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Jenvrin A, Perret A, Palmieri LJ, Soularue E, Broudin C, Rance B, Taieb J, Gallois C. Chemotherapy-induced ileitis associated or not with colitis in digestive oncology patients: An AGEO multicentre study. Dig Liver Dis 2023; 55:1426-1433. [PMID: 37045619 DOI: 10.1016/j.dld.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 02/06/2023] [Accepted: 03/07/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND The characteristics and management of ileitis induced by chemotherapy in cancer patients are poorly described in the literature. METHODS This retrospective multicentre study enroled patients hospitalized in a digestive oncology unit for a symptomatic chemotherapy-induced ileitis. RESULTS Forty-three patients were included, with a regimen based on fluoropyrimidine and/or irinotecan in 95% of cases. Five patients were excluded due to the diagnosis of infectious ileitis (Clostridium difficile in 3 patients, Campylobacter jejuni in 1 patient and cytomegalovirus in 1 patient). The most frequently described symptoms were diarrhoea (77% including 54% of grade 3-4 diarrhoea), abdominal pain (58%), fever (51%) and vomiting (56%). An ileo-colonoscopy was performed in 35% of patients and did not show any specific results or severity criteria. The ileitis was complicated by bowel perforation and/or obstruction in 3 patients. Disease progression was favourable in 1-2 weeks in the vast majority of cases, on symptomatic treatment, allowing resumption of the chemotherapy regimen involved in 67% of patients. CONCLUSION Chemotherapy-induced ileitis is a rare complication that most often involves fluoropyri-midine- and/or irinotecan-based regimens. In most cases, endoscopic examinations were not contributory and do not seem useful in the event of non-severe symptomatology which most often develops favourably on symptomatic therapy, allowing resumption of the chemotherapy involved.
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Affiliation(s)
- Anaïs Jenvrin
- Assistance Publique-Hôpitaux de Paris, Department of Gastroenterology and Digestive Oncology, Hôpital Européen Georges Pompidou, Paris, France
| | - Audrey Perret
- Department of Cancer Medicine, Gustave Roussy Cancer Campus, Villejuif, France
| | - Lola-Jade Palmieri
- Assistance Publique-Hôpitaux de Paris, Gastroenterology and Digestive Oncology Department, Cochin Hospital, Paris, France
| | - Emilie Soularue
- Institut Mutualiste Montsoutris, Department of Medical Oncology, Paris, France
| | - Chloé Broudin
- Paris University; Assistance Publique-Hôpitaux de Paris, Department of Pathology, Hôpital Européen Georges Pompidou, Paris, France
| | - Bastien Rance
- Université Paris Cité, Inserm, Centre de Recherche des Cordeliers; Assistance Publique-Hôpitaux de Paris, Department of Medical Bioinformatics, Hôpital Européen Georges Pompidou, Paris, France
| | - Julien Taieb
- Paris Cité University; Siric CARPEM; Assistance Publique-Hôpitaux de Paris, Department of Gastroenterology and Digestive Oncology, Hôpital Européen Georges Pompidou, Paris, France
| | - Claire Gallois
- Paris Cité University; Siric CARPEM; Assistance Publique-Hôpitaux de Paris, Department of Gastroenterology and Digestive Oncology, Hôpital Européen Georges Pompidou, Paris, France.
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Tah S, Khan S, Kashyap S. Uncommon Presentation of Clostridioides difficile in the Small Bowel: A Case Report and Review of Literature. Cureus 2023; 15:e43460. [PMID: 37711949 PMCID: PMC10498804 DOI: 10.7759/cureus.43460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2023] [Indexed: 09/16/2023] Open
Abstract
Clostridioides difficile infection (CDI) is a prevalent source of hospital-acquired diarrhea. The most common presentation of CDI is colitis. In cases of fulminant colitis/toxic megacolon, a colectomy and end ileostomy are part of the treatment plan. There is evidence to suggest that it may be beneficial to surgically treat severe complex CDI by constructing a loop ileostomy for fecal stream diversion followed by colonic lavage, also referred to as the Pittsburgh protocol, which has demonstrated decreased death rates in this patient population. In our case study, we present a rare case of a 60-year-old female patient diagnosed with fulminant small bowel CDI requiring resection of the necrotic small bowel. This was followed by creating an ileostomy and the Pittsburgh protocol, leading to a complete recovery. With an increasing incidence of CDI, it is important to be aware of the small bowel C. difficile infection and its treatment.
