Colon non tumor
Infectious colitis (specific microorganisms)
Campylobacter jejuni and similar bacteria

Author: Elliot Weisenberg, M.D. (see Authors page)

Revised: 19 December 2015, last major update June 2015

Copyright: (c) 2003-2015, PathologyOutlines.com, Inc.

PubMed Search: Campylobacter jejuni [title] colon
Definition / General
  • Campylobacteriosis refers to disease caused by Campylobacter species and closely related bacteria
  • Campylobacter are comma shaped, gram negative, flagellated, non spore forming, microaerophilic bacteria
  • C. jejuni is by far the most common cause of Campylobacteriosis, and it has >90 serotypes
  • C. fetus Subsp. fetus infection is not rare
  • Other species ("atypical" enteric Campylobacters), including C. coli, C. lari, C. hyointestinalis, Helicobacter cinaedi, C. upsaliensis, Helicobacter fennelliae, and others are rarely isolated and when symptomatic, usually are associated with gastrointestinal illness or periodontal disease
Epidemiology
  • C. jejuni:
    • Causes 1.3 million (CDC) to >2.0 million (Mandell) infections in US annually
    • #1 or #2 most common bacterial cause of diarrheal illness in US
    • Commensal in the wild and in domesticated fowl, cattle, sheep, pigs, goats, dogs, cats, rodents
    • Has a worldwide distribution
    • For human transmission, the most important reservoirs are poultry, sheep, cattle and pigs
    • In the developed world disease is generally sporadic and most commonly occurs after ingestion of undercooked poultry or unpasteurized milk
    • Infection from eating undercooked beef, raw clams and untreated water also occurs
    • Human to human, fecal-oral transmission may occur
    • In commercial slaughterhouses, meat, especially poultry, is commonly contaminated by intestinal contents
  • Campylobacter die quickly in dry and cold conditions limiting environmental spread
  • Pasteurization and chlorine in treated water will kill the organism
  • Outbreaks have occurred following malfunctions of municipal water treatment facilities
  • Infection may occur from direct contact with companion animals, especially puppies or kittens with diarrhea
  • Individuals with occupational exposure to farm animals are at higher risk
  • The bacteria is sensitive to gastric acid and patients on acid reducing drugs such as H2 blockers and proton pump inhibitors are at higher risk
  • In the developing world, infection is mostly human to human and disease is hyperendemic in children under 2 years old; most children have several infections before the age of 2
  • Later in life, most infections are mostly asymptomatic
  • C. fetus subsp. fetus:
    • Has major reservoir in cattle and sheep
    • Reptiles commonly harbor the organism
    • Disease usually occurs in elderly / debilitated patients
    • Disease also reported in men who have sex with men, and rarely in other healthy patients
Sites
  • Disease due to C. jejuni mostly is associated with involvement of the colon; however, the jejunum and ileum may be affected
  • Rarely the bladder, gallbladder or pancreas may be infected through direct extension
  • C. fetus may cause endocarditis, pericarditis, mycotic aneurysms, pneumonitis or CNS infection
  • Rarer enteric Campylobacter species and related organisms usually affect the small and large intestines
Pathophysiology
  • Organisms which survive passage through the stomach multiply in bile and colonize upper small intestine, with subsequent involvement of large bowel
  • Virulence factors include motility (flagella), adherence, invasion and possibly toxin production
  • Adherence and colonization are necessary for invasion
Clinical Features
  • Disease occurs year round but at a higher incidence in summer and early fall
  • Affects people of all ages, but is most common in children under 1 year and adolescents / young adults from 15 to 29 years old
  • Disease is more common in males
  • It is an important cause of traveler's diarrhea
  • C. jejuni:
    • Typically causes acute self-limited illness of watery diarrhea, although dysentery may occur
    • May have a flu-like prodrome for 1 day of fever, malaise, headache or myalgias
    • In addition to diarrhea, patients may experience abdominal pain, tenesmus, nausea or fever
    • Symptoms last from one day to a week or longer
    • The presentation may mimic acute appendicitis
    • Relapse of disease may occur
    • Dysentery is more common in children (50%) than adults (15%)
