmonized, food safety regula- prises 21 recognized species of Gram-positive nonsporulating
tions adopted by different countries,90,287,288 major listeriosis
outbreaks continue to occur worldwide today134,280 with an 1
Division of Neurological Sciences, Vetsuisse Faculty, University of Bern,
increasing incidence rate reported in many countries,45,91,120 Bern, Switzerland
causing a noticeable burden on global public health.60
Corresponding Author:
Lm is an intensely studied pathogen that has been used for Anna Oevermann, Division of Neurological Sciences, Vetsuisse Faculty,
decades as a model for bacterial cell invasion, adaptation to and University of Bern, Bremgartenstrasse 109a, CH-3012 Bern, Switzerland.
subversion of the host-cell molecular machinery,136,233 and for Email: [email protected]
Bagatella et al 187

coccobacillary bacteria.68,171,207,214,241 Among them, Lm is by predominantly food- and environment-associated strains, but to
far the most relevant member in terms of virulence, although a lesser extent also strains associated with clinical disease in
Listeria ivanovii is also regularly associated with disease, but humans and ruminants.151,213,234
exclusively in domestic ruminants. Other species (L. innocua,
L. seeligeri, L. grayi, among others) are only sporadically iden-
Prevalence of Hypervirulent Versus Hypovirulent
tified in human and animal infections.6,131,226,243,244,250,252,274,297
Lm is a particularly versatile bacterium being facultative intra- Lm Clonal Complexes in Disease
cellular, facultative anaerobic, and notably osmo- and halotol- Various CCs from lineage I belonging to serotype 4b (such as
erant, able to replicate in media containing up to 10% NaCl. CC1, CC2, CC4, and CC6) are significantly linked to clinical
Furthermore, it grows in a wide range of temperatures (between cases in humans and have been shown to be hypervirulent in
1 °C and 45 °C) and pH (5–9).51,95 This remarkable resistance experimental models. Additionally, they are better adapted to
to environmental stressors allows the bacterium to survive in a host colonization than clones overrepresented in food and the
wide variety of ecological habitats and within the host.294 environment (such as CC9 and CC121).190,192,199,312 In rumi-
nants, lineage I and, in particular, CC1 and CC4 are signifi-
cantly overrepresented in clinical isolates and notably in
Lm Strain Heterogeneity isolates from neurolisteriosis when compared with other clini-
Epidemiological and experimental studies suggest that the vari- cal listeriosis syndromes such as abortion, mastitis, or gastro-
ability in environmental distribution, virulence, and clinical enteritis. However, other CCs from lineage I (CC2, CC217,
manifestations between different hosts are linked to genetic het- CC6, CC191, CC59) and lineage II (CC7, CC11, CC14, CC37,
erogeneity of Lm.17,190,192,199,213,221 However, the underlying bac- CC204, CC412) are also regularly isolated from diseased ani-
terial determinants and mechanisms driving the variability and mals and their environment. In contrast, other strains, such as
niche adaptation of Lm are not yet clear, and the investigation of CC9, are predominantly detected in food processing facilities
such determinants is currently one focus of research.66 and the environment (Fig. 1).22,79,220,221,277 However, the cause
Characterization of bacterial subtypes and their association with for the epidemiologically evident predominance of a limited
particular niches and virulence has been attempted through vari- number of subtypes in clinical cases of both humans and rumi-
ous techniques.54,177 Classically, serotyping methods based on nants is not exactly understood. Host-associated hypervirulent
specific antisera allowed for the distinction of Lm into 13 sero- clones have been shown to possess conserved virulence
types.271 Despite its low discriminatory power,54,177,266 serotyp- genes,17,149,192,199 whereas environmental clones may harbor
ing has been employed for decades as the standard subtyping inactivating mutations of such genes, making them hypoviru-
technique in epidemiological investigations and provided first lent and potentially accounting for their sporadic association
evidence that Lm subtypes are differentially distributed between with disease. Expression of more stress resistance genes, such
environment and clinical disease.213 Among the 13 serovars, as benzalkonium chloride resistance genes in CC9 and CC121
1/2a, 1/2b, and 4b are the most commonly identified in human strains, together with negative regulation of transcriptional fac-
and animal clinical isolates, with a noticeable preponderance of tors for virulence genes may favor their environmental fit-
serotype 4b in major listeriosis outbreaks157,266,278 and ruminant ness.149,190–192,253,279 Yet, many hypovirulent clones express
neurolisteriosis cases.155,164,251,308 All 3 serotypes, apart from virulence genes crucial for host invasion and may cause severe
being implicated in disease, were additionally isolated from disease in specific circumstances, for example, in immunosup-
food, food processing and farm environments, and animal pressed patients.157,313
feces.26,89,102,152,211,234,277 More recently, molecular typing meth-
ods such as pulsed field gel electrophoresis (PFGE),36,106,123
Global Distribution of Major Lm Clonal Complexes
multilocus sequence typing (MLST),114 and whole-genome
sequencing (WGS)161 (reviewed in Datta and Burall54 and Datta Hypervirulent strains (eg, CC1) that are overrepresented in
et al55) have been employed to link clinical, food, and environ- clinical isolates from major outbreaks appear to be distributed
mental isolates in epidemiological investigations during out- worldwide17,43 and, notably, often appear to share a similar dis-
breaks (PFGE), to study genetic relatedness in Lm populations tribution between humans and ruminants.79,190,192,221 Major Lm
(MLST), or both (WGS). Phylogenetic analyses performed with CCs have also been shown to spread globally over time, caus-
MLST and WGS identified 4 distinct lineages (I–IV), further ing historically relevant outbreaks. Moreover, within a given
subdivided into clonal complexes (CCs) and sequence types geographic region, predominant lineages might shift over
(STs), or sublineages (SLs) and core genome MLST types time.199 For instance, hypervirulent (eg, CC6)17,192 and hypo-
(CTs), respectively. Lm clusters into 2 major lineages (I, II) that virulent (eg, CC9, CC121)17,190 clones are emerging in the 21st
are frequently isolated from diverse sources, and 2 minor lin- century in various continents. This is speculated to occur due to
eages (III, IV) that are only sporadically isolated from animal genetic diversification, possibly as a result of fitness adaptation
infections.213 Of the major lineages, lineage I is the genetically or global dispersion through human travel, animal, or food
most homogeneous and overrepresented in human clinical iso- trade.17,199 CC1 constitutes a notable example in these regards,
lates and ruminant neurolisteriosis cases.79,192,213,221,251 In con- as it is speculated to have spread globally from North America
trast, lineage II is genetically heterogeneous and includes through cattle trade.200 Given the high ability of Lm to adapt to
188 Veterinary Pathology 59(2)

Figures 1–2. Prevalent clonal complexes (CC) and farm-host cycle of Listeria monocytogenes (Lm). Figure 1. The most frequently isolated
Lm CCs from clinical infection in ruminants and the farm environment (from Papić et al220,221). CCs strongly associated with clinical cases are
represented in white (left), strains variably associated with disease and the environment are represented in gray (middle), while environment-
associated strains are represented in black (right). Notice that no Lm strain is exclusively environmental or clinical, hence the gray gradient
background. Figure 2. Lm host-environmental cycle. Bacteria are taken up by ruminants through contaminated feed and may colonize the gut.
Lm is shed to the environment through feces, potentially contaminating crops and water resources, and is also spread in milk. Contaminated
vegetation and water may be taken up by ruminants, thus perpetrating the on-farm infection cycle, while contaminated vegetables and animal
products may pose a risk to human consumers.

disparate environments and hosts, as well as its relevance for Interestingly, serotypes prevalent in human and ruminant infec-
public and animal health worldwide, it is important to map and tions (specifically 1/2a and 4b) were commonly isolated from
understand the distribution and pathogenic potential of fre- wild birds, red deer, wild boars, and black bears, suggesting
quently isolated strains to make surveillance and control more that wild animals might constitute a reservoir for pathogenic
efficient. Moreover, given the potential role of ruminants as strains in the natural environment.138,222,304,314 Invertebrates (eg,
carriers of strains pathogenic for humans, further comparative slugs) and free-living protozoans have also been shown to be
genomic studies are essential to identify strains causing disease capable of supporting bacterial growth, indicating their poten-
in both species, as well as to understand their distinctive fea- tial role as environmental vectors or reservoirs.117,296 Amoebae,
tures of virulence and inter-host transmission. in particular, have been speculated to constitute a niche for Lm,
as they have been shown to phagocytose and host bacte-
ria,169,183,316 while other studies reported them to be bactericidal
Reservoirs of Lm in the Environment (reviewed in Schuppler267). It has therefore been speculated
Lm is considered to be a ubiquitously distributed bacterium, that key Lm virulence genes have emerged during its co-evolu-
remarkably adaptable to a wide range of natural and anthropized tion alongside environmental phagocytic unicellular eukary-
habitats (such as agricultural and food-associated ones), but otes to enhance its survival upon predation.267 Given the
knowledge of its environmental dynamics and ecology is only similarities of amoebas with macrophages, such an adaptation
fragmentary.204,258,298 Importantly, the dynamics of Lm trans- to amoeba could potentially function as a “training ground” for
mission between the natural environment and ruminant and macrophage infection, explaining the ability of Lm to invade
human hosts remain unclear. In nature, Lm has been isolated and survive inside cells of higher vertebrates.183 The ability to
from various sources, including soil, water, and vegetation, as successfully adopt a saprophytic lifestyle in the environment
well as from feces of numerous wild birds and mam- and switch to an opportunistic pathogen in the host by repro-
mals.150,204,296,305,314 Bacteria can be generally isolated from gramming its gene expression raises serious concerns regard-
natural sources in low numbers and with low prevalence. ing food safety and animal health. Considering that no definitive
However, the presence of animals and moisture (in the form of reservoir host has been identified in nature, the possibilities of
bodies of water and precipitation) has been proposed to favor intervention and prevention of its spread into the agriculture
growth and dispersion of Lm in the environment.147,176,258 and farm industry remain currently limited.
Bagatella et al 189