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Affiliation(s)
- Sunanda Tah
- Surgery, Saint James School of Medicine, Arnos Vale, VCT
- Surgery, Beckley Appalachian Regional Healthcare (ARH) Hospital, Beckley, USA
| | - Saqib Khan
- Surgery, Avalon University School of Medicine, Willemstad, CUW
- Surgery, Beckley Appalachian Regional Healthcare (ARH) Hospital, Beckley, USA
| | - Sarang Kashyap
- Surgery, Beckley Appalachian Regional Healthcare (ARH) Hospital, Beckley, USA
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Klimko A, Tieranu CG, Curte AM, Preda CM, Tieranu I, Olteanu AO, Ionescu EM. Clostridioides Difficile Enteritis: Case Report and Literature Review. Antibiotics (Basel) 2022; 11:antibiotics11020206. [PMID: 35203809 PMCID: PMC8868300 DOI: 10.3390/antibiotics11020206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 01/28/2022] [Accepted: 02/02/2022] [Indexed: 12/10/2022] Open
Abstract
Background: Clostridioides Difficile is a well-known pathogen causing diarrhea of various degrees of severity through associated infectious colitis. However, there have been reports of infectious enteritis mainly in patients with ileostomy, causing dehydration through high-output volume; Case presentation: We report the case of a 46-year-old male patient, malnourished, who presented with high-output ileostomy following a recent hospitalization where he had suffered an ileo-colic resection with ileal and transverse colon double ostomy, for stricturing Crohn’s disease. Clostridioides Difficile toxin A was identified in the ileal output confirming the diagnosis of acute enteritis. Treatment with oral Vancomycin was initiated with rapid reduction of the ileostomy output volume; Conclusion: We report a case of Clostridioides Difficile enteral infection as a cause for high-output ileostomy, successfully treated with oral Vancomycin. We also review the existing literature data regarding this specific localized infection.
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Affiliation(s)
- Artsiom Klimko
- Division of Physiology and Neuroscience, “Carol Davila” University of Medicine and Pharmacy, 050747 Bucharest, Romania;
| | - Cristian George Tieranu
- Department of Gastroenterology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.M.P.); (A.O.O.); (E.M.I.)
- Department of Gastroenterology, “Elias” Emergency University Hospital, 011461 Bucharest, Romania
- Correspondence: ; Tel.: +40-765-490-005
| | - Ana-Maria Curte
- Department of Pathology, “Elias” Emergency University Hospital, 011461 Bucharest, Romania;
| | - Carmen Monica Preda
- Department of Gastroenterology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.M.P.); (A.O.O.); (E.M.I.)
- Department of Gastroenterology, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Ioana Tieranu
- Department of Pediatrics, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Andrei Ovidiu Olteanu
- Department of Gastroenterology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.M.P.); (A.O.O.); (E.M.I.)
- Department of Gastroenterology, “Elias” Emergency University Hospital, 011461 Bucharest, Romania
| | - Elena Mirela Ionescu
- Department of Gastroenterology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.M.P.); (A.O.O.); (E.M.I.)
- Department of Gastroenterology, “Elias” Emergency University Hospital, 011461 Bucharest, Romania
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4
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Singla A, Pash D. Diarrhea or No Diarrhea, It Still Hurts: An Atypical Case of Clostridioides difficile. Cureus 2020; 12:e9900. [PMID: 32850262 PMCID: PMC7444969 DOI: 10.7759/cureus.9900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Clostridioides difficile (C. difficile) is a common nosocomial infection that is classically described as profuse watery diarrhea in hospitalized patients after antibiotic use. We present a case of a 76-year-old female who presented to our emergency room with diffuse abdominal pain after consuming meals. This patient had completed treatment with oral vancomycin for C. difficile infection two weeks prior to admission and had been asymptomatic until this point. After receiving treatments for presumed acute mesenteric ischemia did not yield clinical improvement, polymerase chain reaction for C. difficile stool antigen was tested and was positive. While the patient did not have diarrhea, the classical feature of C. difficile infection, she quickly improved after treatment with oral vancomycin.
