CASE REPORTS

an acute disorder within the abdomen. However, Refer to: Heyman MB, Paterno VI, Ament ME: Campylobacter
colitis: A cause of chronic diarrhea in children. West J
the asymptomatic form has been described follow- Med 1982 Sep; 137:243-245
ing a surgical procedure,'3 trauma,'4 percutaneous
cholangiography8 and liver biopsy,9 and sponta-
neous rupture of the extrahepatic biliary tree in
infants and children.'5 In addition to being the first
report of bilious ascites due to spontaneous rupture Campylobacter Colitis
of the gallbladder wall, this case is a poignant A Cause of Chronic Diarrhea
reminder that it is necessary to demand appropri- in Children
ate confirmation of the diagnosis of extrapulmo-
nary tuberculosis. The case also calls attention to MELVIN B. HEYMAN, MD, MPH
the expedience of using a dipstick to assess the San Francisco
presence of bilirubin in ascitic fluid while awaiting
confirmatory biochemical analysis. Because bil- VICTORIA 1. PATERNO, MD
ious ascites can clinically and biochemically simu- MARVIN E. AMENT, MD
late infectious peritonitis, it should be considered Los Angeles
in the differential diagnosis of newly asquired pro-
gressive ascites, with or without fever. INFECTION BY Campylobacter jejuni* has been
Summary described as a gastroenteritis,'-5 with pathologic
involvement of the jejunum and ileum, that spares
The combination of fever, weight loss, painless the colon.2'6 In the past two years, however, sev-
ascites and a positive tuberculin skin test suggested eral cases of adult patients with acute Campylo-
the diagnosis of peritoneal tuberculosis in a 60- bacter colitis have been reported.7-" Campylo-
year-old man with a history of alcoholism. Clinical bacter colitis has not been previously reported in
and laboratory studies were consistent with the children.
diagnosis but results of peritoneal biopsies were A 7-month-old girl with chronic diarrhea pro-
inconclusive. An exploratory laparotomy was ducing blood-streaked feces and a 13-year-old
therefore carried out and surprisingly showed an girl with crampy abdominal pain and bloody diar-
occult perforation of the gallbladder wall, result- rhea are reported to document the existence of
ing in asymptomatic bilious ascites. The case points chronic Campylobacter colitis in infants and chil-
to the need to definitively diagnose the cause of dren and its response to treatment.
ascites before initiating therapy.
REFERENCES Reports of Cases
1. Glassroth J, Robins AG, Snider DE Jr: Tuberculosis in the
1980's. N Engl J Med 1980 Jun; 302:1441-1450 CASE 1. A 7-month-old female infant was seen
2. Farer LS, Lowell AM, Meador MP: Extrapulmonary tuber-
culosis in the United States. Am J Epidemiol 1979 Feb; 109:205-
with a two-month history of diarrhea. Her stool