    • Ingestion of as few as 500 microorganisms may cause disease, with an incubation period of up to 8 days
    • Severity of infection is related to the dose of the inoculate, the virulence of the strain, and the host's immune state
    • Ingestion of higher numbers of organisms results in shorter incubation periods
    • More severe and prolonged disease occurs in patients with defects in either cellular or humoral immunity
    • Complications are uncommon but numerous; includes Guillain-Barré syndrome (GBS) in < 0.1%
      • Molecular mimicry between components of C. jejuni and nervous system gangliosides may occur resulting in cross reactivity between antibodies to C. jejuni and nervous system components
      • It is estimated that up to half of patients with GBS have had prior C. jejuni infection
    • Other potential complications include erythema nodosum, Henoch-Schönlein purpura, myopericarditis, hepatitis, septic abortion, hemolytic uremic syndrome, cellulitis and renal disease including IgA nephropathy and interstitial nephritis
    • Toxic megacolon has been reported
    • In patients with HLA-B27, reactive arthritis may occur
    • Campylobacter has been implicated in immunoproliferative small intestinal disease; may also exacerbate preexisting inflammatory bowel disease
    • C. fetus subsp. fetus affects elderly / debilitated patients and causes systemic illness affecting GI tract, heart, blood vessels, lung, nervous system
Diagnosis
  • Microscopic evaluation of fresh (<2hr) stool may enable a presumptive diagnosis to be made due to characteristic "darting motility"
    • Microscopic stool examination shows leukocytes and red blood cells
    • Diagnosis traditionally has been made by microbiologic culture; special techniques are necessary as Campylobacter species grow more slowly than other enteric organisms and will otherwise be overgrown
      • C. jejuni grows best at 42°C but will grow at 37°C
      • Most laboratories incubate cultures at 42° that may make it impossible to isolate other Campylobacter species besides C. jejuni
    • The diagnosis may also be made by PCR of stool or paraffin blocks, but until recently this has been mostly in research settings (Am J Surg Pathol 2006;30:782)
    • Recently a PCR based assay for testing stool has been introduced that in addition to Campylobacter group bacteria, also detects Shigella species, Vibrio group, Yersinia enterocolitica, Shiga toxin 1 and 2, Norovirus G1/GII, Rotavirus A and Aeromonas species
  • Rarely C. jejuni may be diagnosed by blood culture
    • C. fetus subsp fetus is usually detected in blood cultures
    • If Campylobacter species infection is suspected, blood cultures should be incubated for two weeks due to its slow growth
  • Immunoassays are also available
Prognostic Factors
  • Usually excellent; worse in immunosuppressed patients
Case Reports
Treatment
  • Most cases of C. jejuni do not require antibiotic therapy; if necessary, fluid and electrolyte replacement should be given
  • Antibiotic treatment is recommended in the setting of high fever, bloody diarrhea, patients who have more than 8 bowel movements in a day or disease lasting longer than one week
  • Erythromycin is generally the drug of choice, although tetracyclines, aminoglycosides, chloramphenicol, quinolones, nitrofuran, and clindamycin are also effective
  • Increasing resistance to macrolides (azithromycin, clarithromycin, erythromycin, others) and fluoroquinolones (ciprofloxacin, levofloxacin) is reported
  • In patients with hypogammaglobulinemia, fresh frozen plasma in addition to antibiotics may be useful
Micro Description
  • Biopsy is rarely performed - the non-specific findings are those of acute self-limited colitis
  • Neutrophils are increased within the lamina propria and cryptitis or crypt abscesses often occur
  • Crypt architecture is maintained, although neutrophilic infiltrates may make this hard to appreciate
  • Basal lymphoplasmacytosis is absent
Micro Images

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Cryptitis

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Cystic crypts and cryptitis

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Edema, cryptitis and crypt abscess

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Loss of crypts

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Marked edema

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Neutrophilic aggregates in lamina propria

Differential Diagnosis