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Clostridioides difficile Enteritis Induced Anastomotic Rupture: A Case Report and Literature Review. Case Rep Surg 2020; 2020:9794823. [PMID: 32607274 PMCID: PMC7313094 DOI: 10.1155/2020/9794823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 03/23/2020] [Accepted: 06/11/2020] [Indexed: 12/04/2022] Open
Abstract
Background. A 76-year-old male patient who suffered small bowel anastomotic dehiscence believed to be a complication provoked by Clostridioides difficile enteritis. Case Presentation. The patient was a 76-year-old male who underwent small bowel resection with primary anastomosis for a small bowel obstruction. On postoperative day #7, he rapidly decompensated and upon return to the operating room was found to have complete anastomotic dehiscence with copious enteric spillage. The presentation appeared as if the staple line had burst open. Enteric contents confirmed the diagnosis of Clostridioides difficile enteritis. Subsequent hospital course was complicated by ventilatory-dependent respiratory failure, hemodynamic instability, and persistent anemia secondary to gastric ulcer requiring endoscopic cauterization. After a prolonged hospital course, he eventually progressed and was transferred to a skilled nursing facility on hospital day #42. Discussion. Clostridioides difficile causes inflammation and copious large volume secretions that would theoretically increase intraluminal pressures creating an internal tension. This tension along with other factors from the infection itself would likely be inhibitory of anastomotic healing. Although it is rare, Clostridioides difficile enteritis is being reported with increasing frequency, and in the setting of recent small bowel anastomosis, it should be considered a possible risk factor for anastomotic leak.
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6
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Engevik MA, Danhof HA, Chang-Graham AL, Spinler JK, Engevik KA, Herrmann B, Endres BT, Garey KW, Hyser JM, Britton RA, Versalovic J. Human intestinal enteroids as a model of Clostridioides difficile-induced enteritis. Am J Physiol Gastrointest Liver Physiol 2020; 318:G870-G888. [PMID: 32223302 PMCID: PMC7272722 DOI: 10.1152/ajpgi.00045.2020] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Clostridioides difficile is an important nosocomial pathogen that produces toxins to cause life-threatening diarrhea and colitis. Toxins bind to epithelial receptors and promote the collapse of the actin cytoskeleton. C. difficile toxin activity is commonly studied in cancer-derived and immortalized cell lines. However, the biological relevance of these models is limited. Moreover, no model is available for examining C. difficile-induced enteritis, an understudied health problem. We hypothesized that human intestinal enteroids (HIEs) express toxin receptors and provide a new model to dissect C. difficile cytotoxicity in the small intestine. We generated biopsy-derived jejunal HIE and Vero cells, which stably express LifeAct-Ruby, a fluorescent label of F-actin, to monitor actin cytoskeleton rearrangement by live-cell microscopy. Imaging analysis revealed that toxins from pathogenic C. difficile strains elicited cell rounding in a strain-dependent manner, and HIEs were tenfold more sensitive to toxin A (TcdA) than toxin B (TcdB). By quantitative PCR, we paradoxically found that HIEs expressed greater quantities of toxin receptor mRNA and yet exhibited decreased sensitivity to toxins when compared with traditionally used cell lines. We reasoned that these differences may be explained by components, such as mucins, that are present in HIEs cultures, that are absent in immortalized cell lines. Addition of human-derived mucin 2 (MUC2) to Vero cells delayed cell rounding, indicating that mucus serves as a barrier to toxin-receptor binding. This work highlights that investigation of C. difficile infection in that HIEs can provide important insights into the intricate interactions between toxins and the human intestinal epithelium.NEW & NOTEWORTHY In this article, we developed a novel model of Clostridioides difficile-induced enteritis using jejunal-derived human intestinal enteroids (HIEs) transduced with fluorescently tagged F-actin. Using live-imaging, we identified that jejunal HIEs express high levels of TcdA and CDT receptors, are more sensitive to TcdA than TcdB, and secrete mucus, which delays toxin-epithelial interactions. This work also optimizes optically clear C. difficile-conditioned media suitable for live-cell imaging.
