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Cytopenia in Campylobacter jejuni Enteritis Patients

  • Shuhei Okuyama
  • Hiroaki Kumagai
  • Daisuke Akaneya
  • Katsushi TajimaEmail author
Medicine
  • 54 Downloads
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  1. Topical Collection on Medicine

Abstract

Campylobacter jejuni (C. jejuni) enteritis is generally self-limited, but occasionally triggers extraintestinal associated sequelae. We examined whether cytopenia is associated with C. jejuni enteritis. A retrospective case-controlled study of C. jejuni and Escherichia coli (E. coli) enteritis patients, who were microbiologically confirmed in our hospital from February 2006 to October 2017, was conducted. Leukocytopenia and thrombocytopenia were defined as statuses less than 4.0 × 109/L and 130 × 109/L during their clinical courses, respectively. Clinical and microbiological data were collected. Risk factors for cytopenia were assessed by a multivariate analysis. The two eligible cohorts comprised 138 C. jejuni (71 inpatients) and 35 E. coli (34 inpatients) enteritis patients. The prevalence of leukocytopenia or thrombocytopenia in the C. jejuni patients was 7.9% (11/138) and 5.0% (7/138), and that in the E. coli patients was 0% (0/35) and 5.7% (2/35), respectively. Leukocytopenia was more prevalent in the C. jejuni enteritis inpatients than in the E. coli inpatients, but there were no significant differences in thrombocytopenia in both cohorts. The mean minimum leukocyte values were determined after an average of three admission days in the C. jejuni inpatients. The elevations of C-reactive protein and creatinine were risk factors for thrombocytopenia and leukocytopenia, respectively. Hemophagocytosis was detected in a C. jejuni enteritis patient with cytopenia. The present study suggested that leukocytopenia is a possible extraintestinal sequela in some C. jejuni enteritis patients. Hemophagocytosis should be considered as one of underlying mechanisms when cytopenia is found in these patients.

Keywords

Campylobacter jejuni Thrombocytopenia Leukocytopenia Hemophagocytosis 

Abbreviations

C. jejuni

Campylobacter jejuni

E. coli

Escherichia coli

GBS

Guillain-Barre syndrome

WBC

white blood cell

Cre

creatinine

LDH

lactate dehydrogenase

ALT

alanine aminotransferase

CRP

C-reactive protein

EB

Epstein-Barr

Ig

immunoglobulin

PAIgG

platelet-associated IgG

HUS

hemolytic uremic syndrome

Introduction

Campylobacter jejuni (C. jejuni) is one of the major causes of enteritis, and although this type of enteritis is generally self-limited, severe cases require hospitalization and antimicrobial treatment. This infection occasionally but rarely triggers post-infectious extraintestinal immune responses, including Guillain-Barre syndrome (GBS) and Reiter’s disease, suggesting that C. jejuni infection may evoke specific characteristic immunological responses, such as an autoimmune etiology, in certain patients [1, 2]. The extent of T cell involvement has been suggested to mediate the development of these extraintestinal immune responses, as mainly suggested by animal models [1, 3, 4, 5]. However, the reasons why certain patients develop a more severe acute infection or late extraintestinal sequelae have not been fully elucidated.

Various viral and bacterial infections can cause transient cytopenia [6]. However, there have only been a few cases of C. jejuni enteritis patients complicated by cytopenia [7, 8]. Two previous studies reported that the incidences of leukocytopenia and thrombocytopenia were 10% and 15% in 160 hospitalized patients with campylobacteriosis, respectively, and that leukocytopenia occurred in 7% of 178 patients with group C bacteremia [7, 8]. Group C bacteremia mostly occurred in middle-aged and immunocompromised patients. Recently, Schattner suggested that leukopenia or thrombocytopenia, particularly in febrile patients with diarrhea, may be a differential diagnostic clue for a latent C. jejuni infection, based on its high frequency of complications (up to 30%), by analyzing 20 admitted C. jejuni enteritis patients [9]. Thus, the association between C. jejuni enteritis and cytopenia has remained debatable. Moreover, the underlying mechanisms responsible for cytopenia were left unaddressed, and there were no control enteritis patients in these previous reports.

We encountered a young, competent man with C. jejuni enteritis and marked thrombocytopenia and mild leukocytopenia during his disease process. In the present study, we examined whether C. jejuni infections have an association with thrombocytopenia or leukocytopenia, by retrospectively comparing two cohorts comprising larger numbers of C. jejuni enteritis patients and the control Escherichia coli (E. coli) enteritis patients. This is the first investigation of the pathogenetic mechanism of cytopenia and its risk factors in C. jejuni enteritis patients.