Epidemiology of Lm in the Farm However, animal-farm transmission dynamics and their rel-
Environment evance remain currently rather unclear,298 hampering the pos-
sibilities of adopting effective measures to prevent animal
How ruminants become exposed to Lm in the farm environment infection. The presence of unidentified asymptomatic ruminant
is not exactly understood. Contamination of feed, water, or pas- shedders has the potential to significantly contribute to bacte-
ture appears to be the most likely route through which Lm is rial spread into the food industry via fecal contamination of
transmitted to the livestock host (Fig. 2),101,204 but conditions milk or meat (Fig. 2).38,100,135,141 The numerous outbreaks linked
enabling enrichment of the pathogen in these sources have not to contaminated fresh produce and ready to eat foods37,110 high-
been fully elucidated. The Lm infectious dose remains currently light the importance of following a farm-to-fork strategy by
undefined, estimated to be as low as 104 CFU (colony-forming restricting bacterial contamination at the farm/farm animal
unit) in susceptible humans and as high as 109 CFU for healthy level, in order to ultimately prevent foodborne illness in con-
individuals. Nevertheless, it is believed that infection generally sumers through the application of a One Health approach.
requires high bacterial numbers or repeated consumption of
food sources contaminated with low bacterial levels.32,96,235
Therefore, sources that allow high bacterial replication are also Silage: The Culprit?
most likely to be involved in Lm infection of ruminants. In ruminants, poorly acidified silage has long been implicated
as the main source of bacterial contamination, in which Lm is
Sources of Farm Contamination indeed able to replicate abundantly.99,124,291 Ruminants fed with
high quantities of silage have been reported to excrete bacteria
Interestingly, moist soil, decaying plant matter, and bodies of in their feces more frequently and in higher numbers, and to
water, although shown to provide an appropriate environment develop clinical disease more frequently.14,100,181,205,309 Silage
for bacterial survival, do not favor extensive bacterial growth. feeding during hibernal indoor housing has also been linked to
Moreover, it remains unclear whether they are environmental the seasonality of clinical listeriosis cases in ruminants in
reservoirs without the presence of shedding animals.148,176,258 northern hemispheres increasing during winter and peaking in
Fecal shedding from wild animals and bacterial persistence in spring.47,118,172,193,286 However, different epidemiological stud-
invertebrates and protozoal carriers, as previously discussed, ies failed to link silage feeding to listeriosis outbreaks, chal-
may promote bacterial introduction into the agricultural envi- lenging the common perspective that silage constitutes the
ronment,189,273,282,291 but a direct link between strains isolated exclusive source of infection.33,155,187,289,308 Moreover, studies
from the pristine natural environment, farm environment, and in the southern hemisphere frequently report listeriosis cases in
ruminant host remains to be shown. ruminants unrelated to silage feeding and occurring during the
warmest months of the year or during the transition from rainy
to dry season.237,247,248,256 As listeriosis cases can occur all year
Fecal-Oral Lm Enrichment Cycles in the Farm
round in both hemispheres and with different diets, it appears
Environment? likely that additional factors contribute to infection.
Persistent in-farm transmission cycles and outbreaks have been
increasingly linked to a contaminated animal environ- Predisposing Factors for Lm Infection
ment,38,80,197,204 possibly indicating a role for ruminants them-
selves in sustaining bacterial persistence in their environment. While in humans clinical listeriosis has a clear predilection for
Fecal shedding may facilitate bacterial contamination and per- defined risk groups collectively known as YOPI (young, old,
sistence in the farm ecosystem. Agricultural fertilizers based on pregnant, immunosuppressed),45,104,119,278 predisposing factors
sewage sludge and manure if left untreated can provide means in farmed ruminants have yet to be clearly identified.
for significant contamination of pastures or crops. Sheep Concomitant stressing factors, such as late pregnancy or over-
manure has been the source for the major coleslaw-associated crowding, have been proposed to constitute predisposing fac-
outbreak in 1981 during which the foodborne origin of human tors for listeriosis,51,125,180,205,306 but the extent and mechanisms
Lm infection was discovered.59,111,261 through which they contribute to disease onset have not been
Lm shedding has been observed in healthy rumi- systematically explored. Season and spoiled wet feed due to
nants,89,141,204,286 and cattle have been reported to shed Lm more climatic changes, particularly heavy rains, together with stress-
frequently and at higher bacterial titers than small ruminants, ing factors including overcrowding and inadequate animal
suggesting a potential role for cattle as significant reservoirs for management have also been speculated to increase the inci-
Lm in the context of an animal-farm cycle of transmis- dence of listeriosis.196,245,289,301
sion.80,89,204,205 Various studies also indicate that farm manage-
ment practices may contribute to bacterial contamination of and Molecular Mechanisms of Lm
persistence in the farm environment.38,141,197,205 These observa-
tions point to the relevance of a fecal-oral route in the mainte-
Intracellular Lifestyle
nance of Lm in the agricultural-farm environment, through fecal The pathogenic potential of Lm relies on the intracellular sur-
contamination of plant-derived food or feed (Fig. 2). vival and replication of this microbe. For the intracellular life
190 Veterinary Pathology 59(2)

cycle of Lm (Fig. 3), PrfA (positive regulatory factor A), the to exploit different entry routes and reach various organs.
transcriptional factor initiating the transcriptional switch from However, the impact on host infection of most genes is cur-
the saprophytic (extra-host) to the intra-host infectious stage, is rently unknown, and the function of others that have been
essential. The expression of PrfA itself is thermo-regulated and recently associated with enhanced virulence (eg, LIPI-4)192
becomes efficient at mammalian body temperature (37 °C).292 requires further investigation.
PrfA induces the transcription of virulence factors located on
the crucial Listeria pathogenicity island (LIPI-1) (eg, hly
Listeriosis: Clinical Disease, Pathology,
[LLO], actA, plcA, plcB, and mlp), and additionally virulence
factors outside LIPI-1 (eg, inlA, inlB, inlC, and hpt) that alto- and Pathogenesis
gether are essential for the intracellular infection cycle.58,165,290 Listeriosis occurs most commonly upon oral infection, but can
While Lm enters phagocytes via phagocytosis, it initiates rarely result from local bacterial implantation at body surfaces
internalization in non-phagocytic cells through a process called (keratoconjunctivitis, dermatitis) or from ascending infection
receptor-mediated endocytosis,19 primarily via 2 virulence fac- of the genital tract.125,236,262,294 Following oral infection, Lm
tors, internalin A (InlA) and B (InlB).70,108 Both internalins bind may colonize the gastrointestinal (GI) tract and may either be
to eukaryotic cell membrane receptors, InlA to E-cadherin and shed from subclinical carriers or cause self-limiting enteritis,
InlB to Met, gC1QR, and proteoglycans, respectively.19 although Lm frequently crosses the GI barrier and causes inva-
Following internalization, Lm is temporarily confined to a sive disease. Current research indicates that bacterial crossing
primary vacuole, from which it escapes prior to phagolyso- may happen at the intestinal or oral cavity level, depending on
somal fusion via membranous pores that are formed by listerio- the host and clinical form. The main forms of invasive listerio-
lysin O (LLO). This process is facilitated by the 2 phospholipases sis include septicemia, fetomaternal/perinatal infection, and
PlcA (phospholipase A) and PlcB (phospholipase B). Vacuolar CNS disease (Fig. 5), which tend to occur separately and are
escape enables Lm to avoid phagosomal degradation, which is rarely concomitant in affected individuals or in the same herd
essential for Lm virulence, as shown by the strong attenuation or flock.180,181 The reason why different listeriosis forms sel-
of mutants in which LLO is deleted. Once in the cytosol, the dom overlap remains unknown. As the neurologic manifesta-
bacterium starts rapidly replicating using nutrients acquired tion of the disease (neurolisteriosis) is especially relevant in
from the host cell. Actin assembly-inducing protein (ActA) ruminants, it will be discussed in this review more extensively
promotes intracellular bacterial motility and cell-to-cell spread than other listeriosis forms.
by hijacking and polymerizing actin from the host cytoskele-
ton.159 Polymerized actin can be identified as “actin clouds,”
surrounding Lm, or as polar filaments, termed “actin tails,” Enteric Listeriosis
which enable Lm movement within the cytosol (Fig. 4). By Lm can colonize the GI tract following ingestion via food or
propelling forward, Lm may arrive into a neighbor cell within a feed, but underlying pathomechanisms are yet to be fully eluci-
double-membrane vacuole (named a secondary vacuole) and dated. Survival in the inhospitable GI environment requires
reinitiates a new cycle escaping the vacuole. The dogma of resistance against gastric and biliary acids, which is provided
Lm’s canonical intracytosolic infection cycle was recently by a complex interplay of genes that are mainly coordinated by
challenged by several studies that discovered various intravac- the stress-responsive sigma factor SigB (σB) and PrfA, among
uolar infection stages associated with bacterial survival and others (reviewed in Davis et al56, and Gahan and Hill107).
persistence in different phagocytic and non-phagocytic cell Additionally, Lm needs to escape from the control mechanisms
types.21,163,225 It has been shown in phagocytes21 and more of the commensal microbial community.
recently in epithelial cells225 that bacteria-secreting reduced
amounts of LLO at early stages of infection remain entrapped Molecular pathogenesis of Lm enteritis in mouse models. In orally
in large vacuolar compartments named spacious Listeria- infected mice, enteric colonization is facilitated by the bacte-
containing phagosomes (SLAPs), where they can replicate at a riocin listeriolysin S (LLS), expressed by a subset of lineage I
slow pace.21 Another mechanism of intravacuolar persistence strains.240 Whether luminal colonization is sufficient to cause
associated with slow replication (Listeria-containing vacuoles, isolated enteritis or whether enteritis requires invasion and/or
LisCV) occurs subsequently to downregulation of bacterial crossing of intestinal epithelium is not fully clear. Similarly,
ActA expression in the cytosol during long-term infections bacterial factors involved in enteritis remain to be identified.
(2–3 days post-infection) of epithelial cells.163 Factors enhancing or restricting bacterial invasion of the intes-
The previously mentioned virulence factors are also essen- tinal barrier are not entirely known. Experimental models pro-
tial for host infection, as knock-out mutants for key virulence vide evidence that Lm translocates the intestinal epithelium
genes (eg, prfA, hly, actA, internalins-encoding (via interaction of the major Lm internalins, InlA and InlB, with
genes)20,31,191,215,253 are almost completely attenuated in vivo. their respective cell receptors) without causing significant
However, it remains open for exploration whether they are intestinal inflammation and damage to the intestinal bar-
involved in different invasion routes and organotropism of Lm. rier.173,283 InlA and InlB bind to their cell receptors with vari-
The vast arsenal of additional genes in the Lm genome provides able affinity in different species (reviewed in D’Orazio52,
appealing candidates to potentially explain the versatility of Lm Drolia and Bhunia81, and Hoelzer et al142), with ruminants and
Bagatella et al 191

