Clinical Cases
Nicolas Sultano1,2; Catalina Poggi1; Carolina Diego1; Felipe Higuera1; Esteban González Salazar1
1.Hospital Italiano de Buenos Aires, Argentina
2.mail de contacto: sultano@hospitalitaliano.org.ar
This work is an original unpublished contribution, which has not been sent for publication to any other media outlet. Fulminant colitis is a severe form of acute colitis with mortality rates up to 80%. Over the last years, the prevalence and severity of CD has increased. The case we introduce clearly shows the macroscopic injuries and swelling of the gut caused by CD. Additionally, the colon is very dilated due to Chagas disease. Fulminant colitis is an infrequent condition, and early diagnosis and treatment could prevent fatal outcomes.
Abstract
Fulminant colitis caused by Clostridiodes difficile is characterized by the development of acute inflammation in the colon, which is associated to systemic toxicity, and is a serious form of acute colitis with mortality rates up to 80%. We introduce the case of a 45 year-old man who sought medical attention at the emergency service due to acute abdominal pain, diharrea and fever. Computer tomography imaging showed a diffuse colon wall thickening, including the rectum, accompanied by the striation of nearby tissues and ganglionar formations. In the next few hours the patient's state deteriorated severely, and his requirement for inotropics and lactic acidosis increased. An emergency laparoctomy and a total colectomy were carried out. Fulminant colitis caused by Clostridiodes difficile is a potentially fatal disease. The lability of this disease forces quick responses, and should be considered a medical and surgical emergency in which time is crucial.
Keywords: colitis; clostridium difficile; enterocolitis pseudomembranosa.
Abstract
Clostridiodes difficile´s fulminant colitis is characterized by the development of severe acute inflammation of the colon, associated with systemic toxicity. Fulminant colitis is a serious form of acute colitis with a mortality of up to 80%. We present the case of a 45-year-old man who presented to the emergency department with acute abdominal pain, diarrhea and fever. Computed tomography showed circumferential diffuse parietal thickening of the colon, including the rectum, associated with striation of the surrounding tissues and ganglionic formations. In the following hours the patient evolved with worsening of the general condition, increased inotropic requirements and lactic acidosis. Emergency laparotomy was decided and total colectomy was performed. Fulminant Clostridiodes difficile colitis is a potentially deadly disease. The lability of the pathology in many occasions forces quick decision making, therefore fulminant colitis represents a medical surgical emergency being time crucial.
Keywords: colitis; clostridium difficile; pseudomembranous.
Resumo
A colite fulminante por Clostridiodes difficile é caracterizada pelo desenvolvimento de inflamação aguda grave do cólon, associada a toxicidade sistêmica. A colite fulminante é a forma grave de colite aguda, com mortalidade de até 80%.
Apresentamos o caso de um homem de 45 anos que deu entrada no serviço de urgência por dor abdominal aguda, astenia e náuseas. A tomografia computadorizada mostrou espessamento parietal circunferencial difuso do cólon, incluindo o reto, associado a estriação dos tecidos circundantes e formações ganglionares.
Nas horas seguintes evoluiu com piora do estado geral, aumento da necessidade de inotrópicos e acidose lática. Foi decidida laparotomia de emergência e realizada colectomia total. A colite fulminante por Clostridiodes difficile é uma doença potencialmente mortal. A labilidade da patologia em muitas ocasiões obriga a um comportamento rápido e o paciente com colite fulminante representa uma emergência médico-cirúrgica sendo o tempo cirúrgico crucial.
Palavras chave: colite; clostridium difficile; enterocolite pseudomembranosa.
Clostridiodes difficile (CD) is a Gram positive anaerobic bacillus which is able to form spores. It is present in 20% to 40% of hospitalized patients. Fulminant colitis is the most severe form of acute colitis and has mortality rates of up to 80%.
We highlight the case of a patient with a history of liver transplant and pseudomembranous colitis. We consider immunosuppressed patients are fertile ground for the most severe forms of this disease. Given this complication is rare and rigurous studies are scarce, we consider it necessary to report this case, in order to contribute relevant observations and experience to the diagnosis and treatment of this disease.