217
3. Singh MM, Bhargava AN, Jain KP: Tuberculous peritonitis frequency had increased from the usual one to
-An evaluation of pathogenetic mechanisms, diagnostic proced-
ures, and therapeutic measures. N Engl J Med 1969 Nov; 281:
two yellowish green formed stools to six to eight
1091-1094
4. Borhanmanesh F, Hekmat K, Vaezzadeh K, et al: Tuber-
watery stools per day.
culous peritonitis-Prospective study of 32 cases in Iran. Ann
Intern Med 1972 Apr; 76:567-572
A week after the onset of diarrhea, the feces
5. Burack WR, Hollister RM: Tuberculous peritonitis-A study
of forty-seven proved cases encountered by a general medical unit contained bright red blood with mucus. Cultures
in twenty-five years. Am J Med 1960 Apr; 28:510-523
6. Hyman S, Villa F, Alvarez S, et al: The enigma of tuber- of stool specimens were negative for Salmonella
culous peritonitis. Gastroenterology 1962 Jan; 42:1-6
7. Karney WW, O'Donoghue JM, Ostrow JH, et al: The spec-
and Shigella and a leukocyte count showed a leu-
trum of tuberculous peritonitis. Chest 1977 Sep; 72:310-315
8. Stein JA, Price JB: Asymptomatic bilious ascites after per-
kocytosis. The patient responded to a milk pro-
cutaneous transhepatic cholangiogram. Gastroenterology 1973 May;
64:1013-1014
tein-free formula, Pregestimil (Mead Johnson
9. Avner DL, Berenson MM: Asymptomatic bilious ascites
following percutaneous liver biopsy. Arch Intem Med 1979 Feb;
Nutritional Division, Evansville, Indiana), and
139:245-246
10. Conn JH, Chavez CM, Fain WR: Bile peritonitis: An ex-
the diarrhea and blood in the feces ceased. Ten
perimental and clinical study. Am Surg 1970 Apr; 36:219-224
11. Thoren L: Bile peritonitis-Il. Experimental studies of
days later, her fecal output increased and became
plasma volume loss, haptoglobin concentration in serum and kidney
lesions in bile peritonitis. Acta Chir Scand 1963 Jul-Aug; 126: *This has recently been upgraded from Campylobacter fetus
114-122 subspecies jejuni to a separate species.
12. Means RL: Bile peritonitis. Am Surg 1964 Sep; 30:583-588 From the Department of Pediatrics, UCLA School of Medicine.
13. Ellis H, Adair HM: Bile peritonitis-A report of fifteen Dr. Heyman is now affiliated with the Department of Pediatrics,
patients. Postgrad Med J 1974 Nov; 50:713-717 Gastroenterology Unit, University of California, San Francisco.
14. Elmslie RG, White IT: Experimental inquiry into the sig- Submitted, revised, August 5, 1981.
nificance of trypsin in bile peritonitis, with particular reference to
the human secretions. Br J Surg 1966 Dec; 53:1063-1067 Reprint requests to: Marvin E. Ament, MD, Department of
15. Lees W, Mitchell JE: Bile peritonitis in infancy. Arch Dis Pediatrics, UCLA School of Medicine, MDCC 22-340, Los
Child 1966 Apr; 41:188-192 Angeles, CA 90024.