Figures 3–7. Lm intracellular lifestyle and host infection pathways. Figure 3. Lm intracellular lifecycle. Bacterial internalization in non-
phagocytic cells is mediated by internalin A (InlA) and internalin B (InlB) (1), following which Lm is enveloped in a single-membrane primary
vacuole. In macrophages and epithelial cells, Lm may persist and multiply in non-acidified vacuoles (spacious Listeria-containing vacuoles, SLAPs)
(2). Alternatively, in the canonical intracytosolic lifecycle, Lm escapes from the primary vacuole by secreting listeriolysin O (LLO) and PlcA/B (3).
Free bacteria in the cytosol multiply and polymerize actin through actin assembly-inducing protein (ActA) in order to avoid autophagy (4) and
spread to neighboring cells (5). In the new cell, Lm is enveloped in a double-membrane secondary vacuole (6), which is again lysed by LLO and
PlcA/B (7) allowing for vacuolar escape into the cytoplasm (8). Following this phase, Lm can be recaptured in acidic vacuoles (Listeria-containing
vacuoles, LisCVs) through xenophagy-like processes in epithelial cells (9). A subpopulation of intravacuolar bacteria may resist degradation
and slowly multiply, while few others degenerate (asterisk). Lm can then escape from these vacuoles and re-initiate an infectious cycle. Figure
4. Lm (green) infection in an epithelial cell line (Caco-2 cells, blue: DAPI-stained nucleus). Intracytosolic bacteria polymerize actin (red) as
polar “actin clouds” (arrowheads) or propulsive “actin tails” (arrow). Fluorescence microscopy. Figure 5. Schematic Lm infectious cycle in
the host. Bacteria access the host through ingestion and transit across the GI tract, potentially causing gastroenteritis. Once Lm crosses the
GI barrier it spreads hematogenously to its primary target organs (liver and spleen). If the infection is not cleared in these sites, septicemic
spread to secondary target organs results in meningoencephalitis (in monogastric animals), fetoplacental infection, and mastitis. Ocular and
192 Veterinary Pathology 59(2)

humans allowing for both InlA- and InlB-mediated cell coagulative necrosis were observed in the liver following
entrance. On the other hand, mice are quite resistant to GI enteritis.93,94,109 Orally infected sheep, however, carried bacte-
crossing due to a single amino-acid polymorphism in their ria in the spleen, liver, and lymphoid organs in the absence of
E-cadherin, which impairs its affinity for InlA.172 In this spe- clinical signs,317 indicating that Lm intestinal infection and
cies, Lm was shown to primarily enter M cells residing in Pey- translocation to visceral organs may occur asymptomatically.
er’s patches by either InlB-mediated endocytosis or As asymptomatic fecal shedders are relatively common and
macropinocytosis.44 In mice expressing “humanized” E-cad- overt disease is infrequently identified, clinically evident
herin, bacterial InlA binds luminally expressed E-cadherin on enteric listeriosis in ruminants seems to constitute a fairly
intestinal goblet cells, allowing for bacterial crossing of the exceptional event.
intestinal epithelium by exocytosis into the lamina propria at In humans, GI colonization can also be asymptomatic with
the villus level.206 It has been proposed that Lm additionally bacterial shedding in feces.129,201 Alternatively, it can lead to
accesses luminal E-cadherin exposed at villus tips during epi- self-limiting gastroenteritis with acute clinical manifestation
thelial renewal.224 Last, LAP (Listeria adhesion protein) was characterized by fever, diarrhea, and arthromyalgia. These
shown to cause the opening of cellular junctions and bacterial signs can be prodromic to invasive infection in predisposed
crossing of the intestinal barrier upon binding to its receptor patients.212 Pathological data, unlike in ruminants, are lacking,
Hsp60 on intestinal epithelial cells in mice, independently of possibly due to the self-limiting nature of the disease. Therefore,
InlA/E-cadherin interaction.82 Intestinal crossing into the lam- cellular targets of Lm in human gastroenteritis remain unknown.
ina propria is relatively silent in terms of inflammation,283
while bacterial entry into the Peyer’s patches triggers a strong
Listerial Septicemia
inflammatory response173 and proliferation of intestinal epithe-
lium with resulting loss of goblet cells and decrease of the Following intestinal breaching, Lm enters a bacteremic phase
mucus layer thickness.64 in which it spreads hematogenously to the viscera, mainly liver
and spleen.125,186,317 It is assumed that hepatic and splenic infec-
Enteritis in natural hosts. Mechanisms of bacterial interaction tion can be either temporary in asymptomatic animals or pro-
with the ruminant GI tract, on the other hand, are completely vide a replication niche for further septicemic spread if the
unknown. Clinically associated strains, however, often display bacterium overcomes local innate immunity.262,317 In the latter
marked lysozyme resistance together with enhanced invasive- case, systemic spread and colonization of other organs, notably
ness.22,302 It has therefore been speculated that these strains placenta and brain, can occur (Fig. 5).294 Pathomechanisms of
might better survive abomasal passage and are more efficient listerial septicemia are largely unknown. Recent evidence in
in invading conjunctival and caruncular epithelial tissues. experimental models suggests that hypervirulent strains are apt
In ruminants, the enteric location of Lm is most commonly to thrive for a longer time in spleen and liver of infected mice,
associated with prolonged fecal shedding in asymptomatic ani- thus increasing the chance of secondary bacteremia with infec-
mals. However, acute enteric listeriosis has been reported in tion of target organs,295 which might explain the propensity of
sheep and cattle of different age.47,93,94,109,317 Affected animals such strains to cause invasive disease.
may show lethargy, anorexia, hyperthermia, and diarrhea. Septicemic listeriosis is best known in humans, affecting
Clinical enteric listeriosis is associated with abomasitis and about one third of patients with invasive disease. It is poten-
enteritis consisting of multifocal neutrophilic infiltrations, tially associated with fatal complications such as disseminated
which are strikingly centered on the muscularis mucosae where intravascular coagulation and multi-organ failure.67,262 Focal
bacteria reside inside myocytes.47,93,94,109 The cause and mecha- infections after septicemic events include myocarditis and val-
nisms of muscular targeting are not known. Associated fibrino- vular endocarditis, hepatitis and cholecystitis, splenic absces-
suppurative mesenteric lymphadenitis with intralesional sation, peritonitis, osteomyelitis, arthritis, pneumonia, and
bacteria further supports bacterial crossing of the GI barrier endophthalmitis.67,260,262 In non-ruminant mammals, septice-
during enteritis.93,94,109 Moreover, small parenchymal pyogran- mic listeriosis occurs more frequently than other forms of the
ulomas, mononuclear periportal infiltration, or foci of disease. In ruminants, septicemia occurs mainly in perinatal or
Figures 3–7 (Continued). cutaneous listeriosis resulting from direct Lm implantation also occur and are not depicted in the diagram. Figure
6. Proposed neural invasion route in rhombencephalitis. Bacteria access nerves following penetration through mucocutaneous barriers.
Centripetal migration from the periphery to the brainstem occurs intraaxonally and is mediated by actin polymerization (inset: transmission
electron microscopy image showing intraaxonal Lm, one of which is surrounded by polymerized actin [arrow]). Following access to the
brainstem, Lm spreads within the brain causing rhombencephalitis. Virulence factors putatively involved in the neural invasion route are
indicated in green (see main text for further details). Figure 7. Proposed hematogeneous routes in blood-borne neurolisteriosis. Bacteria
access the brain by breaching the blood-brain barrier (BBB) (left) or the blood-cerebrospinal fluid barrier (B-CSFB) (right) in 3 possible ways.
Blood-borne extracellular Lm are directly internalized in endothelial cells of the BBB or the B-CSFB, respectively, and from there access
the meningeal or neuroparenchymal space or the choroid plexus (CP) epithelium and then the CSF compartment by cell-to-cell spread (1).
Alternatively, infected leukocytes cross the BBB or B-CSFB carrying Lm into the neuroparenchyma or CSF compartment (2). Last, leukocytes
may carry peripherally phagocytosed Lm to the cerebral or CP endothelium and interact with the endothelium allowing Lm spread from the
phagocyte to endothelial cells (3). Virulence factors putatively involved in hematogeneous brain invasion are indicated in green (see main text
for further details).
Bagatella et al 193

