|Year : 2020 | Volume
| Issue : 1 | Page : 32-34
Postendoscopic variceal sclerotherapy campylobacter jejuni bacteremia
Deema Hussam Al Soub, Mashuk Uddin, Nadia Karim Bakhsh
Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar
|Date of Submission||25-Dec-2019|
|Date of Acceptance||31-Jan-2020|
|Date of Web Publication||12-Mar-2020|
Dr. Deema Hussam Al Soub
Department of Internal Medicine, Hamad Medical Corporation, P.O. Box 3050, Doha
Source of Support: None, Conflict of Interest: None
Campylobacter jejuni bacteremia is rare. We herein report a case of C. jejuni bacteremia in a patient with multiple risk factors, including diabetes mellitus, liver cirrhosis, and hepatocellular carcinoma. The presentation was nonspecific. Diagnosis was made only after positive blood culture which took 5 days. The organism was resistant to several antibiotics; however, treatment with azithromycin was associated with successful outcome.
Keywords: Bacteremia, Campylobacter jejuni, endoscopic sclerotherapy
|How to cite this article:|
Al Soub DH, Uddin M, Bakhsh NK. Postendoscopic variceal sclerotherapy campylobacter jejuni bacteremia. Libyan J Med Sci 2020;4:32-4
| Introduction|| |
Endoscopic variceal ligation (EVL) and endoscopic variceal sclerotherapy (EVS) are the main therapeutic procedures for the emergency treatment and secondary prophylaxis of esophageal varices in cirrhosis. Postendoscopic bacteremia has been reported after EVS and EVL. Camara et al. were the first to report early postsclerotherapy bacteremia. Other reports on the incidence of early bacteremia postinjection sclerotherapy have varied widely from 5% to 50%., In a meta-analysis of 19 studies, it was found that the frequency of bacteremia after EVS was 17%, which was higher than the frequency of bacteremia after EVL, which was 6%. One study found that all postendoscopic-positive blood cultures emerged following emergency sessions but not elective procedures. It is believed that the bacteremia is the result of bacterial translocation of endogenous microbial flora into the bloodstream. The most common organisms causing bacteremia post-EVL and EVS are Streptococci, coagulase-negative Staphylococci (CNS), Escherichia More Details coli, and Klebsiella spp. Literature search did not reveal any case of Campylobacter jejuni bacteremia following variceal sclerotherapy.
C. jejuni is a common cause of bacterial enteritis in developed countries. Campylobacter bacteremia is rare accounting for <1% of the total incidence of all Campylobacter infections., Underlying conditions known to predispose for Campylobacter bacteremia include HIV infection, liver diseases, transplant recipients, and malignancies., We herein describe a case of C. jejuni bacteremia following EVS in a patient with liver cirrhosis and hepatocellular carcinoma and review pertinent literature.
| Case Report|| |
A 61-year-old male, known to have diabetes mellitus, hepatitis C-related cirrhosis, portal vein thrombosis, presented with a previous history of schistosomiasis and Hassab's operation done in Egypt in 1991. He is also known to have hepatocellular carcinoma diagnosed 5 months before admission for only palliative treatment. He was admitted to the hospital on October 23, 2017, with upper gastrointestinal bleeding, for which he had undergone endoscopy, and was found to suffer from bleeding gastric varices, for which he had sclerotherapy. He was discharged home on October 26, 2017; however, he was readmitted on November 3, 2017, with the complaints of decreased food intake, dizziness, easy fatigability, nausea but no vomiting, abdominal pain, or change in bowel habit and no fever. On examination, he was jaundiced, drowsy, with evidence bilateral flapping tremors (asterisks). Temperature was 39.6°C, blood pressure 131/74 mmHg, pulse rate 90/min, and respiratory rate 18/min. Laboratory investigation revealed: WBC 9900/mm3, Hb 12.1 g/dL, platelets 157,000/mm3, C-reactive protein 17 mg/dL, procalcitonin 0.11 ng/mL, aspartate aminotransferase 89 U/L, alanine aminotransferase 42 U/L, creatinine 108 μmol/L, and lactic acid 4.6 mmol/L. Chest X-ray showed increased bronchovascular markings. He was diagnosed as chest infection and was given ceftriaxone. Blood culture collected on November 3, 2017, was reported negative after 48 h. Two days after admission, the patient felt better and was discharged home on oral cefuroxime to be continued for 7 days. However, 3 days after discharge, the microbiology laboratory reported a growth of C. jejuni in the initial blood culture that was sensitive to erythromycin but resistant to ciprofloxacin and tetracycline. The patient was called for admission and was given intravenous azithromycin for a total of 14 days. He improved and was discharged home.