THE WESTERN JOURNAL OF MEDICINE 243

 CASE REPORTS

bloody for the second time. Treatment with half- tion of Donnatal (hyoscyamine sulfate, atropine
strength soybean formula for a month as an out- sulfate, scopolamine hydrobromide and pheno-
patient, followed by peripheral vein total parenteral barbital) and Hycodan (hydrocodone bitartrate
nutrition as an inpatient, was unsuccessful in and homatropine methylbromide) did not relieve
stopping the blood-streaked diarrhea. Eight weeks her symptoms. With each episode of cramps, she
into her illness she had her first fever and was had a bowel nmovement of a small amount of
transferred to UCLA Hospital, Los Angeles. diarrheal feces that, on microscopic examination
Her height was 70.5 cm (75th percentile) and of a specimen, showed sheets of polymorphonu-
weight was 7.32 kg (40th percentile). The find- clear leukocytes. She was admitted to UCLA Hos-
ings on physical examination were normal. Labo- pital because of the severity of cramps, weight
ratory studies showed the following values: serum loss of 3 kg and persistence of diarrhea.
sodium 142 mEq per liter, serum chloride 106 Height was 146 cm (below the fifth percentile)
mEq per liter, serum bicarbonate 16.4 mEq per and weight was 30.5 kg (below the fifth percen-
liter (normal 23 to 29), serum aspartate amino- tile). The patient had a flat abdomen with in-
transferase (AST, formerly SGOT) 41 IU per liter crease in bowel sounds and diffuse abdominal ten-
(normal 6 to 36), serum alanine aminotransferase derness with guarding. The results of the rectal
(ALT, formerly SGPT) 11 IU per liter (normal 10 examination were normal and the remainder of
to 45), serum protein 6.6 grams per dl and serum her physical examination elicited no abnormal-
albumin 4.1 grams per dl. Analysis of urine was ities. Significant laboratory findings included a
normal. Hemoglobin was 11.2 grams per dl, leukocyte count of 7,700 per cu mm with 64
hematocrit 33.6 percent; leukocyte count was 10,- percent segmented neutrophils, 28 percent band
500 per cu mm, with 10 percent segmented neutro- forms and 8 percent monocytes. Proctosigmoido-
phils, 2 percent band forms, 74 percent lympho- scopic examination showed spontaneous friability
cytes and 8 percent monocytes; platelet count was of the rectal mucosa to 18 cm, with a general loss
490,000 per cu mm. Admission stool specimen of vascular pattern. A stool specimen taken during
examination showed five to six leukocytes and this examination grew C jejuni. Her condition
erythrocytes per high-powered field; all stool spe- gradually improved in the third week of her illness
cimens had a normal pH of 6.5 and were read as without antibiotic therapy, and pain ceased in the
negative with Clinitest and Hematest (Ames fourth week. Repeat culture of a stool specimen
Company, Inc.). Proctosigmoidoscopic examina- was negative for the organism.
tion showed punctate ulcerative lesions extending
the entire 10 cm examined; however, areas of Discussion
normal vascular pattern were seen adjacent to Infection caused by C jejuni has been typically
spontaneously friable mucosa. Rectal valves were described as an acute gastroenteritis presenting
edematous. Rectal suction biopsy specimens with symptoms of fever, abdominal pain and
showed acute and chronic colitis. Cultures of a diarrhea, often with bright red blood.,-4 Infants
stool specimen from the proctosigmoidoscopic and children who have a history of diarrhea of
examination grew C jejuni and were negative for longer than 14 days ( "chronic diarrhea") and
other enteric pathogens. She was treated with colitis should still be considered to have an infec-
administration of erythromycin ethylsuccinate, 50 tious diarrhea until cultures of stool specimens are
mg per kg of body weight per day for ten days. reported negative for Campylobacter; Shigella,
The stool frequency decreased to one a day, and Salmonella and Yersinia.
the stool specimens became free of erythrocytes The diarrhea associated with proved Campylo-
and polymorphonuclear leukocytes. Culture of a bacter gastroenteritis usually lasts from one day
stool specimen was repeated a week after complet- to three weeks, though reports suggesting chronic
ing a course of antibiotic medications and did not infection exist.6 l Three cases of prolonged
grow Campylobacter. diarrhea have been reported associated with isola-
CASE 2. A 131/2-year-old girl had crampy lower tion from blood culture of "Vibrio-like" organ-
abdominal pain for a week and a half. Three days isms, now reclassified as Campylobacter organ-
after the onset of the cramps, she had three red, isms. Wheeler and Borchers6 reported the cases of
mucoid stools. The cramping episodes occurred two siblings, an 11-month-old infant and a 4-
four to five times a day. The maximum tempera- year-old child, with nine-month histories of four
ture recorded was 38°C (100.5°F). Administra- to five episodes of diarrhea. Culture of a blood