juvenile infections and manifests with hyperthermia, anorexia, enteritis.180,259 Fetal lesions are indicative of oral infection, as
and diarrhea.125,180,181,306 Although clinically evident septicemia they reflect the distribution observed in listerial septicemia.
is uncommon in adult ruminants, placentitis often occurs as a Perinatal listeriosis in animals typically develops within 2
frequent sequela of systemic bacteremia. weeks from birth, following in utero infection, and usually
manifests with multiple necrotic foci in the liver, spleen, and
other organs.137,180,272,306 Occasionally, it can manifest as neuro-
Fetomaternal Listeriosis listeriosis characterized by fibrinosuppurative meningoenceph-
Lm manifests a particular tropism for the pregnant uterus, alitis with vasculitis, thrombosis, perivascular cuffs, and
which is rapidly colonized.30,125,180,294,306 In ruminants, fetal microabscesses, the latter predominating in the brainstem.137,272
infection can develop from transplacental hematogenous trans- Of note, L. ivanovii can also be responsible for fetomaternal
mission and inhalation of contaminated amniotic fluid, usually infection with a similar clinicopathological presentation in
leading to stillbirths, while in humans it has also been proposed ruminants, albeit less frequently than Lm,6,274 but has not been
to develop from ascending infection from the maternal lower associated with neurolisteriosis.
reproductive tract.180,236,306 It is unknown if the latter pathway In humans, maternal infection commonly presents with mild
also occurs in ruminants. Mechanisms of listerial invasion of and unspecific signs of malaise, chorioamnionitis and preterm
the pregnant uterus are not yet fully understood.293 Studies delivery, miscarriage, stillbirths, or fetal death.185,236 Neonatal
have commonly relied on in vitro models of placental tropho- listeriosis results in septicemia and encephalitis in infants, with
blasts, placental explants, or in vivo infection of pregnant ani- typical widespread multifocal granulomas (granulomatosis
mals (most commonly rodents).39,182,236 These studies identified infantiseptica) occasionally seen in early-onset cases.185,236
a variable role for InlA- and InlB-mediated cell entrance,
depending on species-specific permissiveness, and a role for
Listerial Mastitis
LLO and ActA in placental replication and placental-fetal
spread, respectively.39,182 Epidemiological data support InlA’s Mastitis caused by Lm has been reported exclusively in rumi-
role in placental invasion of pregnant women, as clinical iso- nants, ranging from subclinical chronic interstitial inflamma-
lates from abortions invariably express nontruncated InlA.149 tion to severe suppurative inflammation.27,118,284,311 These
Additionally, InlP, a recently identified Lm virulence factor, infections are thought to arise hematogenously or through local
appears to be essential for placental invasion in pregnant invasion via the teat canal. It is currently not known whether it
rodents, and its deletion significantly attenuates bacterial also occurs in other species, and molecular mechanisms under-
growth in human placental organ cultures.98 InlP interacts with lying mastitis and Lm interaction with the mammary epithe-
the cytosolic protein Afadin, involved in cell-cell junctions, on lium remain completely unexplored. Infected animals respond
the basal face of polarized epithelial layers, promoting bacte- poorly to treatment. In latent infections transient bacterial
rial transcytosis through the formation of actin-rich protru- excretion in milk may occur for prolonged periods.118,307
sions.97 The role of the previously mentioned virulence factors Subclinical bacterial shedding in milk has been reported in
in ruminants has not been characterized, as in vitro models of cows, ewes, and goats in both natural and experimental infec-
ruminant placental infection are only recently being devel- tions, and its association with contaminated milk products has
oped.22,249,253,254 As hypervirulent strains (CC1, CC4-CC217, been proposed in numerous studies as a source for human
CC6,221 CC14,277 CC5922) are associated with abortions, infection.2,105,145,220,231,265,284 Hypervirulent strains belonging to
knowledge on pathomechanisms of fetoplacental infection in CC2, CC4, and CC11, in particular, were found to be signifi-
ruminants might benefit from investigation of such strains in cantly associated with subclinical mastitis in dairy cattle.220
these in vitro systems. Hypervirulent CC1 strains, however, were isolated most com-
monly from dairy products and were more efficient in coloniz-
Abortion in natural hosts. Although experimental inoculation of ing the GI tract in infected mice.190 Hence, further studies on
Lm in pregnant ruminants has been shown to be capable of mastitis- and milk-associated clones are required to clarify
causing abortion regardless of the gestational stage,125,142 it is whether dairy products are possible relevant vectors between
not known whether and how frequent early embryonic death “farm” and “fork.”
occurs in invasive infection.236 Abortions in ruminants typi-
cally ensue during the third trimester of pregnancy, either spo-
Cutaneous and Ocular Listeriosis
radically or as outbreaks.125,181,306 Infection at early third
trimester may cause fetal death and placental retention with Cutaneous and ocular listeriosis are rare forms and occur fol-
minor maternal sequelae, while near term infection potentially lowing direct bacterial implantation in the absence of enteric
causes serious complications for pregnant dams including dys- infection and bacteremia. Cutaneous listeriosis has been
tocia, severe metritis, and septicemia.30,180,259,306 The affected observed in humans exposed to infected abortive material from
placenta shows multifocal cotyledonary necrosis and exudative ruminants and presents as mostly self-limiting papulo-pustular
intercotyledonary placentitis, while aborted fetuses are usually dermatitis, cellulitis, or skin abscesses. It may also occur in
autolytic and manifest miliary foci of necrosis in various immunosuppressed and elderly patients unrelated to any con-
organs, especially in liver and spleen, and severe necrotizing tact with animal sources. Moreover, Lm has been sporadically
194 Veterinary Pathology 59(2)