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Affiliation(s)
- Melinda A. Engevik
- 1Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas,2Department of Pathology, Texas Children’s Hospital, Houston, Texas
| | - Heather A. Danhof
- 3Alkek Center for Metagenomic and Microbiome Research, Baylor College of Medicine, Houston, Texas,4Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas
| | | | - Jennifer K. Spinler
- 1Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas,2Department of Pathology, Texas Children’s Hospital, Houston, Texas
| | - Kristen A. Engevik
- 3Alkek Center for Metagenomic and Microbiome Research, Baylor College of Medicine, Houston, Texas,4Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas
| | - Beatrice Herrmann
- 1Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas,2Department of Pathology, Texas Children’s Hospital, Houston, Texas
| | - Bradley T. Endres
- 5Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas
| | - Kevin W. Garey
- 5Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas
| | - Joseph M. Hyser
- 1Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas,2Department of Pathology, Texas Children’s Hospital, Houston, Texas
| | - Robert A. Britton
- 3Alkek Center for Metagenomic and Microbiome Research, Baylor College of Medicine, Houston, Texas,4Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas
| | - James Versalovic
- 1Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas,2Department of Pathology, Texas Children’s Hospital, Houston, Texas
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7
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The Impact of pH on Clostridioides difficile Sporulation and Physiology. Appl Environ Microbiol 2020; 86:AEM.02706-19. [PMID: 31811041 DOI: 10.1128/aem.02706-19] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 12/03/2019] [Indexed: 12/18/2022] Open
Abstract
Clostridioides difficile is a pathogenic bacterium that infects the human colon to cause diarrheal disease. Growth of the bacterium is known to be dependent on certain bile acids, oxygen levels, and nutrient availability in the intestine, but how the environmental pH can influence C. difficile is mostly unknown. Previous studies indicated that C. difficile modulates the intestinal pH, and prospective cohort studies have found a strong association between a more alkaline fecal pH and C. difficile infection. Based on these data, we hypothesized that C. difficile physiology can be affected by various pH conditions. In this study, we investigated the impact of a range of pH conditions on C. difficile to assess potential effects on growth, sporulation, motility, and toxin production in the strains 630Δerm and R20291. We observed pH-dependent differences in sporulation rate, spore morphology, and viability. Sporulation frequency was lowest under acidic conditions, and differences in cell morphology were apparent at low pH. In alkaline environments, C. difficile sporulation was greater for strain 630Δerm, whereas R20291 produced relatively high levels of spores in a broad range of pH conditions. Rapid changes in pH during exponential growth impacted sporulation similarly among the strains. Furthermore, we observed an increase in C. difficile motility with increases in pH, and strain-dependent differences in toxin production under acidic conditions. The data demonstrate that pH is an important parameter that affects C. difficile physiology and may reveal relevant insights into the growth and dissemination of this pathogen.IMPORTANCE Clostridioides difficile is an anaerobic bacterium that causes gastrointestinal disease. C. difficile forms dormant spores which can survive harsh environmental conditions, allowing their spread to new hosts. In this study, we determine how intestinally relevant pH conditions impact C. difficile physiology in the two divergent strains, 630Δerm and R20291. Our data demonstrate that low pH conditions reduce C. difficile growth, sporulation, and motility. However, toxin production and spore morphology were differentially impacted in the two strains at low pH. In addition, we observed that alkaline environments reduce C. difficile growth, but increase cell motility. When pH was adjusted rapidly during growth, we observed similar impacts on both strains. This study provides new insights into the phenotypic diversity of C. difficile grown under diverse pH conditions present in the intestinal tract, and demonstrates similarities and differences in the pH responses of different C. difficile isolates.
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Matsuda K, Hashiguchi Y, Tsukamoto M, Ohno K, Okada Y, Yagi T, Fukushima Y, Horiuchi A, Shimada R, Ozawa T, Hayama T, Tsuchiya T, Tamura J, Iinuma H, Nozawa K, Sasajima Y, Kondo F. A case report of successful management of fulminant Clostridium difficile colitis post-ileostomy reversal with administration of vancomycin through a transverse colostomy. Surg Case Rep 2019; 5:181. [PMID: 31776700 PMCID: PMC6881489 DOI: 10.1186/s40792-019-0744-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 10/30/2019] [Indexed: 11/15/2022] Open
Affiliation(s)
- Keiji Matsuda
- Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan.
| | - Yojiro Hashiguchi
- Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Mitsuo Tsukamoto
- Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Kohei Ohno
- Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Yuka Okada
- Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Takahiro Yagi
- Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Yoshihisa Fukushima
- Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Atsushi Horiuchi
- Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Ryu Shimada
- Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Tsuyoshi Ozawa
- Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Tamuro Hayama
- Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Takeshi Tsuchiya
- Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Junko Tamura
- Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Hisae Iinuma
- Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Keijiro Nozawa
- Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Yuko Sasajima
- Department of Pathology, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Fukuo Kondo
- Department of Pathology, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
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9
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Abstract
We report an atypical case of Clostridium difficile (C.difficile) infection in a 35-year male who presented to the hospital because of diffuse abdominal pain associated with nausea and vomiting. Patient denied diarrhea or hematochezia. On physical examination, he was afebrile, but tachycardic and hypotensive. Abdominal examination revealed mild diffuse tenderness without signs of peritonitis. Lab work up was significant for leucocytosis and elevated serum lactate. Computed tomography (CT) of the abdomen and pelvis with intravenous (IV) contrast was done with findings suggestive of enteritis. Initial work up did not reveal any source of infection, so he was treated with broad-spectrum antibiotics for severe sepsis of unknown origin. Broad-spectrum antibiotics were continued for two days without significant improvement in signs and symptoms; stool studies were obtained which showed positive C.difficile on polymerase chain reaction (PCR) after which oral vancomycin was started and IV antibiotics were stopped. The patient's signs and symptoms improved after a couple of days of oral vancomycin and he was discharged home to complete a 14-day course of oral vancomycin.
