3054 Getting to the Bottom of Incessant Diarrhea

Abstract

INTRODUCTION: Clostridium difficile infection (CDI) is a common cause of recurrent diarrhea. Up to 35% of patients experience recurrent infection after initial therapy. Patients with recurrent CDI are occasionally treated empirically with antibiotics. There has been an increase in recurrence in CDI over recent years. In fact, there is a 50-60% chance of a repeat recurrence. Persistent diarrhea is also caused by microscopic colitis, which occurs 7.9 per 100,000 person years. It has been associated with the use of NSAIDs and proton-pump inhibitors (PPI). We present a case of a patient with recurrent CDI who was eventually diagnosed with microscopic colitis. CASE DESCRIPTION/METHODS: A 41-year-old male with a history for DM type 1, renal failure, GERD presented with persistent diarrhea for the past 5 years. His temperature was 98.3 F, HR 87 bpm, BP 123/89 mmHg, and RR was 20 per minute. Physical exam was unremarkable. Laboratory studies were insignificant. CT with contrast was negative for any pathologies. Initial stool testing was negative for CDI. A colonoscopy with biopsy was performed which showed no abnormal findings. He was treated with IV fluids and loperamide. His symptoms persisted and repeat stool was positive for Clostridium difficile toxin. According to guidelines at the time of presentation, he was started on metronidazole and his PPI was discontinued. His symptoms resolved over 48-72 hours and he was discharged. Two weeks later, he presented again with CDI and was treated with oral vancomycin and discharged. He presented with diarrhea 2 months later and was treated empirically with metronidazole, showing minimal to no improvement of his symptoms. Stool studies were negative for Clostridium difficile toxin. A repeat colonoscopy with biopsy showed lymphocytic infiltrates within the colonic mucosa, confirming the diagnosis of lymphocytic microscopic colitis. He was started on budesonide with a good clinical response and was discharged. Follow-up at our clinic showed near-resolution of his symptoms. DISCUSSION: Recurrent diarrhea is a bothersome symptom. Our patient's microscopic colitis was overshadowed by his history of CDI. He was treated empirically for CDI, exposing him to antibiotics and delaying appropriate treatment. Antibiotics may create iatrogenic consequences such as antibiotic resistance. Clinicians must be aware that patients with history of recurrent CDI may have other underlying etiologies for persistent diarrhea.