Fulminant colitis due to Clostridiodes difficile (CD) is characterized by the development of acute inflammation of the colon, accompanied by systemic inflammation. 20% to 40% of hospitalized patients are colonized by this bacteria, and fulminant colitis is the most severe form of acute colitis, with mortality rates up to 80% (1)(2). We introduce the case of a 45-year old man with a history of chagasic megacolon who required a liver transplant due to alcoholic cirrhosis three months prior, and sought emergency medical treatment due to acute abdominal pain, diharrea and fever.
This is a high mortality condition that requires intensive medical care and early surgery in cases that do not respond to treatment (3)(4).
A 45 year-old man is hospitalized due to acute abdominal pain, asthenia and nausea which developed during the last 48 hours. His medical history included Chagas with colonic involvement and alcoholic hepatic chirrosis that required an orthotopic hepatic transplant three months prior to the development of symptoms and had a torpid postop. 19 days after transplant he experienced diarrhea with GDH and positive CD toxin, given which he was prescribed 125mg of oral Vancomicine every 6 hs for ten days. 22 days after the transplant he presented with an asymptomatic reactivation of chronic Chagas, with 49 parasytes/ml as measured by quantitative Polymerase Chain Reaction (parasyte load), for which he was prescribed Benznidazol for 60 days, and deteriorated rapidly. Then, after 30 days he newly required medical attention due to the reactivation of colitis with positive CD toxin, for which he was given vancomicine with tapering . During postop his kidney function deteriorated and he required hemodialysis three times per week.
Upon being hospitalized, he explained he had experienced abdominal distension for months, which he believed were functional in origin and did not require a specific medical treatment. He was under immunosuppressive treatment: meprednisone 12 mg/day and tacrolimus 5 mg/12 hs.
Physical examination revealed he had 90/60 mmHg arteril pressure; heartrate and respiratory rate 146 per minuto and 16 per minute, respectively. Abdominal signs revealed mild distenson, associated to generalized pain, with voluntary defense, without signs of peritoneal reaction.
Lab studies showed total leukocytes of 98.700 mm3 (80% segmented neutrophils, 10% band neutrophils , 10% monocytes), 10.4 g/dl hemoglobin, 31.5 % hematocrit, 237.300/mm3 platellets, 7.5 mg/dL creatinine, ph 7.27, pco2 3, lactacidemia 2.22 mmol/L. Blood culture were negative and GDH and CD toxin were positive (antigen and CD toxin).
We carried out pelvic and abdominal computed tomography studies which revealed diffuse wall thickening in the colon and rectum, accompanied by striation in nearby tissues and adenomegalia. These findings were indicative of an infectious process affecting the colon (Figure 1).
During the fllowing hours, the patient's general state worsened, and his requirements for inotropes and lactic acidosis increased. Orotracheal intubation was carried out, crystalloids were administered for plasma expansion and it was decided that surgical intervention was required, given the patient's state.
Surgical exploration showed the colon was very dilated, had no peristaltic movements, the colon walls had edema, and there was aboundant free fluid, which was consistent with pancolitis. We carried out total colectomy and terminal ileostomy. Given the patient's critical state, it was decided that closing the abdominal wall should be put off, and the abdomen was left open and connected to a continual aspiration system. 48-hours later we carried out a programmed surgical reeexploration and the abdominal wall was closed. The dried piece showed findings consistent with pseudomembranous pancolitis (Figure 2).
During postop, the patient's state developed favorably. Leukocyte counts returned to normal values, his general condition improved, and he was discharged from hospital after a lengthy stay (30 days). Histopathological examination of the dried colon showed mucous tissues had areas with glandular detachment, eroded surface and pseudomembranes adjacent to the chorion, which are common signs of colitis caused by CD. In the myenteric plexus we observed hypoganglionosis, which was more pronounced near the distal end, which was consistent with his medical history.
CD is an anaerobic gram positive spore-forming bacillus, which can produce exotoxins and cause pseudomembranous colitis in susceptible patients.
CD is a common cause of acute diarrhea after the transplant of solid organs, together with norovirus, citomegalovirus and other pathogens. There is evidence that its incidence and morbimortality are higher in most subgroups of immunosuppressed patients. In a metaanalysis of 30 studies published between 1991 and 2014, over a population totalling 21 683 patients who underwent solid organ transplants, recurrence was higher than in the general population, the prevalence of severe colitis was 5.3 times greater and the prevalence of colectomy due to severe colitis was 2.7 times higher as compered to the general population (5). In over 49 198 cases of solid organ transplant, ICD patients had mortality rates that were three times higher, more prolonged stays, higher costs, more graft complications and higher need for colectomy, as compared to the population without transplants (6).