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Affiliation(s)
- Haisam Abid
- Internal Medicine, Bassett Medical Center, Cooperstown, USA
| | - Edward Bischof
- Internal Medicine, Bassett Medical Center, Cooperstown, USA
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10
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Clostridium difficile Enteritis after Total Abdominal Colectomy for Ulcerative Colitis. Case Rep Crit Care 2019; 2019:2987682. [PMID: 30863646 PMCID: PMC6378043 DOI: 10.1155/2019/2987682] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Revised: 01/03/2019] [Accepted: 01/17/2019] [Indexed: 01/29/2023] Open
Abstract
Introduction Isolated Clostridium difficile small bowel enteritis is a rare condition with significant morbidity and mortality. Presentation of Case An 83-year-old female with refractory ulcerative colitis underwent a total proctocolectomy and end ileostomy. Her postoperative course was complicated with return to the operating room for repair of an incarcerated port site hernia. Subsequently, she developed septic shock and multiorgan failure requiring intubation and mechanical ventilation, renal replacement therapy, and high dose vasopressors. Diagnostic workup revealed diffuse small bowel wall thickening on computed tomography scan as well as positive nucleic acid amplification test for C. difficile toxin B gene. Despite treatment with antibiotics and maximum attempts at resuscitation, the patient expired. Discussion. C. difficile infection most commonly affects the colon but rarely can involve the small bowel. The pathogenesis of C. difficile enteritis is unclear but is believed to mirror that of colitis. Surgical patients are susceptible for C. difficile infection, as they tend to be relatively immunosuppressed in the postoperative period. Radiologic findings of enteritis may mimic those of colitis and this includes small bowel dilation and thickening. Treatment for this condition has not been well established but it is approached similar to colitis. Conclusion Despite an increase in the number of case reports of C. difficile enteritis, it continues to be a rare but potentially fatal infection. Clinicians should maintain a high index of suspicion especially in patients with inflammatory bowel disease who undergo colon resections.
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11
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Akiyama Y, Sasaki A, Endo F, Nikai H, Amano S, Umemura A, Baba S, Chiba T, Kimura T, Takahara T, Nitta H, Otsuka K, Mizuno M, Kimura Y, Koeda K, Iwaya T. Outcomes of esophagectomy after chemotherapy with biweekly docetaxel plus cisplatin and fluorouracil for advanced esophageal cancer: a retrospective cohort analysis. World J Surg Oncol 2018; 16:122. [PMID: 29966526 PMCID: PMC6027574 DOI: 10.1186/s12957-018-1420-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 06/22/2018] [Indexed: 02/08/2023] Open
Abstract
Background Docetaxel, cisplatin, and 5-fluorouracil (DCF) therapy can cause severe adverse events, including neutropenia and febrile neutropenia. The feasibility of DCF therapy is a concern, particularly for elderly patients, patients with moderate organ disorders, and patients suffering from malnutrition caused by dysphagia or insufficient oral intake. We introduced a biweekly DCF therapy (bDCF) for the purpose of reducing severe adverse events for these fragile patients. This study investigated the feasibility and outcome of an esophagectomy after bDCF therapy for patients with advanced esophageal squamous cell carcinoma. Methods Fifty-nine patients with esophageal carcinoma underwent an esophagectomy after DCF or bDCF therapy as primary chemotherapy. DCF was administered to 37 patients in the DCF group, whereas bDCF was administered to 22 patients in the bDCF group. Results Patients in the bDCF group were significantly older than those in the DCF group (p = 0.016). Heart and pulmonary comorbidities were significantly more common in the bDCF than in the DCF group (p < 0.001 and p = 0.039, respectively). Grade 3 or 4 neutropenia was less frequent in the bDCF than in the DCF group (40.9 vs. 81.1%, p = 0.002). Anorexia was more frequent in the DCF group than in the bDCF group (18.9 vs. 0%, p = 0.030). The clinical response rate of the bDCF group was significantly higher than that of the DCF group (86.4 vs. 62.2%, p = 0.047). There was no significant between-group difference in the postoperative morbidity rate (bDCF 45.5% vs. DCF 32.4%) or in the histological therapeutic effect. Conclusion The results demonstrate that primary bDCF therapy for high-risk patients with advanced esophageal cancer is feasible and safe in both chemotherapeutic and perioperative periods without a reduction in the efficacy of DCF therapy.
