SESSION TYPE: Critical Care Student/Resident Cases
PRESENTED ON: Monday, October 22, 2012 at 01:45 PM - 03:00 PM
INTRODUCTION: The incidence of Clostridium Difficile (an anaerobic spore forming bacillus) infection has been increasing in frequency and severity worldwide. This has been associated with a hypervirulent strain B1/NAP/027, increasing use of broad spectrum antibiotics & advancing age.1, 2, 3
CASE PRESENTATION: A 75 year old black male with no history of recent antibiotic use or C. difficile, presented to the ER with a 3 day history of mild abdominal pain & diarrhea. Abdominal CT scan revealed severe pancolonic wall thickening. He was treated with intravenous fluids, morphine and discharged, but returned 3 days later with worsening abdominal pain & hematochezia. Exam revealed tachycardia, a distended tympanitic abdomen with voluntary guarding, but no rebound tenderness. Labs now showed albumin 2.0; WBC count = 22.6; lactate= 4.9, creatinine = 2.0. Repeat abdominal CT scan showed increased pancolonic thickening, pericolonic inflammation & free fluid. C. difficile toxin assay was positive. A diagnosis of C. difficile pancolitis was made and therapy begun with IV flagyl, PO & rectal vancomycin. His condition worsened & on day 5, he was taken to the operating room for a total abdominal colectomy with ileostomy (TAC). Pathology revealed transmural colitis with perforation. His post op course was complicated by an ischemic stroke & pulmonary embolism and he was discharged to rehab after a 3 month stay.
DISCUSSION: Fulminant clostridium difficile colitis (FCDC) is rare, with 3-8% of C. difficile infections progressing to FCDC.2 Classification by expert opinion of the Society for Healthcare Epidemiology of America & the Infectious Diseases Society of America, define severe disease as an increase in serum creatinine >50% above baseline & a WBC >15,000. TAC is the current standard of care for patients unresponsive to medical therapy. While no validated severity scoring system exists to aid in the diagnosis of FCDC or timing of TAC, timely emergency surgery has been shown to reduce mortality.1 Mortality rates for TAC remain high (34-80%),2 with various studies showing that: age (>65 yrs), elevated WBC, increased lactate, acute renal failure, low albumin, and vasopressor requirements pre-op correlate with an increased mortality.1, 2, 3
CONCLUSIONS: Mortality rates for FCDC unresponsive to medical therapy approach 100%.2 If there is no improvement with medical therapy within 24-72hrs, prompt surgical therapy should be obtained.2
1) Lamontagne F, Labbe AC, et al. Impact of emergency colectomy on survival of patients with fulminant Clostridium difficile colitis during an epidemic caused by a hypervirulent strain. Ann Surg 2007: 245: 267-72.
2) Jaber MR, Olafsson S, et al. Clinical review of the management of fulminant Clostridium difficile. Am J Gastroenterol 2008; 103: 3195-3203.
3) Pepin J, Vo TT, et al. Risk factors for mortality following emergency colectomy for fulminant Clostridium difficile. Dis Colon Rectum 2009 Mar; 52(3): 400-405.
DISCLOSURE: The following authors have nothing to disclose: Olakitan Ketiku, Richard Okafor
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