Campylobacter beyond the gut: A case series of Campylobacter jejuni bacteraemia with atypical presentations

Introduction

Campylobacter jejuni is responsible for entero-invasive diarrhoea. Bacteraemia is rare, and when it occurs, Campylobacter fetus is more frequently isolated. ¹ Unusual manifestations and diagnostic challenges associated with these infections may lead to potential delays in diagnosis and treatment.

Case series

Case 1

A male patient in his mid-sixties presented with complaints of breathlessness and jaundice for five days. He was undergoing treatment for tuberculous ascites on ethambutol and levofloxacin (modified antitubercular treatment) for two months, had chronic kidney disease on maintenance haemodialysis, diabetes mellitus with diabetic retinopathy, and systemic hypertension on medication for three years. In his past medical history, there was history of repeated admissions for abdominal distension requiring multiple ascitic taps, but no history of foreign food intake nor consumption of uncooked meat. He was normotensive (140/90 mmHg) and had mild to moderate ascites. Initial laboratory evaluation demonstrated anaemia, deranged liver function tests, and markedly elevated serum creatinine levels (0.046 mmol/L); in view of the recent initiation of antitubercular therapy, drug-induced hepatitis was initially suspected.

Paired automated blood cultures (BD BACTEC^TM) were sent from his arteriovenous fistula site, which flagged positive within 48h. Although the initial Gram stain was reported as inconclusive, careful re-evaluation of the smear revealed thin, fragile, Gram-negative bacilli (Figure 1). No growth was observed on routine culture the following day. On suspicion of a fastidious organism, plates were placed in a 5% CO₂ incubator for 48h, after which growth was observed on the blood and chocolate agar plates (Figure 1). Identification from the colonies by Matrix-Assisted Laser Desorption/Ionization Time-of-Flight Mass Spectrometry (MALDI-TOF MS) (Biomerieux^TM) revealed Campylobacter jejuni subspecies jejuni. Cefoperazone-sulbactam which was started empirically was continued as the patient's clinical condition improved. At discharge, azithromycin 500 mg od for three days was prescribed.

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Figure 1.

(A) Gram-stained picture: curved spiral, S-shaped or gull-winged, or long spiral gram-negative bacilli. (B) C. jejuni growth on blood agar plate.

Discussion

Campylobacter jejuni bacteraemia is an uncommon manifestation (seen in <1% of patients) and is probably under-recognized in clinical practice. ¹ It occurs predominantly in males with chronic liver disease and multiple comorbidity, including chronic liver or renal disease, and immuno-suppression,^2–4 with fever and abdominal pain being common, and diarrhoea seen in 17%. ⁵

In our cohort, gastrointestinal manifestations were variable; two patients did not experience diarrhoea, whilst the second case had acute gastrointestinal symptoms. Here radiological features of colitis were initially attributed to IgA vasculitis, but subsequent identification of C. jejuni and her clinical response to therapy suggested an infectious contribution. Overall, this highlights the ability of Campylobacter jejuni to cause bacteraemia in atypical presentations, leading to delays in management.^6–9 From a diagnostic perspective, Campylobacter should be considered when slender, curved Gram-negative bacilli are seen on Gram stain and appropriate processing under micro-aerophilic conditions should then be pursued. Although most gastro-intestinal infections are self-limiting, bacteraemia in high-risk patients warrants prompt antimicrobial therapy. All our patients responded well to macrolides; however, emerging resistance may limit empirical treatment options. ¹⁰