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Affiliation(s)
- Yuji Akiyama
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan.
| | - Akira Sasaki
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan
| | - Fumitaka Endo
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan
| | - Haruka Nikai
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan
| | - Satoshi Amano
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan
| | - Akira Umemura
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan
| | - Shigeaki Baba
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan
| | - Takehiro Chiba
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan
| | - Toshimoto Kimura
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan
| | - Takeshi Takahara
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan
| | - Hiroyuki Nitta
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan
| | - Koki Otsuka
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan
| | - Masaru Mizuno
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan
| | - Yusuke Kimura
- Department of Palliative Medicine, Iwate Medical University School of Medicine, Morioka, Iwate, Japan
| | - Keisuke Koeda
- Department of Medical Safety Science, Iwate Medical University School of Medicine, Morioka, Iwate, Japan
| | - Takeshi Iwaya
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan
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12
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Siddiqui J, Campion T, Wei R, Kuzmich S. Clostridium difficile enteritis: diffuse small bowel radiological changes in a patient with abdominal sepsis. BMJ Case Rep 2018; 2018:bcr-2017-222209. [PMID: 29374636 DOI: 10.1136/bcr-2017-222209] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
While imaging appearances of pseudomembranous colitis are commonly recognised, radiological manifestations of Clostridium difficile-associated enteritis are poorly understood which, combined with the rarity of this infection involving small bowel, makes establishing the correct diagnosis challenging. Therefore, in order to encourage awareness of readers, we present a case of C. difficile enteritis that manifested as abdominal sepsis complicating the postoperative period in a middle-aged woman with fistulating Crohn's disease and defunctioning ileostomy. Radiological appearances are described based on three consecutive CT studies performed 5 days prior to onset of symptoms, during the peak of enteritis, corresponding with the patient's clinical deterioration, and also 35 days later following treatment and resolution.
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Affiliation(s)
| | | | - Rui Wei
- Imaging Department, Barts Health NHS Trust, London, UK
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Kochhar G, Edge P, Blomme C, Wu XR, Lopez R, Ashburn J, Shen B. Clostridium difficle Enteropathy Is Associated With a Higher Risk for Acute Kidney Injury in Patients With an Ileostomy-A Case-Control Study. Inflamm Bowel Dis 2018; 24:402-409. [PMID: 29361091 DOI: 10.1093/ibd/izx034] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is traditionally considered a colon-affecting disease with frequent pseudomembrane formation. However, multiple case reports have documented the existence of CDI in the small bowel, and the literature on outcome of C difficile enteropathy (CDE) is sparse. The aims of our study are to identify risk factors and to assess patient-related outcomes associated with CDE. METHODS This is a case-control study involving 112 patients at our tertiary care center. Patients with an ileostomy who tested positive for C difficile toxins were assigned to the study group (n = 34). The control group included patients with an ileostomy who tested negative for the C difficile toxins (n = 78). Via chart review, we collected data on baseline characteristics, laboratory values, potential risk factors, and outcome measures. RESULTS Patients in the study and control groups were comparable in baseline and laboratory characteristics. In univariate analysis, CDE was associated with a history of smoking (hazard ratio [HR], 2.1; 95% confidence interval [CI], 1.06-4.3; P = 0.034), the presence of alcohol use (HR, 3.7; 95% CI, 1.05-12.8; P = 0.042), and older median age at the time of ileostomy (HR, 1.2; 95% CI, 1.07-1.3; P = 0.001). In multivariate analysis, no significant association between established CDI risk factors (eg, prior exposure to antibiotics and the use of proton pump inhibitors or histamine 2 receptor blockers) and the risk for the CDE was found. Only a history of alcohol intake was found to be associated with CDE (HR, 3.9; 95% CI, 1.09-14.1; P = 0.036). No significant difference in mortality was found in the study and control groups (2.9% vs 1.3%, P = 0.52), but patients with CDE were more likely to have acute kidney injury (AKI) than those without CDE (odds ratio, 4.0; 95% CI, 1.2-13.0. P = 0.023). CONCLUSIONS We identified a history of alcohol use a risk factor for CDE. Furthermore, CDE was found be associated with an increased risk for developing AKI.