isolated from “pox-like” skin lesions in pigs and from a dog spongiform encephalopathies (TSE) rank neurolisteriosis
with papulo-pustular dermatitis.125,178,194,230 among the most frequent neurological diseases affecting rumi-
Listerial keratoconjunctivitis and uveitis is rather common in nants. The prevalence among CNS diseases ranges between
ruminants (with a reported farm prevalence of up to 8.6%),87,88 8% and 35.8%,3,115,146,174,193,208,282 and small ruminants appear
especially in cattle, as outbreaks or sporadic cases.87,167,170 to be more susceptible than cattle. The disease occurs either as
Sporadic cases have also been rarely reported in horses.92,246 single or multiple cases, including outbreaks (most frequently
The infection most likely arises from direct conjunctival implan- seen in sheep and goats), in a herd or flock.125,126,180,198,289,309
tation of contaminated material during feeding and is strongly There appears to be no particular sex-, breed-, or age-related
associated with big bale silage and ring feeding (hence the name predisposition. Some authors speculate that most cases occur
“silage eye”).88 Listerial keratoconjunctivitis is only rarely concomitantly with tooth loss and eruption,14,126,198 while other
described in immunocompetent human patients, most frequently studies describe the highest prevalence of rhombencephalitis
following exposure to farm environment, suggesting silage or cases beyond teething.208,209
infected animals as the origin for the infection.143 Barely any-
thing is known about pathogenetic mechanisms of listerial inva- Clinical manifestations of rhombencephalitis in ruminants. In wild,
sion into ocular tissues. Interestingly, a frequent involvement of farmed, and other domesticated ruminant species, CNS infection
the oculomotor nucleus in ruminant neurolisteriosis cases sug- follows the pattern of rhombencephalitis in adult animals and
gests that conjunctival tissue might provide a bacterial port of septicemic episodes in young animals.50,125,137,237,306 Clinical
entry in neurolisteriosis,209 although experimental conjunctival signs of rhombencephalitis are similar in all ruminant species
instillation of Lm in various animal species could only rarely and commonly appear unrelated to stressful conditions or any
produce encephalitis.125 other clinical sign.198,210,289,309 Several studies claim a prolonged
incubation period lasting between 2 and 6 weeks. However, neu-
rological signs generally manifest acutely and progressing rap-
Neurolisteriosis idly, more so in small ruminants than in cattle. Fever can be
CNS infection has been reported in many species and is a sig- present during early phases of infection but is not con-
nificant problem in humans and domestic ruminants. Despite stant.5,30,125,180,181 Typically, rhombencephalitis signs in rumi-
its low incidence, averaging 1 to 11 cases/million persons nants manifest as unilateral or, less frequently, bilateral brainstem
annually, listeriosis accounts for the highest fatality rate among and cranial nerve deficits.28,30,180,198,268 Unilateral facial and
all food acquired illnesses in humans.60,195,275 Neurolisteriosis, tongue paralysis are common and result in ipsilateral drooping of
which occurs in up to 79% of non-perinatal and 19% of perina- ear, eyelid, lip, and muzzle, and hypersalivation, anorexia, and
tal cases, respectively, considerably contributes to mortality, dehydration, respectively. Deficits of the oculomotor, facial, and
being associated with fatality rates of 17% to 30% in spite of trigeminal nerves can lead to loss of reflexes, strabismus, sec-
antimicrobial treatment.29,40,60,203,275 Unfortunately, similar data ondary exposure keratitis, and rarely blindness. Vestibular signs,
for ruminant listeriosis are unavailable, as large-scale surveil- consisting of head tilt and nystagmus, appear ipsilaterally, if the
lance studies are currently lacking. Moreover, in contrast to brainstem is involved, or contralaterally to the side of the lesion
humans, animal listeriosis is not included among notifiable dis- if cerebellar peduncles are affected. The topography of the brain-
eases in reporting systems of many countries, which severely stem and cranial nerve lesions (V–XII) is usually responsible for
hampers the possibility of accurately estimating its incidence. the variability in clinical manifestations (Table 1). Delayed pro-
Neurolisteriosis manifests in pathologically distinct forms, prioception is common, superficial sensitivity is generally
which is clearly indicative of different neuroinvasive pathomecha- reduced, and spinal reflexes can be weak or absent. Small rumi-
nisms among species (Figs. 6, 7). In humans and monogastric ani- nants generally display more severe signs than cattle. If able to
mals 3 forms can be distinguished, of which meningitis/ stand, they are ataxic and can manifest circling movements
meningoencephalitis is the most frequent manifestation (Figs. 8– (hence the name “circling disease”). In later stages of disease,
11), while brain abscessation and brainstem encephalitis (rhomb- they often show depression and recumbency, and death can
encephalitis) occur less commonly.15,125,306 By contrast, occur within 48 hours. On the other hand, cattle show milder
rhombencephalitis is clearly the most common phenotype in rumi- clinical signs (typically head tilt) and tend to succumb later to the
nants (Figs. 12–39).210 As the pathogenesis of the various neurolis- disease. Fatality rates are high in spite of treatment, especially if
teriosis forms is largely reflected in the pathological phenotype, not instituted early.30,125,198,309 Rarely, myelitis without brainstem
the pathology will be discussed prior to the pathogenesis. involvement has been reported in sheep, with variable clinical
signs ranging from limb weakness to quadriplegia and death.112,270
Cerebrospinal fluid (CSF) features can be quite variable, show-
Rhombencephalitis: Incidence and Clinical Disease ing either mononuclear or neutrophilic pleocytosis, and Lm iso-
Initially described as “circling disease” in sheep,116 rhomben- lation from CSF fails in up to 90% of cases.35,229,269
cephalitis occurs worldwide in farmed small ruminants and
cattle, and accounts for the vast majority of invasive clinical Rhombencephalitis in non-ruminant species. In non-ruminant ani-
infections caused by Lm in these species.63,198,309 Data from mals, the brainstem can be targeted in meningoencephalomy-
numerous retrospective studies and surveys of transmissible elitis during septicemia,125,306 and rhombencephalitis without
Bagatella et al 195

Figures 8–15. Neurolisteriosis: principal patterns of meningitis and rhombencephalitis. Figures 8–11. Listeriosis, brain, cotton-top tamarin
(Saguinus oedipus). Figures 8–9. Severe suppurative ventriculitis/ependymitis (Figs. 8–9, arrowheads) and meningitis (Fig. 9, arrow). Note
the absence of neuroparenchymal lesions. Hematoxylin and eosin (HE). Figure 10. Suppurative ependymitis: neutrophils occupy the lumen
of the cerebral aqueduct (asterisk), multifocally infiltrating the adjacent neuroparenchyma and causing ependymal erosion and hyperplasia
(inset). HE. Figure 11. Suppurative meningitis: neutrophils are confined to the subarachnoid space (asterisk) without invading the underlying
cerebellar neuroparenchyma. HE. Figures 12–15. Listeriosis, medulla oblongata, ruminants. Figures 12–13. Sheep. There are multifocal
areas of hemorrhage and malacia (arrowheads). Figure 14. Sheep. Multifocal linear, deeply basophilic lesions corresponding to perivascular
cuffs (arrows) and irregular, variably basophilic lesions corresponding to microabscesses (arrowheads) are present in the neuroparenchyma.
HE. Figure 15. Cow. Cardinal lesions of rhombencephalitis: microabscesses, recognizable as scattered foci of phagocytes infiltrating the
neuroparenchyma (arrowheads), and a perivascular cuff (arrow), predominantly consisting of mononuclear cells accumulating in the perivascular
space (inset). HE. Microscopic features of microabscesses are illustrated in Figures 23–26.
196 Veterinary Pathology 59(2)

generalized brain involvement has only been reported in a

cat242 and a horse.255
Rhombencephalitis is uncommon in humans, accounting for
only 1% to 24% of all neurolisteriosis manifestations.12,15,203,285
Interestingly, several studies report that similar to ruminants and
in contrast to meningitis/meningoencephalitis, the vast majority
of rhombencephalitis cases occur in individuals without underly-
ing clinical conditions. Clinical signs tend to present in a peculiar
biphasic fashion, with prodromic unspecific signs including
fever, malaise, headache, nausea, and vomiting lasting up to 2
weeks, followed by rapidly appearing neurological signs indica-
tive of brainstem involvement, unilateral facial palsy being the
most frequently recognized.12,15,285 Such a biphasic pattern has
not been reported in ruminant rhombencephalitis.

Neuropathology of Rhombencephalitis
The pathology of rhombencephalitis is rather peculiar, particu-
larly regarding the topography and nature of its inflammatory
lesions. The brainstem is specifically targeted, which is quite
unusual for encephalitis. Moreover, cardinal lesions consist of
a combination of suppurative/granulomatous foci (so-called
microabscesses) alongside mononuclear perivascular cuffs
(Fig. 15), which is fairly uncommon for bacterial encephalitis,
but consistent with an intracellular microorganism. Lesions in
ruminant rhombencephalitis are generally quite massive. They
can span from the medulla oblongata and pons to regions local-
ized caudally (cervical spinal cord) and rostrally (cerebellum,
midbrain, thalamus, exceptionally hippocampus, basal nuclei,
Figures 16–21. Schematic topography of microabscess and cerebral cortex) in the affected animal.5,42,49,209,216 Notably,
as investigated in 41 ruminants (cattle, goats, sheep) with
lesions appear to be continuous along the neuraxis, with gener-
neurolisteriosis (from Henke et al139). Brain areas are color-coded:
red indicates areas affected by microabscesses in >50% of animals, ally higher severity and chronicity in the pontomedullary area
orange indicates areas affected in 25% to 50% of animals, and yellow than in other brain regions (Figs. 16–22).42,209
areas affected in <25% animals, respectively. Figure 16. Cerebral Microabscesses can range from small, delineated lesions to
hemisphere and corpus striatum. Microabscesses are frequently large coalescing areas, occurring both in gray and white matter.
located within white matter tracts, especially of the internal Frequently, they manifest a peculiar pattern in which they
capsule (orange), and less frequently within the corona radiata and appear to follow the direction of axonal fibers or single cranial
caudate nucleus (yellow). Figure 17. Cerebral hemisphere and
nerve nuclei, and rarely lesions affecting both a cranial nerve
thalamus. Microabscesses most frequently involve white matter
tracts of the internal capsule (orange), but also affect the thalamic and its fibers can be observed (Fig. 31). In the brainstem,
nuclei and optic tract (yellow). Figure 18. Cerebral hemisphere, microabscesses frequently affect the trigeminal spinal, facial,
midbrain, and hippocampus. The fasciculi tegmenti are heavily hypoglossal, and oculomotor nuclei and their tracts.139,209 The
targeted (red), followed by various white matter tracts and nuclei composition of microabscesses varies with chronicity: early
with their associated fibers. The hippocampus and cerebrum are lesions appear as small agglomerations of neutrophils and
spared. Figures 19–21. Brainstem and cerebellum. The reticular microglia (Fig. 23), progressing to almost purely neutrophilic
formation (Fig. 19 [pons level], Figs. 20, 21 [rostral and caudal
microabscesses (Fig. 24) followed by a mixture of neutrophils
medulla oblongata]) and the spinal tract of cranial nerve (CN) V
(Fig. 21) are frequently affected (red). Less frequently affected and macrophages (Fig. 25), and finally by chronic granuloma-
structures include the rostral cerebellar peduncle (Fig. 19), the tous lesions where macrophages predominate and in which
medial longitudinal fasciculus (Figs. 19–21), nuclei of CN-VIII (Figs. multinucleated giant cells may be occasionally seen (Fig.
20, 21), and the corpus medullare of the cerebellum (Fig. 20, 26).39,46 Large coalescing microabscesses may have an exten-
orange). Microabscesses may also be observed in other CN nuclei sive central necrotic core (Fig. 35), appearing similar to an
and associated tracts (Figs. 19–21), middle cerebellar peduncle (Figs. abscess but devoid of a fibrous capsule, and can progress to
19, 20), cerebellar nuclei (Fig. 20), and folia (Figs. 19, 20, yellow).
frank malacia with infiltration of numerous gitter cells.42,49
Figure 22. Schematic representation of microabscess frequency in
rhombencephalitis in the sagittal view. The brainstem (dark red) is Associated features include prominent perivascular cuffs pre-
targeted most extensively, most severely and more chronically than dominantly composed of mononuclear cells, gliosis, focal
other brain areas (light red) (IC, internal capsule; T, thalamus; M, edema, and vascular damage characterized by fibrinoid necro-
midbrain; CM, corpus medullare; MO, medulla oblongata). sis of the vessel wall, perivascular exudation of proteinaceous
Bagatella et al 197