Materials and Methods

Case Presentation

A 17-year-old, generally healthy high school student without allergies visited the emergency room in the Yamagata Prefectural Central Hospital, complaining of diarrhea, fever, and nasal bleeding. He had consumed a tofu burger in a cooking school class 2 days prior, and thereafter, he and his four colleagues presented with diarrhea and fever. The physical examination revealed mild hepatosplenomegaly without lymph node swelling. His laboratory findings were as follows: white blood cells (WBCs) 3.3 × 109/L (neutrophils 64%, lymphocytes 32%, and monocytes 4%); hemoglobin 12.5 g/dL; reticulocytes 2.76 × 104/μL; platelets 24 × 109/L; blood urea nitrogen 14.5 mg/dL; creatinine (Cre) 0.71 mf/dL; lactate dehydrogenase (LDH) 338 IU/L (normal, < 120); alanine aminotransferase (ALT) 21 IU/L (normal, < 45); aspartate aminotransferase (AST) 33 IU/L (normal, < 34); C-reactive protein (CRP) 16.9 mg/dL; iron 125 μg/dL (normal, 50–190); and ferritin 400 ng/mL (normal, 30–310). Anti-Epstein-Barr (EB) virus immunoglobulin (Ig) G and IgM were positive and negative, respectively. His blood was negative for cytomegalovirus, herpes simplex virus, and EB virus DNAs. The platelet-associated IgG (PAIgG) level was slightly increased to 112 ng/107 cells (normal, < 46). The IgE level was increased to 3077 IU/mL (normal, < 283). Serial blood cultures were all negative. C. jejuni was isolated from his and his colleague’s stools, and thus the tofu burger might have caused the C. jejuni food-poisoning enteritis. On the fifth day after admission, atypical lymphocytes, with a large nucleus and a basophilic cytoplasm (Fig. 1a, b), emerged in his peripheral blood (WBCs 2.5 × 103/μL, lymphocytes 61%, and atypical lymphocytes 8%). A flow cytometric analysis revealed that his total lymphocyte populations were positive for CD3 (84%), CD4 (56%), CD8 (27%), CD19 (10%), T cell receptor alpha/beta (79.4%), and T cell receptor gamma/delta (3%). The larger populations in the lymphocytes were positive for CD19 (55%) and CD3 (24%), and negative for CD20. A polymerase chain reaction (PCR) study for the Ig heavy chain gene and the T cell receptor-β gene rearrangement revealed oligoclonal B cells and T cells in the peripheral blood. A bone marrow specimen showed myeloid hyperplasia and platelet hemophagocytosis (Fig. 1c), without any pathological cells. The atypical lymphocytes vanished in the peripheral blood on the twenty-fifth disease day, and a subsequent PCR study confirmed the disappearances of the oligoclonal T and B lymphocytes. Therefore, these findings suggested that the transiently appearing oligoclonal T and B lymphocytes corresponded to his atypical lymphocytes. His symptoms were relieved by the administration of an antibiotic (ciprofloxacin) for C. jejuni. Seven days after hospitalization, his minimum leukocyte value was observed, and its complete recovery required 3 months. The thrombocytopenia and the elevation of PAIgG persisted for a long period. All of his colleagues quickly improved without exhibiting cytopenia.
Fig. 1

Representative atypical lymphocytes and hemophagocytosis. a, b Atypical lymphocytes, with a large nucleus and a basophilic cytoplasm, transiently emerged in the peripheral blood. c Hemophagocytosis in his bone marrow

Patients and Methods

To ascertain whether C. jejuni enteritis is associated with cytopenia, we compared the prevalence of cytopenia between C. jejuni and control E. coli enteritis patients, and examined the risk factors for cytopenia in C. jejuni enteritis patients. The study and control groups were patients newly and consecutively diagnosed with C. jejuni enteritis and E. coli enteritis, who visited our hospital from February 2006 to October 2017. Eligible patients had microbiologically confirmed C. jejuni or E. coli enteritis. Clinical and laboratory information was available within 28 days after their disease onsets. The eligible patients in both groups had no evidence of preexisting cytopenia, and hemolytic uremic syndrome (HUS) patients were excluded from the two cohorts. Leukocytopenia and thrombocytopenia were defined as statuses less than 4.0 × 109/L and 130 × 109/L during their clinical courses, respectively. We also compared the maximum leukocyte values of the two cohorts. The clinicolaboratory characteristics of each group were compared using the Fisher method, and the risk factors for thrombocytopenia and leukocytopenia in the C. jejuni group were analyzed using a multivariate method involving the following variables: gender, AST, ALT, LDH, Cre, and CRP. Correlations were calculated using simple linear regression analyses. All statistical analyses were performed using the EZR software [10]. Differences with a value of P < 0.05 were considered significant.