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Affiliation(s)
- Gursimran Kochhar
- Department of Gastroenterology and Hepatology, the Cleveland Clinic Foundation, Cleveland, Ohio
| | - Preston Edge
- Department of Gastroenterology and Hepatology, the Cleveland Clinic Foundation, Cleveland, Ohio
| | - Courtney Blomme
- Department of Gastroenterology and Hepatology, the Cleveland Clinic Foundation, Cleveland, Ohio
| | - Xian-Rui Wu
- Department of Colorectal Surgery, the Cleveland Clinic Foundation, Cleveland, Ohio
| | - Rocio Lopez
- Department of Quantitative Sciences, the Cleveland Clinic Foundation, Cleveland, Ohio
| | - Jean Ashburn
- Department of Colorectal Surgery, the Cleveland Clinic Foundation, Cleveland, Ohio
| | - Bo Shen
- Department of Gastroenterology and Hepatology, the Cleveland Clinic Foundation, Cleveland, Ohio
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15
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Khan SA, Towheed A, Tul Llah S, Bin Abdulhak A, Tilson-Mallett NR, Salkind A. Atypical Presentation of C. Difficile Infection: Report of a Case with Literature Review. Cureus 2016; 8:e563. [PMID: 27190728 PMCID: PMC4859815 DOI: 10.7759/cureus.563] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Clostridium difficile (C. difficile) is a gram-positive, obligate, anaerobic spore-forming bacillus first reported by Hall and O'Toole in 1935. It occurs mostly after antibiotic use and invariably presents with watery diarrhea. We describe an atypical presentation of C. difficile in a 64-year-old Caucasian female who presented to the our emergency department with abdominal pain, nausea, and vomiting for one day. A complete blood count revealed leukocytosis 30 x 109/L and a subsequent computed tomography (CT) scan of the abdomen and the pelvis, showed fluid filled small bowel loops consistent with enteritis. Her presentation was unusual for lack of diarrhea, the hallmark of C. difficile infection. She was admitted and treated with oral vancomycin. The polymerase chain reaction (PCR) value in the stool for C. difficile was positive. The patient responded very well: her abdominal pain resolved and leukocyte count normalized after a few doses of vancomycin (125 mg po qid). The patient's progress was followed in our clinic for the last three months.
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Affiliation(s)
- Salman A Khan
- Department of Internal Medicine, University of Missouri-Kansas City
| | - Arooge Towheed
- Department of Medicine, School of Medicine, University of Missouri-Kansas City
| | - Sibghat Tul Llah
- Department of Medicine, School of Medicine, University of Missouri-Kansas City
| | - Aref Bin Abdulhak
- Department of Medicine, School of Medicine, University of Missouri-Kansas City
| | | | - Alan Salkind
- Department of Internal Medicine, University of Missouri-Kansas City
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16
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Bouza E, Del Vecchio MG, Reigadas E. Spectrum of Clostridium difficile infections: Particular clinical situations. Anaerobe 2015; 37:3-7. [PMID: 26700883 DOI: 10.1016/j.anaerobe.2015.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 12/07/2015] [Accepted: 12/12/2015] [Indexed: 02/08/2023]
Abstract
Incidence, pathogenesis, diagnostic techniques and therapeutic management of CDI have prompted abundant and adequate recent literature. However, report on clinical manifestations of CDI is frequently biased by the type of patients selected, the retrospective nature of many papers, the epidemic or endemic characteristics of the population reported. This article seeks to review some less discussed clinical and epidemiological aspects of CDI trying to include the clinical manifestations of this disease in unselected populations and also including discussion of CDI in specific groups of patients such as patients without colon and rectum, pediatric and critical care patients.
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Affiliation(s)
- Emilio Bouza
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid (UCM), Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES CD06/06/0058), Madrid, Spain.
| | - Marcela González Del Vecchio
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid (UCM), Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Elena Reigadas
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid (UCM), Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.
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17
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Two Patients with Fulminant Clostridium difficile Enteritis Who Had Not Undergone Total Colectomy: A Case Series and Review of the Literature. Case Rep Surg 2015; 2015:957257. [PMID: 26682082 PMCID: PMC4670630 DOI: 10.1155/2015/957257] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 11/01/2015] [Accepted: 11/02/2015] [Indexed: 01/04/2023] Open
Abstract
Introduction. Clostridium difficile is the most common cause of healthcare associated infectious diarrhea, and its most common clinical manifestation is pseudomembranous colitis. Small bowel enteritis is reported infrequently in the literature and typically occurs only in patients who have undergone ileal pouch anastomosis due to inflammatory bowel disease or total abdominal colectomy for other reasons. Presentation of Cases. We report here two cases in which patients developed small bowel C. difficile enteritis in the absence of these underlying conditions. Discussion. Neither patient had underlying inflammatory bowel disease and both had a significant amount of colon remaining. Conclusion. These two cases demonstrate that small bowel C. difficile enteritis should be included in the differential diagnosis of patients on antibiotic therapy who demonstrate signs and symptoms of worsening abdominal disease during their postoperative course, even if they lack the major predisposing factors of inflammatory bowel disease or history of total colectomy.