Figures 23–33. Listeriosis, brain, ruminants. Histopathological features of rhombencephalitis. Hematoxylin and eosin (HE). Figures 23–26.
Temporal evolution of microabscesses. Figure 23. Midbrain, cow. Very early lesion consisting of a small aggregate of neutrophils and microglial
cells (arrowheads). Figure 24. Midbrain, sheep. Acute microabscesses mainly contain neutrophils and can be associated with necrotic
neurons (arrowhead). Figure 25. Medulla oblongata, cow. Subacute to chronic microabscesses are characterized by an increasing number
of macrophages and lymphocytes and marked reduction in neutrophils. Figure 26. Medulla oblongata, cow. Chronic microabscesses may
contain multinucleated giant cells (arrowheads). Figure 27. Cerebellum, cow. Mononuclear meningitis. Note the perivascular cuff in proximity
to the subarachnoid space (arrowhead). Figures 28–29. Midbrain, cow. Neuronal damage in rhombencephalitis. Figure 28. Neurons in
proximity to microabscesses can undergo neuronophagia (arrowhead). Figure 29. Axonal spheroids are often seen in close association
with leukocytes (arrowheads). Figure 30. Midbrain, cow. Vascular damage in rhombencephalitis indicated by perivascular infiltration of
mononuclear cells and fibrin deposition. Figure 31. Medulla oblongata, sheep. Microabscesses involve the hypoglossal nucleus (arrow) and
the intraparenchymal roots of the hypoglossal nerve (arrowheads). Figure 32. Medulla oblongata, cow. Perivascular cuff composed almost
exclusively of eosinophils. Figure 33. Third ventricle, goat. Subependymal abscess with neutrophils infiltrating the neuroparenchyma (arrow).
198 Veterinary Pathology 59(2)

Figures 34–39. Listeriosis, medulla oblongata, sheep. Lm association with lesions in rhombencephalitis. Figure 34. The majority of
bacteria are located within a microabscess and in close association with phagocytes. Immunohistochemistry (IHC) for Listeria. Figure 35.
Extracellular bacterial colonies (arrowheads) in the necrotic center of an acute microabscess (asterisk). HE. Figure 36. Bacteria inside a
neuron (arrowhead). Notice the perineuronal inflammatory infiltrate composed primarily of neutrophils (arrows). Figure 37. Bacteria within
a neuron (left arrowhead) and a phagocyte (right arrowhead). Neutrophils (arrows) are near the infected neuron. IHC for Listeria. Figures
38–39. Bacterial colonies inside an axon (arrowheads). HE (Fig. 38) and IHC for Listeria (Fig. 39).

fluid, and hemorrhages (Fig. 30).209 Axonal spheroids are fre- seen in the neighborhood of microabscesses (Fig. 28), and it is
quently located in proximity to microabscesses (Fig. 29), but it unknown whether it is elicited by intraneuronal Lm, by neutro-
is unclear whether axonal destruction occurs due to direct bac- phils attacking neurons, or by some other mechanism.
terial axonal damage or as collateral damage due to local secre- Meningitis is also frequently present, often as an extension of
tion of toxic/inflammatory mediators. Neuronal necrosis is also local perivascular cuffs or microabscesses (Fig. 27), but mild
Bagatella et al 199

Table 1. Affected cranial nerve (CN) nuclei and associated clinical The overall pattern and distribution of rhombencephalitic
signs of Listeria monocytogenes infection in ruminants (from Walland lesions in human patients closely resemble ruminant rhomben-
et al298). cephalitis, indicating similar pathogenetic mechanisms in both
Affected CN nuclei Clinical signs hosts.11,210

Trigeminal nerve (V) Chewing difficulties

Reduced palpebral and menace Pathogenesis of Rhombencephalitis
reflex Route of invasion. The mechanisms through which Lm selec-
Dropped jaw tively targets the brainstem in naturally infected hosts, espe-
Reduced sensitivity of the head to
cially ruminants, have been the object of speculation for
touch
decades. Very little is known about the pathogenesis of rhomb-
Facial nerve (VII) Drooping eyelid, ear, and lip
Reduced palpebral and menace
encephalitis, partially due to the lack of adequate experimental
reflex animal models, although several rhombencephalitis models
Vestibulocochlear nerve (VIII) Nystagmus have been proposed over the years.5,8,7,23,154,273 Nevertheless,
Glossopharyngeal nerve (IX) Swallowing difficulties pathological specimens provide strong evidence that the infec-
Vagus nerve (X) Swallowing difficulties tion route differs from septicemic listeriosis and meningitis/
Hypoglossal nerve (XII) Tongue paralysis meningoencephalitis. Some authors have suggested a hematog-
Vestibular system Circling, head tilt, leaning toward enous origin for the infection, given the distribution of the
one side inflammatory infiltrate and the association of early microglial
foci with bacteria in the vicinity of parenchymal microvascula-
ture.49 The nature, distribution, and evolution of lesions in
rhombencephalitis, however, is highly suggestive of a local-
ized Lm centripetal intraaxonal spread from peripheral sites to
meningeal lymphocytic infiltrates may occur in sites distant the brainstem (Fig. 6).5,11,14,43,209,216,303 Lesions are character-
from parenchymal lesions.209 Moreover, cranial nerve ganglio- ized by brainstem targeting with a distinct pattern of involve-
neuritis, especially of the trigeminal nerve, can often be seen ment of cranial nerve nuclei and their root fibers,11,209 a feature
ipsilaterally to the parenchymal lesions.4,14,42,216 Rarely, epen- that would not be expected from a hematogenous invasion
dymitis is observed when microabscesses breach the ependy- route during septicemia, which generally causes random
mal barrier (Fig. 33).209 lesions throughout the whole brain. Additionally, dating of
Bacteria in varying numbers are generally associated with lesions reveals a consistent pattern with most chronic lesions in
phagocytes in microabscesses (Fig. 34) but can also be seen the brainstem and more acute lesions in the rostral brain, indi-
extracellularly, occasionally forming colonies (Fig. 35) and cating that the infectious process originates in the brainstem
inside neurons, axons, and neuropil, particularly during early and subsequently spreads to remote areas. Marked widespread
stages (Figs. 36–39).139,209,216 meningitis and ependymitis, typically seen in blood-borne neu-
Perivascular cuffs and microabscesses tend to be more rolisteriosis (Figs. 8–11), is lacking in rhombencephalitis (Fig.
severe in small ruminants, in which a neutrophilic component 14). Moreover, cranial nerve ganglioneuritis, especially of the
of the latter predominates (Figs. 24, 35), which is compatible trigeminal nerve, frequently occurs ipsilaterally to the CNS
with the more fulminant clinical course of the disease in these lesion and is often more chronic, which is not suggestive of
species.209 Microabscesses containing predominantly macro- hematogenous spread.5,14,42,216 Bacteria may be observed uni-
phages are instead more common in cattle, in which multinu- laterally in cranial nerve axons and ganglia of naturally infected
cleated giant cells and perivascular eosinophils can be animals and humans, as well as their intra-encephalic fibers
occasionally seen (Figs. 26, 32).209 and nuclei, once again suggesting localized instead of hema-
Despite the inflammation being severe on microscopic togenous spread.11,42,209,216 Taken together, the absence of con-
examination, gross pathology can be unrewarding, as macro- comitant systemic infection, lack of generalized brain and
scopic lesions are frequently absent or subtle on cut section. In cranial nerve involvement, and the presence of bacteria in
a number of cases, areas of malacia, presenting as brownish intact axons strongly indicates that the infection does not arise
discoloration with or without tissue loss, and multifocal hemor- hematogenously or spread peripherally to the nerves from
rhages, can be observed (Figs. 12, 13). Rarely, frank abscessa- infectious foci within the brain.5,14,42,216 Experimental modeling
tion can occur. In contrast, severe inflammation was found to of rhombencephalitis in animals has been attempted through
be consistently detected on magnetic resonance imaging (MRI) various routes,210 but could only be replicated via feeding of
scans of infected small ruminants, in which the MRI lesion dis- bacteria-soaked abrasive foodstuffs or bacterial injection in the
tribution was rather specific for neurolisteriosis.239 However, lip, conjunctival sac, dental pulp, or snout in small ruminants
despite the diagnostic value of MRI for in vivo diagnosis in and mice, indicating that Lm can access nerve endings after
ruminants, associated costs impede its wide use in farm breaching of mucocutaneous barriers.5,10,14,154 Additionally,
animals. mice injected with Lm in the triceps surae, or sciatic nerve
200 Veterinary Pathology 59(2)

