Campylobacter jejuni infection associated with myopericarditis in adolescents: report of two cases

Myocarditis in a Pediatric Patient with Campylobacter Enteritis: A Case Report and Literature Review

Myocarditis represents a potential complication of various infectious and noninfectious agents and a common diagnostic challenge for clinicians. Data regarding Campylobacter-associated myocarditis are limited. Here, a case of a 13-year-old female with Campylobacter jejuni gastroenteritis complicated by myocarditis is presented, followed by a literature review in order to retrieve information about Campylobacter-associated carditis in the pediatric population. A search on MEDLINE/PubMed yielded 7relevant cases in the last 20 years. Most of them (six/seven) were males and the mean age was 16.1 years. All patients presented with gastrointestinal symptoms followed in six/seven cases by chest pain within two to seven days. Campylobacter was isolated from stool cultures in six patients; abnormal electrocardiographic findings were detected in six; and abnormal echocardiographic findings in three of the cases. Five patients were treated with antibiotics. Full recovery was the clinical outcome in six patients, whereas one patient died. Concerning the nonspecific symptoms of patients with myocarditis, high clinical suspicion of this complication is necessary in cases where patients with a recent infection present with chest pain and elevated cardiac biomarkers.

Epidemiologic and clinical profiles of bacterial myocarditis. Report of two cases and data from a pooled analysis

We aimed to characterize the epidemiology, diagnostic peculiarities and outcome determinants of bacterial myocarditis.

Two cases from our institution and literature reports were collected ending up with a total of 66 cases. In 37 (56%) patients, the diagnosis was confirmed by magnetic resonance and histopathological criteria. The other patients were classified as having possible myocarditis.

Only occurrence of rhythm disturbances was associated with the specific diagnosis of myocarditis (p = 0.04). Thirty-two (48%) patients presented with severe sepsis that was associated with a worse prognosis. At multivariate analysis, left ventricular ejection fraction (LVEF) at admission and heart rhythm disturbances were associated with incomplete recovery (odds ratio (OR) 1.1, 95% (CI) 1.03–1.2, p = 0.004 and OR 6.6, 95% CI 1.35–32.5, p = 0.02, respectively).

In summary, bacterial myocarditis is uncommon. Most commonly, it is secondary to septic dissemination of bacteria or to transient secondary myocardial toxicity.

Campylobacter jejuni-associated perimyocarditis: two case reports and review of the literature

Background

Campylobacter spp. are among the most common bacterial causes of gastroenteritis world-wide and mostly follow a benign course. We report two cases of Campylobacter jejuni-associated perimyocarditis, the first two simultaneous cases published to date and the third and fourth cases over all in Sweden, and a review of the literature.

Case presentation

A previously healthy 24-yo male (A) presented at the Emergency Department(ED) with recent onset of chest pain and a 3-day history of abdominal pain, fever and diarrhoea. The symptoms began within a few hours of returning from a tourist visit to a central European capital. Vital signs were stable, the Electrocardiogram(ECG) showed generalized ST-elevation, laboratory testing showed increased levels of C-reactive protein(CRP) and high-sensitive Troponin T(hsTnT). Transthoracic echocardiogram (TTE) was normal, stool cultures were positive for C Jejuni and blood cultures were negative. Two days after patient A was admitted to the ED his travel companion (B), also a previously healthy male (23-yo), presented at the same ED with almost identical symptoms: chest pain precipitated by a few days of abdominal pain, fever and diarrhoea. Patient B declared that he and patient A had ingested chicken prior to returning from their tourist trip. Laboratory tests showed elevated CRP and hsTnT but the ECG and TTE were normal. In both cases, the diagnosis of C jejuni-associated perimyocarditis was set based on the typical presentation and positive stool cultures with identical strains. Both patients were given antibiotics, rapidly improved and were fully recovered at 6-week follow up.

Conclusion

Perimyocarditis is a rare complication of C jejuni infections but should not be overlooked considering the risk of heart failure. With treatment, the prognosis of full recovery is good but several questions remain to be answered regarding the pathophysiology and the male preponderance of the condition.

