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Case 6: The Surprising Christmas Party

Mr and Mrs Orrhoea share everything. However, when they both awoke one morning 7 days before
Christmas with Diarrhoea & Vomitting, they thought it a bit much. The husband, Rhyn, had a headache
and seemed to be experiencing a mild fever. His wife, Di, also felt feverish and had both abdominal pain
and aching joints. They decided to make an appointment with their GP.
Upon examination, Dr Runns finds that both Rhyn and Di have a temperature (38 and 38.5 respectively)
with pain and tenderness in the right lower abdominal quadrant. Dr Runns suspects food poisoning. He
provides Rhyn and Di Orrhoea each with a sample pot to collect a stool sample and a specimen card
requesting routine microbiology analysis. He asks whether their symptoms have lasted longer than a week
and if the symptoms are becoming more severe. As the answer to both these questions was no Dr Runns
does not prescribe any treatment at this time, but they are advised to drink plenty of water and over-thecounter rehydration drinks are recommended. They are told that antibiotics may be administered later
dependent upon the laboratory results or if their symptoms persist or deteriorate.
After 4 days they are called back in to see their GP and are told that the microbiology department has
cultured Campylobacter organisms. Further, their specimen had been passed on to the Food, Water and
Environmental (FWE) laboratory that had further identified Campylobacter jejuni. The couple were asked
how they were feeling and both reported that their fever and aches and pains had disappeared, the
vomiting had stopped and the diarrhoea was now mild (<twice per day) and improving. The Orrhoeas ask
the doctor where they may have picked-up the infection, as they have concerns over a meal that they ate at
a Christmas party a couple of weeks previously: others attending the meal had experienced similar
symptoms.
Dr Runns informs them that C. jejuni infection can be associated with undercooked poultry and
unpasteurised milk products. He explains that the infection is usually self-limiting and that their symptoms
were typical of C. jejuni.
Dr Runns informs them that the FWE laboratory has notified the faculty of Public Health Medicine of a
possible C. jejuni outbreak and that the couple should expect a letter or visit from an Environmental Health
Officer (EHO).
Case 6 the surprising Christmas party.
Symptoms
Rhyn

Di

headache
seemed to be experiencing a mild fever
38C

feverish
abdominal pain
aching joints
38.5 C

Diarrhoea
Vomiting
pain and tenderness in the right lower abdominal quadrant
symptoms less than a week
symptoms are not becoming more severe
4 days later:
Campylobacter jejuni cultivated from stool sample
fever and aches and pains had disappeared,
the vomiting had stopped
the diarrhoea was now mild (<twice per day) and improving

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Gastroenteritis is a common condition where the stomach and intestines become inflamed. It is usually
caused by a viral or bacterial infection.
(Source: http://www.nhs.uk/Conditions/Gastroenteritis/Pages/Introduction.aspx)

Campylobacter jejuni- a food-borne pathogen generally associated with faecal contamination of food or
water is a common cause of bacterial enteritis.
Key points:

Spirally shaped, flagellate bacteria.

Small, Gram-negative rods.
Single flagellum at one or both poles. High mobility.
Oxidase and catalase tests positive.
Carbohydrate test negative.
80-85% human campylobacter infections.
Recovery: 3-7 days.
Do not multiply in food. explosive food-poisoning outbreaks are rare.
Colonize mucous membranes and penetrate mucous with particular facility.
The jejunum and ileum colonized the first. Extend distally. The colon and rectum infected.
Symptoms usually evident within 7 days.
The generally self-limiting clinical presentation includes:
o Acute abdominal pain,
o Diarrhoea: Likely to result from:
The production of toxins cytolethal distending toxin (blocks the cell cycle of host
cells).
Disruption of the intestinal mucosa due to cell invasion. inflammatory response.
o Vomiting.
Well-developed infection:
o Mesenteric lymph nodes are enlarged, fleshy and inflamed.
o Transient bacteraemia.
Disruption of glycosylation pathways in C. jejuni affects host cell invasion and intestinal
colonization. Extensive glycosylation may reflect molecular mimicry of host epitopes as part of a
strategy to avoid host immune responses.
Immune response:
o Humoral antibodies appear after 10 days.
o Peak in 2-4 weeks. *seriously?? Different than in the case*
o Most antibodies IgG.
o Healthy person exposed to repeated infection shows a progressive increase in IgA.
Substantial immunity.
o Mild watery diarrhoea or even asymptomatic colonization, may result in increased level of
immunity and/or development of tolerance from repeated infections.
Examination of mucosa shows:
o Acute neutrophil response Mesenteric lymph nodes are enlarged.
o Oedema.
o Sometimes superficial ulceration.
Antibiotic treatment required in severe cases.
Clinical features of campylobacter enteritis:

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o
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Average incubation period - 3days. Range 1-7 days.

Start with abdominal pain, diarrhoea, or an influenza-like prodrome of fever, aching and
sometimes with rigors and sweating.
o Abdominal pain and diarrhoea the main symptoms. Caused by the bacterial infection of the
stomach and bowel.
o Watery diarrhoea. Prostration.
o Leukocytes in the faeces.
o Frank blood in the faeces may appear.
o Cannot be distinguished clinically from salmonella or shigella infection.
o The immune response against the C. jejuni may result in an autoimmune reaction against
the hosts own tissues. After 1-2 weeks:
Aseptic arthritis:
Affects ankles, knees, wrists.
Self-limiting.
Affects 1-2% of patients.
Guillain-Barre syndrome:
Affects 1 out of 1000 patients per year.
May cause serious and fatal paralysis.
Antibodies cross-react with the myelin in nerve sheaths, causing
demyelination.
Nearly 30% cases related to C. jejuni.
Diagnosis:
o Incubation at 42-43oC rapid growth of C. jejuni.
o Incubation for 48h.
o Isolation of campylobacters from faeces requires selective culture to inhibit competing faecal
flora.
o Charcoal-based blood-free agar containing bile acids is used as a selective culture.
o Isolation by a membrane inoculation (laid on non-selective media). C. jejuni small
enough to swim through the membrane, which is removed before incubation.
Sources and transmission:
o Animal hosts -direct contact with farm and domestic animals.
o Raw or inadequately pasteurized milk.
o Untreated water.
o Raw or undercooked meat and poultry
o Possible transmission from flies.
(Source: Greenwood, D., Barer, M., Slack, R., Irving, W., (2012). Medical Microbiology. 7th ed.
London: Churchill Livingstone)

Diarrhoea -loose or watery stools at least three times a day. Blood/ mucus can appear in the stools
with some infections.

Signs of dehydration:
o thirst,
o less frequent urination than normal,
o dark-coloured urine,
o dry skin,
o fatigue,
o light-headedness,
o inability to sweat Headache,
o muscular cramps,

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Sunken eyes.

Symptoms of severe dehydration in adults include:

o Weakness.
o Confusion.
o Rapid heart rate.
o Coma.
o A greatly reduced amount of urine that you make.
(Source: http://www.webmd.com/digestive-disorders/diarrhea-10/prevent-dehydration
http://www.patient.co.uk/health/acute-diarrhoea-in-adults-leaflet)

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Investigation:
o Haematology
FBC a folate- and B12- deficient megaloblastic anaemia.
o Biochemistry
Serum, calcium, phosphate may reveal biochemical osteomalacia.
Serum albumin may be low.
o Microbiology
Stool examination.
o Histopathology
Small bowel biopsies suggest the diagnosis by showing inflamed mucosa with partial
villous atrophy.
(Source: Axford, J., OCallaghan, C.,(2004). Medicine. 2nd ed.Oxford: Blackwell Publishing)

Fever present due to inflammation. See: immunity notes.

A very restricted range of the upper physiological temperatures supports the activation of
resting lymphocytes for proliferation and effector formation in the two major limbs of the
immune system, cell-mediated immunity and humoral immunity. (Source:
http://www.ncbi.nlm.nih.gov/pubmed/9100921).
Headaches. Why???
What other test is necessary be carried on?
Cannot be distinguished clinically from salmonella or shigella infection. Why????