| Discussion|| |
Campylobacter, particularly C.jejuni, has been established as the most common cause of bacterial gastroenteritis worldwide,, with an estimated prevalence of 2–20 million cases annually in the states of the European Union alone. In the US and Europe, bacteremia has been reported to occur in 0.1%–1% of Campylobacter cases., Bacteremia appears to occur more frequently among immunosuppressed patients or those with other comorbidities,, although a surveillance study in Finland noted that 53 of 76 cases of bacteremia (70%) occurred in patients without any underlying disease. Fernández-Cruz et al. reported in a recent overview of Campylobacter bacteremia that only 0.24% of all hospitalized patients with bloodstream infections could be associated with Campylobacter spp. and that these bacteremias were community-acquired in 81% of cases.C.jejuni was the most often isolated bacterium next to Campylobacter fetus and Campylobacter coli. One of the possible reasons for the low incidence of bacteremia is the poor performance of automated blood culture systems for the detection of Campylobacter spp. Another cited explanation is that in modern clinical microbiology laboratories, the incubation period for blood culture bottles is usually limited to 4–5 days. As the detection of Campylobacter-related bacteremia requires a median growth rate exceeding 5 days for a substantial proportion of isolates, it is therefore conceivable that many episodes of Campylobacter-related bacteremia may go unnoticed. It has been therefore recommended by some authors that the contents of blood culture bottles should be subcultured onto solid media at the end of the standard 5-day incubation period.
Post-EVS bacteremia is not uncommon with an incidence of 17% reported in one meta-analysis. The most common organisms causing bacteremia following endoscopic sclerotherapy of esophageal varices are Streptococci, CNS, E. coli, and Klebsiella spp. and are believed to result of bacterial translocation of endogenous microbial flora into the bloodstream. Review of the literature revealed no case of C. jejuni bacteremia post-EVS.
Our patient had several risk factors for C. jejuni bacteremia, including hepatitis C-related liver cirrhosis and hepatocellular carcinoma. These two risk factors have been cited as the most common risk factors for C. jejuni bacteremia. We believe that the organism was introduced in our patient during EVS because of the temporal relation to the procedure since it developed few days after the procedure.
An important finding in our patient is the delayed isolation of the organism which took 5 days of incubation to become positive. This finding coincides with the findings in the literature and emphasizes the importance of alerting the microbiology laboratory protocols to prolong the incubation of the blood cultures, when there is a strong suspicion of C. jejuni bacteremia. The isolate was resistant to ciprofloxacin and tetracycline which are usually active against C. jejuni. Fluoroquinolones are usually considered the first-line agents for the treatment of C. jejuni infections; however, the prevalence of fluoroquinolone-resistant Campylobacter is rising. Resistance rates of greater than 50% have been reported in Spain, Hungary, and several developing countries. Fortunately, resistance to macrolides among Campylobacter has remained stable at <5% in most parts of the world, making it the first choice for empiric therapy for patients with C. jejuni infections.
| Conclusion|| |
C. jejuni bacteremia remains rare. Important risk factors include liver cirrhosis, immunosuppression, and cancer. Identification of the organism requires prolonged blood incubation. Resistance to many antibiotics, especially for fluoroquinolones, is rising; however, it remains low for macrolides making it the best choice for empiric therapy.
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Conflicts of interest
There are no conflicts of interest.
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