developed ascending unilateral myelitis unless nerve resection survival, lower bacterial load, and delayed intra-encephalic
was performed, further indicating that bacteria can efficiently spread in comparison to a inlA/B-deletion mutant that retained
spread to the CNS via intra-axonal migration.10,154 a virulence comparable to the wild-type.263 These findings
indicate that PlcB is relevant for neurovirulence in vivo, while
Mechanisms of Lm entrance into nerves. Although it is rather InlA and InlB do not play a role during the intra-encephalic
clear that bacteria can access the brainstem via nerve fibers, it stage.
remains uncertain how Lm enters the nerve fibers themselves
and whether invasion of the neuraxonal compartment involves Phagocytes as local bacterial amplifiers?
direct interaction with neuronal receptors or receptor-indepen- Additional factors involved in intra-encephalic Lm dissemina-
dent cell-to-cell spread. While intraneuronal and intra-axonal tion are currently unknown, but a role for phagocytes has been
bacteria can be observed in natural cases,41,42,139,184,209 Lm does proposed based on observations in natural infections.139
not appear to be particularly neurotropic in vitro. Infection of Neutrophils and, less frequently, macrophages were shown to
ruminant and rodent dissociated brain cell cultures and organo- access the axonal space and phagocytose intra-axonal bacteria,
typic brain slices indicates that neurons are not heavily targeted while a high bacterial load was found inside adaxonal microab-
in contrast to other cells (notably, microglia) and are variably scesses, as previously reported in other studies.62,139,209 It was
infected depending on their anatomical origin and culturing therefore suggested that Lm could replicate locally in microab-
methods.69,71,133,227,228 An InlA-dependent mechanism of inva- scess-associated phagocytes and subsequently reenter the neur-
sion of cranial nerves has been proposed in ruminants, in which axonal compartment, further propagating the infection. This
Lm may initially invade E-cadherin expressing oral epithelium view is in line with studies in mice and ruminants showing that
or myelinating Schwann cells and subsequently spread to the innate immune response is inefficient in providing steriliz-
neighboring axons.184 Phagocytes have also been hypothesized ing immunity in listeriosis, and resolution of infection appears
to provide a source for axonal infection by ActA-dependent to be dependent on the adaptive immune response.18,62,168,257
bacterial cell-to-cell spread.71 Moreover, experimental infec- The ability of Lm to survive inside phagocytic cells further sup-
tions in mice suggested a role for PlcB-dependent spread from ports this view,57,158 but the protective role of the immune
peripheral macrophages to the trigeminal nerve.153,154 Whether response or its impact in ruminant neurolisteriosis remain
the mechanisms mentioned above are also relevant for natu- severely underinvestigated in comparison to murine experi-
rally occurring infection in natural hosts is yet unknown. mental models in which the immune responses toward Lm have
been extensively dissected.53,189,219 Overall, additional studies
Mechanisms of intra-axonal and intra-encephalic spread. Actin are required to unravel the role of phagocytes in bacterial per-
polymerizing bacteria have been observed inside axons of sistence and potential intra-encephalic spread.
pathological specimens and ActA-dependent intraneuronal
migration has been reported to occur in cultured bovine neuro- Bacterial strains in rhombencephalitis. Further relevant yet
nal cells, indicating that actin-based motility plays a role in Lm unclear aspects of ruminant neurolisteriosis are the bacterial
intra-axonal spread.139,216 This is further supported by the dose required for establishing infection and potential predis-
observation of severely impaired neuroinvasion of actA-dele- posing factors.210 Despite common bacterial exposure, as indi-
tion mutants in the murine intranasal infection model.218 This cated by widespread/high prevalence of LLO antibodies in the
study also showed that LLO and, partially, ActA are required bovine population,24 and frequent asymptomatic fecal shed-
for efficient breaching of the olfactory epithelium prior to the ding,89,204,286 only a limited number of animals develop brain
neuronal invasion, indicating their possible role in peripheral disease. It has been suggested that in such cases immune
barrier breakdown, brain invasion, and spread. responses mounted against orally acquired bacteria are ineffi-
Experimental and pathological evidence suggests that, after cient in preventing neuroinvasion.180 Inefficiency of preexist-
entry into the brain, Lm efficiently disseminates within the ing immunity might be partially dependent on the bacterial
brain. Topographical distribution of microabscesses in natu- strain, but its involvement in neuroinvasion in ruminants
rally infected ruminants suggests that intra-encephalic bacte- remains unknown. Interestingly, immunization with a homolo-
ria spread between anatomically connected brain structures gous strain induced a protective brain response in mice,264
via white matter fiber tracts.139 Intra-axonal migration is fur- while outbreak-isolated strains displayed neuroinvasiveness
ther supported by bacterial association with axons in naturally regardless of preexisting immunity toward a reference strain.114
infected cases and ruminant organotypic brain slices.133,209 The high prevalence of hypervirulent and hyperinvasive CCs,
ActA-mediated actin polymerization has been observed in particularly CC1, in ruminant rhombencephalitis cases could
neurons in vitro and in situ,139 suggesting its participation in be in line with such observations.13,79,132,221,251 Although
intra-encephalic spread, but its role in vivo has only been par- genomic comparisons identified putative CC-specific neuro-
tially explored.218 PlcB-mediated cell-to-cell spread has also virulence factors,4,13 their role in hypervirulence was not con-
been implicated in intra-encephalic spread, as mice intracere- firmed.122,254 Thus, strain-related Lm neurovirulence factors in
brally infected with a plcB-deletion mutant showed prolonged ruminants require further exploration.
Bagatella et al 201

