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WSU Medical School
Wayne State University
Introduction: Campylobacter species are a common infectious cause of acute diarrhea worldwide. Small gram-negative bacteria, Campylobacter species are commonly transmitted fecal-orally and frequently found nonpathogenically in the guts of animals including chickens, creating a risk for frequent animal-human transmission. Campylobacter jejuni, one of the most important Campylobacter species for human health, typically produces a watery or inflammatory diarrhea. It is common in developing countries and outbreaks are often linked to contaminated water, unpasteurized milk, undercooked poultry, and contact with animals or infected persons. C. jejuni is a fastidious, gram-negative spiral-shaped rod which is best detected by culture but can also be seen on microscopic examination of a stool sample of a symptomatic patient with enteritis. Microscopy typically also reveals red blood cells or neutrophils. Culture is usually performed using a selective agar with sheep blood, vancomycin, amphotericin B, cephalothin, polymyxin B, and trimethoprim, incubated at 42 degrees with 5-10% oxygen, 1-10% carbon dioxide, and some hydrogen. C. jejuni typically presents in adults with diarrhea, commonly associated with abdominal pain and a high fever. The diarrhea is usually watery but frequently becomes bloody. Symptoms usually peak for 24-48 hours before gradually resolving, but some cases can last up to a week. While antibiotics are not typically necessary, as the course is short, they are commonly used in more severe or prolonged cases or in cases where the patient has immunosuppression or immunodeficiency. Infection can spread to contiguous organs, including the pancreas or gallbladder, and bacteremia can lead to seeding of distant organs, though bacteremia is rare and usually occurs only in immunocompromised patients. Complications of infection can include Guillain-Barre syndrome, reactive arthritis, and spontaneous abortion.
Case description: Our patient is a 57-year-old woman with a past medical history of decompensated NASH cirrhosis and type II diabetes mellitus currently undergoing workup for a pancytopenia who presented to our emergency department with low-grade fever two days after bone marrow biopsy. She was found to have a two-day history of explosive watery yellow stool without any nausea, vomiting, or abdominal discomfort. Her temperature was 38.1 degrees Celsius with an increase in white blood cells to 4,000 from her baseline of 3,000, with minor increases in creatinine and liver enzymes stable as per her baseline. On CT, she had mild duodenitis. Influenza and Clostridium difficile workup were negative. Stool and blood cultures were taken and she was started on IV vancomycin and cefepime for her neutropenic fever. Stool culture came back positive for C. jejuni and blood cultures later came back positive for the same, demonstrating curved gram-negative bacteria. Due to her neutropenia and her existing once-weekly ciprofloxacin dosing for spontaneous bacterial peritonitis prophylaxis, she was treated azithromycin for a total of 7 days. During her inpatient stay, her bone marrow biopsy also came back and appeared normal. She was discharged to follow up on the pancytopenia with her usual doctors, continuing her SBP prophylaxis and counseled on common complications of C. jejuni.
Discussion: Bacteremia is an uncommon consequence of C. jejuni enteritis, though it is also likely underreported due to difficulty in culturing and lack of indication in many patients. Risk of bacteremia increases with immunocompromise, but patients who are not immunocompromised may also be affected. C. jejuni can evade host defenses with several virulence factors, including flagella, cytotoxin, and serum resistance. Risk is also increased with old age and male gender, as well. While most cases may go unnoticed due to the short, self-limiting course of the diarrheal illness, an increased suspicion in patients with immunocompromise may be warranted.
Wiseman, Natalie M. and Failla, Andrew, "Campylobacter jejuni bacteremia in the setting of pancytopenia" (2020). Case Reports. 6.