The incidence of CD was higher in solid organ transplants varies based on the transplanted organ: it is es
lower in kidney transplants (0.77% a 11.3%), intermediate in heart transplants (1.23% a 8%), and higher in lung and liver transplants (0.63%-19%
and 1.93-22.9%, respectively) (7). Almost all infections occur during the first 30 days after transplant. Around 2% to 3% of healthy adults, 20% to 40% of hospitalized patients and up to 70% of healthy infants are colonized by CD (8)(9).
In the pathogeny of CD, one of the main mechanisms involved is the alteration of microflora in the small intestine and the colon due to the use of antibiotics. Disease can show up in different forms, depending on the patient's immunity. While some patients remain asymptomatic carriers, others can develop severe colitis or fulminant colitis.
Clinical manifestations are usually absent in asymptomatic carriers; however, in symptomatic patients, manifestations go from mild diarrhea to hypotension, shock, and multi-organ failure. Fast and accurate diagnosis is possible using laboratory studies with an adequate level of sensitivity and abdominal imaging. PCR tests for CD toxin have high sensitivity and and high specificity.
Computer tomography can show thickened walls, rarefied adipose tissues nearby, colon frame dilation, and in some cases even the rectum, as in the case of our patient.
The goals of treatment include reducing the risk of colon perforation, managing changes in internal medium and correcting factors that trigger systemic effects. General treatment includes basic systemic support with fluids, electrolytes (mainly potassium and magnesium) and a close clinical and surgical vigilance. Based on guidelines by the American College of Gastroenterology, proper treatment requires ceasing and prescribing initial medical treatment for (10).
nasogastric tube or via retention enema, during 10 days (BIII).
Fulminant colitis caused by CD is defined as a severe infection complicated by systemic inflammatory response syndrome that does not respond to medical treatment, causing multi-organ failure and imminent death when there is no surgery. The severity of this condition, in many cases, requires haste, and fulminant colitis is a medical and surgical emergency in which time is crucial to reduce mortality (11). Surgical treatment can be either subtotal colectomy or terminal ileostomy. (12)
Summarizing, this case study reports an infrequent but potentially deadly complication in a patient diagnosed with fulminant colitis by CD. We stress the need for quick diagnosis, for putting general support measures in place early, and provinding eventual surgical treatment in selected cases. The decision to carry out an urgency colectomy is largely based on observation, on how experienced surgeons are, and is the result of interdisciplinary work. Considering the low frequency of fuliminant colitis surgery and the lack of rigurous studies with large samples, we deem it necessary to contribute to general knowledge of this potentially deadly complication.
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Responsibility for this work lies exclusively with those who collaborated in conducting this study.
None.
The present work did not receive any funding
This article contains original work exclusively and has not been sent for publication to any other scientific media outlet, nor in partial nor in total form.
Those who participated in conducting this study grant authorship rights to Universidad Nacional de Córdoba for publication in Revista de la Facultad de Ciencias Médicas and translation into english.
All authors participated in the design and conduction of this study, collected data and helped in writing the manuscript, and claim responsibility for its content and the contents and approve its final version.
Obra derivada: Traducción del artículo "Colitis fulminante por Clostridiodes difficile en paciente con antecedentes de trasplante de hígado: una complicación potencialmente mortal", escrito por Poggi et al, publicada en Rev Fac Cien Med Univ Nac Cordoba. 2023; 80 (1), realizada por la Revista de la Facultad de Ciencias Médicas de Córdoba
This derivative work is a translation of the article "Colitis fulminante por Clostridiodes difficile en paciente con antecedentes de trasplante de hígado: una complicación potencialmente mortal", authored by Poggi et al, published in Rev Fac Cien Med Univ Nac Cordoba. 2023; 80 (1), produced by Revista de la Facultad de Ciencias Médicas de Córdoba
Recibido: 2022-05-08 Aceptado: 2022-06-27
DOI: http://dx.doi.org/10.31053/1853.0605.v80.n1.37579
https://creativecommons.org/licenses/by-nc/4.0/
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