244 SEPTEMBER 1982 * 137 * 3

 CASE REPORTS
specimen from the infant grew Vibrio and the REFERENCES
1. Blaser MJ, Berkowitz ID, LaForce FM, et al: Campylobac-
sibling had a positive hemagglutination titer to the ter enteritis: Clinical and epidemiologic features. Ann Intern Med
1979 Aug; 91:179-185
same Vibrio. Both responded to treatment with 2. Rettig PJ: Campylobacter infections in human beings. J
streptomycin sulfate. Another case of "related Pediatr 1979 Jun; 94:855-864
3. Pai CH, Sorger S, Lackman L, et al: Campylobacter gastro-
Vibrio" cultured from a blood specimen was re- enteritis in children. J Pediatr 1979 Apr; 94:589-591
4. Karmali MA, Fleming PC: Campylobacter enteritis in chil-
ported by Cadranel and co-workers'2 in a 16- dren. J Pediatr 1979 Apr; 94:527-533
month-old child who had recurrent diarrhea for 5. Torphy DE, Bond WW: Campylobacter fetuts infections in
children. Pediatrics 1979 Dec; 64: 898-903
five months. 6. Wheeler WE, Borchers J: Vibrionic enteritis in infants.
Am J Dis Child 1961 Jan; 101:60-66
The absence of malabsorption in our cases im- 7. Lambert ME, Schofield PF, Ironside AG, et al: Campylo-
bacter colitis. Br Med J 1979 Mar 31; 1:857-859
plies limited or absent mucosal damage to the 8. Willoughby CP, Piris J, Truelove SC: Campylobacter colitis.
J Clin Pathol 1979 Oct; 32:986-989
small bowel, wherein this organism has been cul- 9. Price AB, Jewkes J, Sanderson PJ: Acute diarrhoea: Campy-
tured in previous reports. lobacter colitis and the role of rectal biopsy. J Clin Pathol 1979
Oct; 32:990-997
Ulcerative colitis or Crohn's disease should 10. Blaser MJ, Parsons RB Wang W-LL: Acute colitis caused
by Campylobacter fetus ssp jejuni. Gastroenterology 1980 Mar;
only be diagnosed after the presence of enteric 78:448-453
11. Svedhem A, Kaijser B: Campylobacter fetuis subspecies
pathogens and parasites is ruled out, typical his- jejuni: A common cause of diarrhea in Sweden. J Infect Dis 1980
Sep; 142:353-359
tologic evidence is obtained or classical findings 12. Cadranel S, Rodesch P, Butzler JP, et al: Enteritis due to
of ulcerative colitis or Crohn's disease are seen "related Vibrio" in children. Am J Dis Child 1973 Aug; 126:
152-155
in barium enema studies. The findings of leuko- 13. Vanhoof R, Vanderlinden MP, Dierickx R, et al: Suscepti-
bility of Campylobacter fetuts subsp. jejuni to twenty-nine anti-
cytes and blood in the feces, colitis with inflamed microbial agents. Antimicrob Agents Chemother 1978 Oct; 14:
553-556
friable mucosa on sigmoidoscopic examination,
and inflammatory reaction with crypt abscesses
and mucus depletion on histologic examination of
rectal biopsy specimens are similar to that of Refer to: Carr KW, Johnson AD, Gregoratos G: Transient bifas-
adult cases of Campylobacter colitis.7-'0 One 14- cicular block following blunt chest trauma. West J Med
1982 Sep; 137:245-249
year-old pediatric patient with similar pathologic
findings has been described who had a barium
enema study showing pancolitis; symptoms re-
solved after treatment with erythromycin.7 As Transient Bifascicular
suggested previously,7-'0 a first attack of "ulcera- Block Following Blunt
tive colitis" that does not later recur may in some
cases actually be an infectious disease caused by Chest Trauma
C jejuni.
Erythromycin proved to be an effective anti- KENNETH W. CARR, MD
microbial agent and is considered one of the drugs ALLEN D. JOHNSON, MD
of choice for treatment of Campylobacter infec- GABRIEL GREGORATOS, MD
tions. Relapses have not been reported to occur San Diego
after treatment with this medication.' Other anti-
biotics with high activity against C jejuni include ALTHOUGH CONDUCTION DEFECTS caused by blunt
gentamicin, chloramphenicol, furazolidone and chest trauma are probably not rare, well-docu-
the tetracyclines.13 mented cases have been reported infrequently.
In summary, two cases of chronic colitis caused Dolara and Pozzil in 1966 reviewed 23 cases of
by C jejuni are presented. Physicians caring for trauma-related atrioventricular (AV) block re-
children should consider Campylobacter entero- ported between 1912 and 1938. Only a few met
colitis in the differential diagnosis in infants with most or all of the following criteria: youthful age,
chronic diarrhea, especially if gross blood is absence of preexisting heart disease, great mag-
present in the feces. A sigmoidoscopic examina- nitude of injuring force, repolarization changes on
tion would be helpful in obtaining stool specimens electrocardiograms suggestive of associated myo-
for isolation of pathogenic organisms and for From the Division of Cardiology, Department of Medicine,
Veterans Administration Medical Center and University of Cali-
evaluating a patient with bloody diarrhea. How- fornia Medical Center, San Diego.
Submitted, revised, August 3, 1981.
ever, a fresh stool specimen is adequate for the Reprint requests to: Kenneth W. Carr, MD, Cardiology Sec-
tion, (111A), Veterans Administration Medical Center, 3350 La
diagnosis of C jejuni, if cultured appropriately. Jolla Village Drive, San Diego, CA 92161.

THE WESTERN JOURNAL OF MEDICINE 245