Brain Abscessation Pathogenesis of Meningitis/Meningoencephalitis

Rarely, Lm can cause single or multiple cerebral and cerebellar Little is known about the pathomechanisms involved in blood-
abscesses in human patients, especially if immunocompro- borne neurolisteriosis in naturally susceptible hosts and studies
mised.1,46,48,61,84,203 However, they are not reported to occur on Lm brain infection in monogastric animals other than rodents
with a similar pattern in ruminants. The distribution of brain are virtually nonexistent. Surveys on human neurolisteriosis
abscesses strongly indicates hematogenous entry of Lm into the are rare,8,29,217,223 generally include small patient cohorts and
brain. However, abscesses in the deep white matter may be bacterial typing has been rarely performed.161,175 Therefore,
aligned along connected white matter fiber tracts suggesting neuroinvasive strains remain poorly characterized.
that following hematogenous invasion Lm may enter and
spread within axons from original foci of infection.25,144 This Bacterial strains in meningitis/meningoencephalitis. Lineage I
pattern parallels that seen in rhombencephalitis cases in rumi- hypervirulent clonal complexes (CC1, CC2, CC4, CC6) were
nants,139 indicating that, no matter how Lm enters the brain, it shown to be significantly associated with fetomaternal and,
can spread within the brain along axonal pathways and that notably, CNS infection, possibly indicating their proclivity
similar mechanisms of intra-encephalic Lm spread are shared toward efficient breaching of placental and neural barriers.160,192
between rhombencephalitis and brain abscesses. Experimental in vivo infections correlated the novel LIPI-4
gene-cluster (encoding a putative cellobiose-family phos-
photransferase system) in CC4 strains to such enhanced inva-
Meningitis/Meningoencephalitis: Clinical Disease
siveness, but underlying mechanisms are yet unknown.192
and Pathology Interestingly, other frequently isolated neurovirulent CCs (eg,
The most frequent neurolisteriosis manifestation in humans is CC1) do not possess LIPI-4, indicating that factors specifically
meningitis/meningoencephalitis, which predominantly occurs involved in neuroinvasiveness remain to be discovered or
in predisposed individuals (especially elderly and immunosup- might differ among hypervirulent strains. Emerging CC6
pressed patients) and is the consequence of hematogenous strains were increasingly found in cases of meningitis with
spread to meninges and brain during bacteremia.29,40,203,275 poorer prognosis,160,161 possibly due to a plasmid conferring
Clinical signs appear between 1 and 14 days following con- resistance to antibiotics and disinfectants.166 However, they
taminated food consumption9,121 and variably include fever, were less neurovirulent than CC1 strains in mice infected intra-
headache, neck stiffness, altered sensation, seizures, and focal cisternally and their neuroinvasive mechanisms were not
neurological signs.29,40,203 Severe long-term neurologic impair- assessed.162 Thus, further studies on listerial meningitis isolates
ment persists after recovery and treatment in up to 60% of sur- are needed to characterize strain-specific factors involved in
viving patients, which can manifest altered consciousness, neuroinvasiveness and neurovirulence.
sensorimotor dysfunctions, or rarely cranial nerve pal-
sies.29,40,61,203 Bacterial isolation from hematologic and CSF Route of invasion in meningitis/meningoencephalitis. Most of the
samples yields positive results in about 60% and 40% of cases, knowledge concerning mechanisms of Lm brain invasion was
respectively, which is in contrast to the low rate of bacterial derived from mouse infection models, in which artificial routes
isolation in rhombencephalitis.29,40,203 of inoculation (intravenous, intracerebral, intracisternal) are
Lesions mainly consist of mild to severe multifocal or dif- often used to bypass the GI phase.16,108,155,181,244,252 Despite prov-
fuse meningeal inflammation with focal cortical infiltration, ing useful for circumventing the species-specific barrier posed
diffuse ventriculitis with ependymal erosion and focal periven- by the lack of affinity of InlA for murine E-cadherin,172 such
tricular infiltration, meningeal and parenchymal vasculitis, approaches poorly translate to infection dynamics observed in
thrombosis, and small parenchymal perivascular abscesses.86 natural hosts. Despite these caveats, pathological and experi-
The inflammatory infiltrate is mostly composed of monocytes/ mental findings indicate that CNS invasion in blood-borne liste-
macrophages and neutrophils, with frequent efferocytosis of riosis is achieved through breaching of the blood-brain barrier
phagocytes operated by macrophages, while bacteria can be (BBB) or blood-cerebrospinal fluid barrier (B-CSFB; Fig. 7).
seen intra- and extracellularly in the meninges, parenchymal Direct infection of brain endothelium or choroid plexus epithe-
abscesses, and ependyma.86 Neurolisteriosis in monogastric lial cells from bloodstream bacteria has been proposed as a
mammals and birds is rarely encountered and, like in humans, likely route of hematogenous brain invasion following bactere-
prevalently manifests as meningoencephalomyelitis in the con- mia.65,77 A second mechanism for Lm CNS entry is the so-called
text of septicemia (Figs. 8–11), especially in juvenile animals “Trojan horse” model, in which bacteria are transported to the
or in association with concurrent predisposing conditions in brain as cargo in infected circulating phagocytes, efficiently
adults.51,125,242,306 On the other hand, meningoencephalitis is sheltered from extracellular factors.65,73,77
extremely rare in ruminants and is usually observed during
perinatal septicemia, in which patterns of hematogenous neuro- Direct invasion of the BBB/B-CSFB by extracellular bacte-
listeriosis and rhombencephalitis are concurrently fea- ria. Direct bacterial invasion of brain endothelium is supported
tured,137,272 possibly suggesting simultaneous hematogenous by clinical and pathological findings. Lm is frequently isolated
and ascending brain invasion. from the blood of patients with meningitis,29,40,203 and bacteria
202 Veterinary Pathology 59(2)

have been identified in the cytosol and adhering to the vas- Invasion via infected phagocytes (“Trojan horse” model). The
cular side of cerebral endothelial cells in meningoencephali- “Trojan horse” model of listerial brain invasion claims that
tis cases.158 Moreover, bacteremia appears to be a requirement phagocytes containing intracellular bacteria enter the blood-
in murine experimental brain invasion, especially following stream from peripheral sites of infection and carry intracellu-
sublethal inocula, in which bacteria are initially cleared from lar Lm to or across the BBB and B-CSFB.77 Numerous in vivo
the bloodstream, proliferate in the liver, and then undergo a studies have shown that peripherally infected monocytes can
subsequent secondary wave of hematogenous spread follow- allow Lm survival following phagocytosis and greatly enhance
ing proliferation in liver and spleen. This can provide means bacterial brain invasion.72,75,156,188 It is currently unclear whether
for bacterial invasion of brain endothelium and choroid plexus Lm invades the BBB/B-CSFB by spreading to the endothelium
epithelial cells, with subsequent translocation across the from luminally adhering phagocytes or whether bacterial escape
BBB/B-CSFB.16,72,156 Experimental findings also indicate that follows phagocyte transmigration across brain barriers. Never-
Lm is capable of efficiently infecting human brain microvas- theless, cell-to-cell spread appears to be essential for bacterial
cular endothelial cells (HBMECs) in vitro.127,128 Mechanisms dissemination through this infection route. Macrophages in
responsible for such invasion are still controversial, as some human neurolisteriosis cases can host cytosolic Lm displaying
authors speculate that an InlB-dependent internalization is actin polymerization,158 indicating that bacteria have the poten-
required,127,128 while others could not find any evidence for an tial to undergo intercellular spread following phagocytosis.
InlA or InlB role in bacterial entrance into endothelial cells.310 Similar findings have also been reported in mice, in which Lm
Recently, InlF has been shown to be involved in the invasion of was shown to polymerize actin inside monocytes adhering to
various cells (including a human brain endothelial cell line) by brain endothelial vessels.188 In vitro studies, in which bacteria
interacting with surface-expressed vimentin and, concurrently, were able to efficiently spread from infected macrophages to
InlF deletion mutants were deficient in their ability to colonize HBMECs and rat spinal neurons in a PlcB- and ActA-dependent
the brain of intravenously infected mice.113 Mechanisms under- manner, respectively, further support the idea that intracellular
lying this interaction, however, remain unknown. As an alter- Lm can spread from infected phagocytes to cells of both vascu-
native route to BBB invasion, Lm has also been proposed to be lar and neural compartments.71,128
capable of invading the B-CSFB in vivo,238 a process that was It is not precisely known how infected phagocytes are tar-
shown to require both InlA and InlB in vitro.130 Another bacte- geted to the brain. Peripheral infection with Lm has been pro-
rial surface protein, the autolysin IspC expressed by serotype posed to enhance monocyte recruitment to the brain even
4b strains, has been shown to promote bacterial attachment before neuroinvasion occurs. Indeed, proinflammatory cyto-
and invasion of choroid plexus epithelial cells and is involved kines released in the plasma (especially IFN-γ) were shown to
in virulence factor regulation, positively contributing to brain activate monocyte-recruiting inflammatory pathways in the
invasion in intravenously infected mice.300 brain prior to detectable cerebral infection.74,78 Subcutaneous
In addition to the previously mentioned ones, other Lm viru- infection in mice also resulted in upregulation of adhesion mol-
lence factors can enhance brain invasion in the context of ecules (ICAM-1, P-selectin) in cerebral endothelium days
hematogenous infection. However, their precise mechanisms before brain infection was detected,179 but it is not known
and interaction underlying brain invasion and their relevance in whether the process is involved in enhanced influx of infected
CNS infection of naturally susceptible hosts remain unex- monocytes and adhesion to the cerebral vasculature. Moreover,
plored. The bacterial surface protein Vip, expressed in lineage it remains unknown whether bacterial spread from monocytes
I and II strains, has been shown to bind host cell gp96 and to brain endothelial cells could enhance the recruitment pro-
appears to be relevant for cell and brain invasion.34 A gene cess. Lm invasion of HBMECs has been shown to induce
encoding a putative leucine-rich-repeat-containing protein upregulation of adhesion molecules (E-selectin, ICAM-1) and
(LMOh7858_0369) from a serotype 4b strain was also found to chemoattractant cytokines (IL-8, IL-15),299,310 but it is unknown
be relevant for systemic and brain invasion in an intravascular whether this process also occurs in vivo. Last, a significant
sepsis mouse model.315 upregulation of MCP-1 was shown to occur in infected mice’s
In spite of such observations, the importance of free bacteria brains concomitantly with influx of infected monocytes,75 but
in the bloodstream in establishing cerebral invasion has been it is unclear whether MCP-1 initiates monocyte recruitment.
called into question in the context of natural infection, as anti- An explanation for monocyte predisposition in carrying intra-
bodies present in normal adult human serum strongly inhibit cellular Lm to the brain was recently proposed.188 Lm may pro-
HBMECs invasion.140 Moreover, mice systemically infused with long the intravascular survival of infected monocytes via
gentamicin (an antibiotic that poorly diffuses intracellularly but InlB-mediated selective block of CD8+ T-cell mediated killing,
rapidly inhibits or kills extracellular bacteria) show a bacterial thereby enhancing the chances of bacterial transmission to the
brain burden similar to untreated mice, indicating that most bac- brain. It is interesting to note that mononuclear phagocytes
teria that enter the brain are intracellular.76,188 Thus, additional appear to play a central role in brain invasion independently of
mechanisms involving infected phagocytes sheltering and trans- the neurolisteriosis form, despite being considered to be at least
porting intracellular Lm to the brain have been speculated to play partially bactericidal.57 Further studies focusing on their inter-
a pivotal role in hematogenous neurolisteriosis. action with Lm in the context of neuroinfection, therefore, will
Bagatella et al 203

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The author(s) declared no potential conflicts of interest with respect to 384.
the research, authorship, and/or publication of this article. 19. Bierne H, Cossart P. Listeria monocytogenes surface proteins: from genome
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The author(s) disclosed receipt of the following financial support for
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the research, authorship, and/or publication of this article: The writing
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