Results

A total of 143 C. jejuni and 50 E. coli enteritis patients were enrolled. The eligible study population comprised 138 C. jejuni (71 inpatients and 67 outpatients) and 35 E. coli (34 inpatients and 1 outpatient) control enteritis patients (Table 1). The E. coli group developed 15 HUS patients, whereas no patients in the C. jejuni group developed HUS. The prevalence of leukocytopenia or thrombocytopenia was 7.9% (11/138) and 5.0% (7/138) in the C. jejuni patients, and 0% (0/35) and 5.7% (2/35) in the control E. coli patients. The prevalence of leukocytopenia or thrombocytopenia tended to be higher in the C. jejuni enteritis patients than in the E. coli patients, but was not significant. In this study, cytopenia was mild in both groups except for two cases, including ours. However, the leukocytopenia prevalence in inpatients with C. jejuni enteritis (15.5%: 11/71) was significantly higher than that in inpatients with E. coli enteritis (0%: 0/34). The multivariate analysis revealed that CRP or creatinine elevation was a risk factor for thrombocytopenia and leukocytopenia, respectively (Table 2) (Sup. 1). The mean maximum leukocyte values were higher in E. coli patients (9290/μL; 6520–13,190) than in C. jejuni patients (6560/μL; 3420–11,200) (Sup. 2). In the present C. jejuni inpatients with cytopenia, their minimum leukocyte values were not detected at the time of admission, but after three admission days on average (Sup. 3). In contrast, the leukocyte values in the E. coli inpatients were not decreased after three admission days (Sup. 4).
Table 1

Characteristics of C. jejuni and E. coli enteritis patients

Characteristics

Number (n)

  (inpatients)

C. jejuni

138

(71)

E. coli

35

(34)

P value

Male/female (n)

88/50

17/18

0.122

Age (mean years)

30.7 ± 23.4

38.7 ± 26.0

0.121

Leukocytopenia: %

  (inpatients)

7.9% (11/138)

15.5% (11/71)

0% (0/35)

0% (0/34)

0.123

(0.015)

Thrombocytopenia: %

  (inpatients)

5.0% (7/138)

8.4% (6/71)

5.7% (2/35)

5.8% (2/34)

1

1

C. jejuni, Campylobacter jejuni; E. coli, Escherichia coli; n, number of patients

The two-sided P value was determined by Fisher’s exact test

Table 2

Association of patient characteristics with cytopenia occurrence in C. jejuni colitis patients

Characteristics

Leukocytopenia

P-v.

Thrombocytopenia

P-v.

(+)

(−)

(+)

(−)

Univariate

11

127

 

7

131

 

  Sex

Male

8

80

0.75

4

84

0.70

Female

3

47

3

47

  AST

1

10

1

1

10

0.45

  ALT

3

13

0.12

2

14

0.19

  LDH

2

9

0.21

1

10

0.45

  Cre

3

8

0.044

0

11

1

  CRP

4

17

0.064

4

17

0.011

Multivariate*

    

  CRP

 

0.18

 

0.006

  Cre

 

0.035

 

0.99

AST aspartate aminotransferase, ALT alanine aminotransferase, LDH lactate dehydrogenase

Cre, creatinine; CRP, C-reactive protein; P-v, P value

*For the multivariate analysis, a logistic regression model was done. Backward stepwise selection identified CRP as an independent variable associated with thrombocytopenia in C. jejuni colitis patients

Discussion

The present study revealed that the prevalence in the C. jejuni inpatients was 15.5% (leukocytopenia) and 7.0% (thrombocytopenia), and the total C. jejuni prevalence was 7.9% (leukocytopenia) and 5.0% (thrombocytopenia). The prevalence of leukocytopenia in this study was lower, as compared with that (30%) of C. jejuni enteritis patients reported by Schattner [9]. This different prevalence may be derived from the criteria for leukocytopenia, the follow-up period, the examination frequency, different C. species, bacteremia, enteritis, and/or inpatients or outpatients in previous reports [7, 8, 9]. In the present study, the prevalence of leukocytopenia in the C. jejuni inpatients was higher than that in the outpatients, and their minimum leukocyte counts were not observed at the admission time, but several days after admission. In fact, unless the present patient was hospitalized, his minimum leukocyte value following 7 days of admission would also has been missed. This process was consistent with a recent report that a 9-month-old boy presenting with C. jejuni enteritis showed pancytopenia at 5 days after discharge, although his initial leukocyte count was normal [11]. In contrast, no patients in the E. coli enteritis group showed leukocytopenia, and the mean maximum leukocyte count was higher than that in the C. jejuni inpatients. These findings suggest that the leukocytopenia occurring in some C. jejuni enteritis patients may be derived from a secondary host immune response, as an extraintestinal sequela. Therefore, we cannot deny the underestimation of the leukocytopenia prevalence in C. jejuni enteritis patients. However, this case-control study was limited, because of the relative comparison of C. jejuni and only E. coli cases.