Is there an unrecognised role for Campylobacter infections in (chronic) inflammatory diseases?

Campylobacter species are one of the major causes of global bacterial-related diarrheal disease worldwide. The disease is most frequently associated with the ingestion of contaminated meat, raw milk, pets, contaminated water, and the organism may be frequently cultured from the faeces of chicken and other domesticated farm animals. Of the 17 established Campylobacter species, the most important pathogens for humans are Campylobacter jejuni (C. jejuni), Campylobacter coli (C. coli) and Campylobacter fetus (C. fetus), which are all associated with diarrheal disease. Further, C. jejuni and C. coli are also associated with the neuroparalytic diseases Guillain-Barré syndrome and Miller Fischer syndrome, respectively, whereas C. fetus is linked with psoriatic arthritis. The discovery of both “molecular mimicry” and translocation-related virulence in the pathogenesis of C. jejuni-induced disease, indicates that Campylobacter-related gastrointestinal infections may not only generate localized, acute intestinal infection in the human host, but may also be involved in the establishment of chronic inflammatory diseases. Indeed, pathogenicity studies on several Campylobacter species now suggest that molecular mimicry and translocation-related virulence is not only related to C. jejuni, but may play a role in human disease caused by other Campylobacter spp. In this review, the authors provide a review based on the current literature describing the potential links between Campylobacter spp. and (chronic) inflammatory diseases, and provide their opinions on the likely role of Campylobacter in such diseases.

Myopericarditis in children: elevated troponin I level does not predict outcome

Myopericarditis is primarily a pericarditic syndrome with some degree of myocardial involvement, as evident by elevated cardiac enzymes. Differentiating myopericarditis from acute coronary syndromes can be challenging and may require coronary angiography or perfusion studies. Data on myopericarditis and its outcome for children are scarce. This study delineates the demography, clinical presentation, and outcomes of myopericarditis for children and evaluates the prognostic value of elevated troponin I. The authors retrospectively reviewed 880 patients younger than 18 years of age who were admitted with diagnoses of chest pain, myocarditis, or pericarditis between 2000 and 2010 at their institution. Myopericarditis was defined as a clinical presentation of pericarditis in the presence of elevated levels of cardiac enzymes. Medical records were reviewed to abstract the demographic data, clinical presentation, evaluation, treatment, and follow-up outcomes. A total of 12 patients (1.4%) with myopericarditis were identified. All the patients were male, 8 (67%) of whom were Caucasian, and their median age was 16 years (range, 11-17 years). Two of the patients (17%) had recently used illicit drugs, and two (17%) had recently smoked cigarettes. At presentation, symptoms included chest pain in 12 patients (100%, 12/12), upper respiratory symptoms in 3 patients (25%, 3/12), and shortness of breath in 3 patients (25%, 3/12). No cardiac murmur or gallop was noted in any patient. Electrocardiographic (ECG) changes included diffuse ST-T changes (5 patients), localized ST-T changes (6 patients), and no ST-T changes (1 patient). All the patients had elevated levels of cardiac enzymes, with a median Troponin I level of 21.4 ng/ml (range, 5.0-134.4 ng/ml) and a median CK-MB level of 50.2 ng/ml (range, 7-135 ng/ml). Echocardiography showed normal left ventricular systolic function in all the patients (median ejection fraction, 61%; range, 56-69%). None had pericardial effusion during the first echocardiographic evaluation. Coronary angiography showed normal coronary arteries in all nine subjects for whom it was performed. Treatment of myopericarditis consisted of ibuprofen, acetaminophen, and/or aspirin. During a median follow-up period of 2 months (range, 2 weeks to 3 years), all the patients were asymptomatic with echocardiography showing normal left ventricular size and function. Myopericarditis was exclusively seen in male adolescents. Despite markedly elevated levels of cardiac enzymes, the clinical evolution of myopericarditis seems benign without any myocardial dysfunction. The inflammatory involvement of the myocardium appears to be self-limited without short-term, overt sequelae. An elevated troponin I level in myopericarditis, unlike acute coronary syndromes, does not seem to carry an adverse prognosis. Further studies are needed to evaluate the long-term prognosis for such patients.