Refractory Clostridium difficile infection masking undiagnosed ulcerative colitis

Abstract

CASE: A 42-year-old Caucasian man presented with a two week history of watery diarrhea, bloating, and abdominal pain. He also reported an unintentional fifteen pound weight loss and fevers up to 103degree F. Initial laboratory studies showed a leukocytosis and microcytic anemia. Although initial stool evaluations were negative for Clostridium difficile toxins A and B, he was started on metronidazole for presumed infectious colitis. The patient's diarrhea persisted despite 8 days of antibiotics and a colonoscopy was performed which revealed severely ulcerated, inflamed, and friable mucosa from the rectum to the ascending colon with multiple areas of white exudate overlying the mucosa. While awaiting pathology, oral vancomycin was initiated for presumed pseudomembranous colitis resistant to metronidazole. A stool aspirate obtained during the colonoscopy was positive for Clostridium difficile toxin. His diarrhea changed from watery to bloody and he began experiencing crampy abdominal pain and tenesmus. Biopsies taken throughout the colon revealed severe acute and chronic inflammation with extensive ulceration, abundant exudates, and crypt abscesses, supporting a diagnosis of ulcerative colitis (UC) and Clostridium difficile colitis. The patient improved after seven days of oral vancomycin and IV solumedrol. Forty-eight hours after being discharged on oral steroids and oral vancomycin, he returned with worsening diarrhea. Therapy with IV solumedrol, mesalamine, and continued oral vancomycin resulted in improvement of his diarrhea. Five days later he was discharged on high dose oral steroids and vancomycin and will be followed in gastroenterology clinic. CONCLUSIONS: Clostridium difficile colitis can mimic and also precipitate an inflammatory bowel disease (IBD) flare. Not only do patients with IBD have a threefold increased rate of infection with C. difficile colitis, but they also have increased length of hospitalization, higher mortality rates and require colectomy more frequently than the average population. Treatment of C. difficile colitis in IBD patients is not clearly defined. Although decreased efficacy of metronidazole has been reported, it is still considered the first-line agent against mild to moderate C. difficile associated diarrhea. Patients with C. difficile colitis that is severe or unresponsive to therapy with metronidazole are treated with oral vancomycin. There is little data available in the literature to provide guidance for the treatment of patients who have ulcerative colitis complicated by infection with C. difficile. Successful treatment of our patient required oral vancomycin for severe C. difficile colitis as well as aggressive simultaneous treatment of his newly diagnosed UC. This case demonstrates the difficulty of diagnosing and treating UC in the presence of severe C. difficile colitis