The mechanism of cytopenia in C. jejuni enteritis patients remained unaddressed in previous reports [7, 8]. In our case, the patient’s bone marrow and laboratory findings showed the development of hemophagocytosis without any reference to EBV infections. Hemophagocytosis, typically presenting with proinflammatory states including fever, cytopenia, and an elevation of CRP, is a complicated and not fully elucidated immune dysregulation disease associated with malignancies, autoimmune diseases, and infections [6]. The prevalence of hemophagocytosis associated with bacterial infections differs in various reports [6, 12]. Several animal studies revealed that C. jejuni infections are associated with the production of proinflammatory cytokines, possibly in the initiation and pathogenesis of hemophagocytosis, and induced an influx of many T and B lymphocytes into extraintestinal sites including the liver, lung, and kidney, as well as the colon mucosa [4, 13]. However, there is only one report in which an immunocompromised patient with acquired immunodeficiency syndrome developed hemophagocytic syndrome induced by multidrug-resistant C. fetus bacteremia and exhibited transient pancytopenia [14]. The present multivariate analysis revealed that high CRP and creatinine levels are risk factors for thrombocytopenia and leukopenia in C. jejuni enteritis patients, respectively. This finding is compatible with analyses of a previous salmonella patient [15]. Therefore, these findings tend to support the hypothesis that hemophagocytosis could be triggered in some characteristic patients, such as our case, possibly resulting in transient cytopenia as an extraintestinal sequela.

Only a few previous reports demonstrated that oligoclonal alpha/beta T cells with restricted diversities were present in patients with hemophagocytosis without EBV infection [16, 17], and a recent report showed that human peripheral C. jejuni–specific CD4-positive T cells could produce proinflammatory cytokines. In our patient, oligoclonal T cells were transiently found during his cytopenia, and disappeared from the blood following his recovery, suggesting a secondary extraintestinal immune response and an association with his hemophagocytosis. However, no examinations of the relationship between T cell clonality and hemophagocytosis development in C. jejuni enteritis patients have been reported.

Oligoclonal B cells also appeared transiently in our patient. A previous study found that C. jejuni enteritis is associated with immunoproliferative small intestinal diseases (IPSID), including mucosa-associated lymphoid tissue lymphoma and lymphoplasmacytic lymphoma, because the early stages of these diseases dramatically respond to antibiotics for C. jejuni [18, 19]. If left untreated, these conditions may lead to a neoplastic progression, resulting in the transient development of oligoclonal B cells [18]. Patients with IPSID syndrome have variable levels of abnormal Ig in the serum. The present patient had elevations of PAIgG and IgE, which possibly contributed to his abnormal immune response to the C. jejuni infection. Finally, this is the first reported case demonstrating hemophagocytosis and oligoclonal T and B cells in a C. jejuni enteritis patient with cytopenia.

Conclusion

The present study showed the prevalence of cytopenia in C. jejuni colitis patients and the possible underlying mechanism of this cytopenia. We recommend that clinicians consider the presence of hemophagocytosis, particularly when C. jejuni enteritis patients have cytopenia.

Notes

Acknowledgments

We thank Harumi Matsumoto for her technical support.

Authors’ Contributions

KT and SO conceived the study and designed its methodological aspects. HK treated the patient. DA performed microbiological culture. The manuscript was prepared by SO and KT. All authors approved the final manuscript.

Funding

This work was supported by a grant-in-aid for scientific research, KAKENHI grant number 16K10376 (K. Tajima), from the Ministry of Education, Culture, Sports, Science, and Technology of Japan.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that there are no conflicts of interest.

Ethics Approval and Consent to Participate

This study was approved by the Ethics Committee of Yamagata Prefectural Central Hospital.

Consent for Publication

Consent for the publication of this case and any additional related information was taken from the patient involved in this study.

Supplementary material

42399_2019_109_MOESM1_ESM.pdf (25.1 mb)
ESM 1 (PDF 25748 kb)

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Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Shuhei Okuyama
    • 1
  • Hiroaki Kumagai
    • 1
  • Daisuke Akaneya
    • 2
  • Katsushi Tajima
    • 1
    Email author
  1. 1.Department of HematologyYamagata Prefectural Central HospitalYamagata-shiJapan
  2. 2.Department of Laboratory MedicineYamagata Prefectural Central HospitalYamagata-shiJapan

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