FULMINANT PSEUDOMEMBRANOUS COLITIS

Kagie, Scott
Medical College of Wisconsin, Milwaukee, WI

LEARNING OBJECTIVES
Diagnosis of C. difficile colitis in patients with other gastrointestinal diseases requires a high index of suspicion and may sometimes be missed. Patient education and compliance are crucial to prevent poor outcomes.

Labs: WBCs: 18,100/cu mm Stool C. difficile NAAT: Positive. Imaging: Abdominal CT revealed pancolitis but no free air. (Figure 1)

She again tested positive for C. difficile Received oral vancomycin and IV metronidazole. Her abdomen was soft but more tender than before. On day 2 of admission her abdominal pain and diarrhea worsened significantly and an abdominal KUB was obtained. (Figure 2) Surgery was consulted She underwent total colectomy with end colostomy. Her condition improved after surgery, and the rest of her hospital stay was uneventful.

CASE
We describe the case of a 45-year-old woman with celiac disease who presented with diarrhea, vomiting, abdominal pain, laryngitis, rhinitis, and fever. General practitioner started zanamivir for likely influenza infection. The next day her symptoms worsened and she was referred to the emergency room due to dehydration and an acutely tender abdomen.
Figure 1. Figure 2. Characteristic appearance of C. difficile on CT scan, microscopy, and endoscopy.4,5

Pertinent History: She had not been strictly adhering to a gluten-free diet. She had recently undergone treatment with cephalexin for a toenail infection She was also exposed to sick contacts through her employment at an assisted living facility.
Examination: Abdomen : Soft, but tender in the periumbilical region with guarding.

HOSPITAL COURSE
She received 1 day of IV hydration, oral vancomycin, and anti-emetics. She was discharged home on metronidazole. Recovered to her baseline over the next 3 days.

DISCUSSION
C. difficile is a spore-forming Gram-positive rod which produces 2 exotoxins (A and B) . More virulent strains also produce binary toxin.1 Typically causes infections in the setting of antibiotic use and immunosuppression. It is believed that alterations in the normal flora caused by antibiotics and immune dysfunction allow C. difficile competitive and selective advantage in the gut flora.

Exposure to the bacteria at the time of antibiotic use is not always necessary due to its presence in the normal flora of 2-5% of the general population and 20-50% of those in long term care.2 The clinical presentation can range from a few days of mild diarrhea to life-threatening pseudomembranous colitis. Although C. difficile is a well-known cause of diarrhea, diagnosis in patients with other gastrointestinal diseases may sometimes be missed.3 Patient education and compliance are crucial to prevent poor outcomes

REFERENCES
1. 2. Bartlett JG. Narrative review: the new epidemic of Clostridium difficile-associated enteric disease. Ann Intern Med 2006; 145:758. Riggs MM, Sethi AK, Zabarsky TF, et al. Asymptomatic carriers are a potential source for transmission of epidemic and nonepidemic Clostridium difficile strains among long-term care facility residents. Clin Infect Dis 2007; 45:992 Kyne L, Sougioultzis S, McFarland LV, Kelly CP. Underlying disease severity as a major risk factor for nosocomial Clostridium difficile diarrhea. Infect Control Hosp Epidemiol 2002; 23:653. Thoeni RF, Cello JP. CT Imaging of Colitis. Radiology 2006; 240:623-638. Limaye AP, Turgeon DK, Cookson BT, Fritsche TR. Pseudomembranous colitis caused by a toxin A(-) B(+) strain of Clostridium difficile. J Clin Microbiol 2000; 38:1696.

3.

She had a recurrence of her symptoms 11 days later and was readmitted.

4. 5.