A 28-year-old man who underwent living-donor kidney transplantation in November 1998 was admitted to our hospital with a fever of 100.2°F (37.9°C) and multiple episodes of nonbloody, watery stools. The patient had been well until 3 days before admission, when he developed high fever, shaking chills, right abdominal pain, and watery stools without nausea or vomiting, all of which gradually progressed. He lost his appetite and experienced unintentional weight loss of more than 3 kg. He denied having traveled recently or changing his usual dietary habits or potable water supply, and no other household members were ill. His immunosuppressive medications included azathioprine 50 mg, cyclosporine 175 mg, and methylprednisolone 4 mg. His major medical and surgical history included end-stage renal disease due to unknown cause, asthma, cataracts, and glaucoma. On admission, the patient’s temperature was 100.2°F (37.9°C), systolic blood pressure was 60 mm Hg, heart rate was 130/min, respiratory rate was 20/min, and oxygen saturation was 98% on room air. He was fully alert and oriented. His skin was dry. His abdomen was soft and flat with mild tenderness in the right lower quadrant; Murphy’s sign and heel drop tests were negative. The remainder of the physical examination was unremarkable. The patient’s laboratory test results showed total white blood cell count of 7.6×103 cells/mL, hemoglobin 15.5 g/dL, urea nitrogen 39.3 mg/dL, and serum creatinine 3.2 mg/dL (baseline 1.0 mg/dL). Intravenous hydration was started. Urine and blood cultures were obtained at that time. A computed tomography scan of the abdomen without the administration of contrast material showed wall thickening of the ileocecal area and ascending colon. Results of urinalysis and stool studies for ova, parasites, and enteric pathogens including Clostridium difficile were negative. Stool samples were plated on charcoal-based selective medium agar in a microaerobic environment for the detection of Salmonella, Shigella, and Campylobacter. After admission, his fever showed some improvement, as did the frequency of the diarrhea. On the seventh day of hospital stay, he again had a temperature of 103.1°F (39.5°C) and his diarrhea worsened. Colonoscopy (Fig. 1) showed an ileocecal ulcer, and an intestinal mucosa biopsy was then performed to enable bacterial and mycobacterium cultures.FIGURE 1: Colonoscopy showed an ileocecal ulcer.The stool culture results detected Campylobacter jejuni, which was sensitive to several antimicrobial classes; therefore, he was started on oral azithromycin for 3 days. Subsequently, the intestinal mucosa culture results also revealed C. jejuni. Blood culture results were negative for C. jejuni. After initiation of antibiotics, the patient became afebrile and asymptomatic. On the 18th day of hospital stay as he remained afebrile and asymptomatic, he was discharged. Although Campylobacter species are the most commonly identified bacterial causes of food-borne acute gastroenteritis in humans, only a few cases of Campylobacter enteritis, including Campylobacter bacteremia, have been reported in renal transplant recipients (Table 1) (1–5). Campylobacter jejuni is one of the two major Campylobacter species, and unlike other enteric infections, such as Shigella or Salmonella, Campylobacter infection is only rarely associated with systemic invasive illness (6–8). Contaminated meat, poultry, and water represent the main reservoirs of human infection.TABLE 1: Reported cases of campylobacter enteritis in renal transplant recipientsAs in this case, gastrointestinal system disorders, such as diarrhea, are frequently observed after transplantation and are an important complication in organ transplant recipients (9). Campylobacter jejuni should always be considered in the differential diagnosis as a potential cause of enteritis in immunosuppressed renal transplant patients presenting with severe diarrhea. Although C. jejuni infection is rarely complicated by an identified bacteremia or extraintestinal localization, failure to initiate timely targeted antibiotic therapy is associated with high mortality rates. The diagnosis and treatment of C. jejuni infection is usually delayed because the bacteria grow very slowly and require special culture media (3). No controlled clinical trials have been published on the optimal antibiotic regimen or therapy duration for the treatment of Campylobacter infections. Infection in immunocompromised hosts usually requires antibiotic treatment because of increased risks of morbidity and mortality (8, 10). Fluoroquinolones and macrolides are used for the empirical treatment of Campylobacter infection. Because the diarrhea and fever continued in our patient, we decided to use antibiotics. We did not choose to modify his immunosuppressive regimen because he became clinically stable overall. As in this case, ongoing gaps in our food safety system continue to place transplant recipients at risk of Campylobacter infection (11) and it is important to recognize and initiate empirical treatment of Campylobacter infection especially in immunosuppressed renal transplant recipients. Naohiko Imai Daisuke Uchida Masaya Hanada Sho Sasaki Yugo Shibagaki Tatsuya Chikaraishi Kenjiro Kimura St. Marianna University School of Medicine Kanagawa, Japan
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Feb 13, 2024
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