Case Presentation: A 70-year-old man with a history of adenoid cystic carcinoma initially presented with a 1-2 week history of olfactory and auditory hallucinations in the setting of intermittent fever. He reported that in addition to those symptoms he had diarrhea, which he attributed to having eaten undercooked meat. His auditory hallucinations involved hearing African tribal music emanating from a fan and hearing voices from a party. He also reported smelling rotting bodies. During his initial admission he was febrile and tachycardic. Workup included labs significant for mild leukocytosis, a negative Northeastern Tick Panel, a normal head CT, and an MRI brain showing a stable tiny vestibular schwannoma. Blood cultures were obtained and were pending at the time of discharge. Given a reassuring workup, despite failure of symptom resolution the patient was discharged. He re-presented when cultures from his initial admission grew Gram negative rods. A CT abdomen/pelvis with IV contrast was obtained due to concern for an intra-abdominal source and showed transverse and descending colon colitis. He was empirically started on ceftriaxone for Gram negative bacteremia, but when cultures ultimately grew C. jejuni he was transitioned to IV levofloxacin. Repeat blood cultures failed to clear and cultures and sensitivities ultimately revealed resistance to fluoroquinolones. He was transitioned to meropenem, quickly recovered, and was discharged home on oral doxycycline to complete a 7-day course of antibiotics. On follow-up with his PCP, he reported complete resolution of hallucinations and diarrheal symptoms.
Discussion: Campylobacter jejuni is one of the leading bacterial causes of diarrheal illness in the United States (1). The course of infection usually involves abdominal pain, diarrhea, fevers, and headache in the first 3-5 days, lasting up to two weeks. The most common complications are Guillain-Barré syndrome (GBS) and reactive arthritis. The mechanism by which GBS occurs involves molecular mimicry between lipo-oligosaccharides on Campylobacter and gangliosides on myelin and axons of peripheral nerves (2). Additionally, there exists in the literature reports of C. jejuni causing acute encephalopathy and acute disseminated encephalomyelitis (ADEM), but the pathogenesis of these complications is currently unknown (3-5). Campylobacter infections are typically treated with either macrolides or fluoroquinolones. However, resistance to quinolones has increased partly due to their indiscriminate use in the treatment of bacterial gastroenteritis and partly due to their use in the treatment of livestock (6). In this case, cultures were sensitive to both tetracyclines and erythromycin. However, given his bacteremia and neurologic symptoms, as well as resistance to fluoroquinolones, the decision was made to switch to meropenem and then complete the course with doxycycline once he improved clinically and cultures cleared.
Conclusions: While C. jejuni infections are well-known for causing GBS, rare cases of other neurologic complications have been recorded in the literature. It does not appear that presentation with isolated auditory or olfactory hallucinations has been reported until this time. Additionally, our case highlights the implications of fluoroquinolone resistance on treating Campylobacter bacteremia. Physicians should consider resistance patterns and antibiotic stewardship when treating both Campylobacter infections and other bacterial diarrheal illnesses.