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Thai H, Guerron AD, Bencsath KP, Liu X, Loor M. Fulminant Clostridium difficile enteritis causing abdominal compartment syndrome. Surg Infect (Larchmt) 2015; 15:821-5. [PMID: 24824419 DOI: 10.1089/sur.2013.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Clostridium difficile infection of the small bowel, or C. difficile enteritis (CDE), is an uncommon condition. Cases reported previously have been described in patients with inflammatory bowel disease (IBD), compromised immune systems, or a history of colectomy or small bowel surgery. CASE DESCRIPTION We present a case of fulminant CDE causing abdominal compartment syndrome following a routine outpatient inguinal hernia repair. This patient developed multiple organ failure dysfunction syndrome requiring surgical abdominal decompression and a small bowel resection. This case highlights the challenges in the diagnosis of CDE, particularly in patients with intact colons and unusual presentations. DISCUSSION A high index of suspicion is required, as early recognition of CDE is essential in reducing morbidity and mortality. This case report is followed by a review of the current literature on CDE, with a focus on the complexities inherent in the identification of this problem and the decision-making process for surgical intervention.
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Affiliation(s)
- Hue Thai
- 1 Department of General Surgery, Cleveland Clinic , Cleveland, Ohio
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19
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Almerie MQ, Culverwell A, Mahon C. Clostridium difficile infection after ileostomy closure mimicking anastomotic leak. BMJ Case Rep 2015; 2015:bcr-2015-210112. [PMID: 26150639 DOI: 10.1136/bcr-2015-210112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Clostridium difficile infection is linked to antibiotic exposure, with elderly and immunocompromised hospitalised patients being particularly at risk. The symptoms range from mild diarrhoea to life-threatening fulminant colitis. We describe an unusual presentation of C. difficile infection after closure of ileostomy in a healthy 60-year-old man with a history of low anterior resection and defunctioning ileostomy for rectal tumour. On the third day postoperatively, the patient developed left lower abdominal pain and profuse diarrhoea. With worsening symptoms and steadily increasing inflammatory markers over the following few days, concerns were raised about an anastomotic leak with pelvic abscess. CT of the abdomen/pelvis on day 7 surprisingly showed colitis in the neorectum/sigmoid colon. A stool test confirmed C. difficile infection.
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Affiliation(s)
| | - Adam Culverwell
- Department of Radiology, Harrogate District Hospital, Harrogate, UK
| | - Christopher Mahon
- Department of General Surgery, Harrogate District Hospital, Harrogate, UK
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Gupta A, Patel R, Baddour LM, Pardi DS, Khanna S. Extraintestinal Clostridium difficile infections: a single-center experience. Mayo Clin Proc 2014; 89:1525-36. [PMID: 25245597 DOI: 10.1016/j.mayocp.2014.07.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 07/07/2014] [Accepted: 07/21/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVES To evaluate the clinical burden of extraintestinal Clostridium difficile infection (CDI) seen at a single institution and to characterize the management and outcomes of these rare infections. PATIENTS AND METHODS A retrospective medical record review was conducted to identify patients with isolation of C difficile from extraintestinal sites from January 1, 2004, through December 31, 2013. Medical records were reviewed and data, including demographic characteristics, microbiology, clinical associations, management, and infection outcomes, were abstracted. RESULTS Overall, 40 patients with extraintestinal CDI were identified: 25 had abdominopelvic infections, 11 had bloodstream infections, 3 had wound infections, and 1 had pulmonary infection. C difficile was isolated with other organisms in 63% of cases. A total of 85% of infections were nosocomial. Factors associated with extraintestinal CDI included surgical manipulation of the gastrointestinal tract (88%), recent antibiotic exposure (88%), malignant tumors (50%), and proton pump inhibitor use (50%). Diarrhea was present in 18 patients (45%), 12 of whom had C difficile polymerase chain reaction (PCR)-positive stool samples. All isolates tested were susceptible to metronidazole and piperacillin-tazobactam. Management included both antimicrobial therapy and guided drainage or surgical intervention in all but one patient. The infection-associated mortality rate was 25%, with death a median of 16 days (range, 1-61 days) after isolation of C difficile. CONCLUSION Extraintestinal CDI is uncommon and often occurs in patients with surgical manipulation of the gastrointestinal tract and well-recognized risk factors for intestinal CDI. Management of extraintestinal CDI includes both antimicrobial and surgical therapies. Extraintestinal CDI is characterized by poor outcome with high mortality.
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Affiliation(s)
- Arjun Gupta
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Robin Patel
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN; Division of Clinical Microbiology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Larry M Baddour
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Darrell S Pardi
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Sahil Khanna
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN.
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