Charles Dac Pham1, Duong Tommy Hua2. 1. Division of Hospital Medicine, Department of Medicine, Harbor-UCLA Medical Center, 1000 West Carson Street, Torrance, CA, 90502, USA. cpham@dhs.lacounty.gov. 2. Division of Hospital Medicine, Department of Medicine, Harbor-UCLA Medical Center, 1000 West Carson Street, Torrance, CA, 90502, USA.
Abstract
BACKGROUND: Clostridium difficile (C. difficile) is a common cause of infectious colitis in individuals with prior antibiotic or hospital exposure. Extraintestinal manifestations of C. difficile infections, however, are rare. Here we present a case of C. difficile appendicitis in an immunocompromised patient. CASE PRESENTATION: A 53-year-old Caucasian male presented to the emergency room for two days of lower abdominal pain associated with nausea and subjective fevers. He otherwise denied having diarrhea or hematochezia. He did not have any recent hospitalizations, nursing home stays, or antibiotic exposure. His past medical history was notable for stage III tonsillar squamous cell carcinoma for which he was status post tonsillectomy, radiation therapy, and chemotherapy (cisplatin 4 days prior to presentation). He was afebrile with tenderness to palpation in the bilateral lower quadrants, right greater than left. His white blood cell (WBC) count was 15.6 × 103 cells/μL. Computed tomography (CT) of the abdomen and pelvis showed marked edema and inflammation of the cecum and ascending colon as well as an enlarged appendix with surrounding inflammatory changes with a small amount of free fluid in the right paracolic gutter. He was treated non-surgically with antibiotics. He did not clinically improve and on hospital day 3, he developed diarrhea for which C. difficile stool polymerase chain reaction was sent. Repeat CT of the abdomen and pelvis was performed which showed progression to pan-colitis and persistent appendicitis. C. difficile testing later resulted positive, for which oral vancomycin was started. The patient markedly improved with medical management alone and was subsequently discharged on oral vancomycin. CONCLUSIONS: Our case highlights the importance of maintaining a high index of suspicion for C. difficile in a patient presenting with both appendicitis and colitis, with prompt diagnosis and treatment being essential.
BACKGROUND:Clostridium difficile (C. difficile) is a common cause of infectious colitis in individuals with prior antibiotic or hospital exposure. Extraintestinal manifestations of C. difficileinfections, however, are rare. Here we present a case of C. difficile appendicitis in an immunocompromised patient. CASE PRESENTATION: A 53-year-old Caucasian male presented to the emergency room for two days of lower abdominal pain associated with nausea and subjective fevers. He otherwise denied having diarrhea or hematochezia. He did not have any recent hospitalizations, nursing home stays, or antibiotic exposure. His past medical history was notable for stage III tonsillar squamous cell carcinoma for which he was status post tonsillectomy, radiation therapy, and chemotherapy (cisplatin 4 days prior to presentation). He was afebrile with tenderness to palpation in the bilateral lower quadrants, right greater than left. His white blood cell (WBC) count was 15.6 × 103 cells/μL. Computed tomography (CT) of the abdomen and pelvis showed marked edema and inflammation of the cecum and ascending colon as well as an enlarged appendix with surrounding inflammatory changes with a small amount of free fluid in the right paracolic gutter. He was treated non-surgically with antibiotics. He did not clinically improve and on hospital day 3, he developed diarrhea for which C. difficile stool polymerase chain reaction was sent. Repeat CT of the abdomen and pelvis was performed which showed progression to pan-colitis and persistent appendicitis. C. difficile testing later resulted positive, for which oral vancomycin was started. The patient markedly improved with medical management alone and was subsequently discharged on oral vancomycin. CONCLUSIONS: Our case highlights the importance of maintaining a high index of suspicion for C. difficile in a patient presenting with both appendicitis and colitis, with prompt diagnosis and treatment being essential.
Authors: L Clifford McDonald; Dale N Gerding; Stuart Johnson; Johan S Bakken; Karen C Carroll; Susan E Coffin; Erik R Dubberke; Kevin W Garey; Carolyn V Gould; Ciaran Kelly; Vivian Loo; Julia Shaklee Sammons; Thomas J Sandora; Mark H Wilcox Journal: Clin Infect Dis Date: 2018-03-19 Impact factor: 9.079
Authors: G Martirosian; M Bulanda; B Wójcik-Stojek; P Obuch-Woszczatyński; G Rouyan; P Heczko; F Meisel-Mikołajczyk Journal: Med Sci Monit Date: 2001 May-Jun
Authors: Fernanda C Lessa; Yi Mu; Wendy M Bamberg; Zintars G Beldavs; Ghinwa K Dumyati; John R Dunn; Monica M Farley; Stacy M Holzbauer; James I Meek; Erin C Phipps; Lucy E Wilson; Lisa G Winston; Jessica A Cohen; Brandi M Limbago; Scott K Fridkin; Dale N Gerding; L Clifford McDonald Journal: N Engl J Med Date: 2015-02-26 Impact factor: 91.245
Authors: Thomas A Brown; Lakshmi Rajappannair; Arthur B Dalton; Ram Bandi; Joseph P Myers; Costas H Kefalas Journal: Clin Gastroenterol Hepatol Date: 2007-07-10 Impact factor: 11.382