Fatal Fulminant Clostridium difficile Colitis in an Immunosuppressed Individual

Clostridium difficile infection (CDI) is one of the most common nosocomial infections with close to half a million cases occurring in United States annually. It has substantial morbidity with up to 2.5% of patients requiring colectomy and mortality rates of up to 16%. We here present a very impressive case of rapidly progressing and ultimately fatal- severe complicated CDI in a relatively young hospitalized patient. A 53-yearold woman with comorbidities of HIV- AIDS, seizure disorder, congestive heart failure presented with diarrhea, dyspnea, productive cough and fever of 101oF. Patient had a pertinent history of two preceding episodes of CDI that were treated with intravenous (I.V) metronidazole and peroral (P.O) vancomycin. Physical examination revealed a febrile patient with hypotension and a diffusely tender abdomen. Initial laboratory values were significant for severe metabolic acidosis (pH-7.11), anemia (Hemoglobin-8.1gm/dL), leukocytosis (18.7 k/μL), elevated serum creatinine (1.7 mg/dL) and hypoalbuminemia (2.3 gm/dL). Computerized tomography (CT) scan of abdomen showed severe pancolitis with surrounding mesenteric infiltration and ascites (Figure-1). Patient had positive stool C. difficile toxin assay. Patient was diagnosed with severe complicated CDI and was started on P.O and rectal vancomycin (500mg every 6 hours); and I.V metronidazole (500mg every 8 hours). Patient had transient improvement over the next five days but had sudden deterioration with hypotension requiring vasopressor support and worsened leukocytosis (70 k/ μL). Patient underwent an emergent laparotomy with colectomy. Specimens revealed a markedly dilated colon (13cm in maximal circumference) with tan-red, granular and edematous mucosa covered by patchy yellow-green friable membrane-like material- giving a polypoid appearance (Figure-2). Histology was consistent with pseudomembranous colitis. Patient unfortunately had progressive worsening of acidosis and multiorgan dysfunction ultimately resulting in her death. Unfortunately this case, though not unique, serves as a stark reminder of the significant morbidity and mortality involved with CDI in spite of aggressive therapy- especially in an immunosuppressed individual. A practicing physician should be acutely aware of emerging hypervirulent strains, novel risk factors that have been identified. The importance of basic preventive measures such as hand washing and food preparation safety cannot be over-emphasized.Figure 1Figure 2