A Case of Recurrent Clostridium difficile Enteritis Treated With Fecal Microbiota Transplant

Abstract

Introduction:Clostridium difficile enteritis (CDE) is a rare but increasingly recognized disease. Risk factors for CDE include gastrointestinal surgery, antibiotic use, and immunosuppression. Case Report: A 38-year-old man with autoimmune alopecia presented with bloody diarrhea and severe abdominal pain. He had 4 self-limited episodes of mild abdominal pain and non-bloody diarrhea in the past 2 years, and had completed several courses of antibiotics for presumed gastroenteritis. He denied NSAID use. On exam, he had diffuse abdominal tenderness with voluntary guarding. Laboratory evaluation revealed WBCs of 15.8 x 10ˆ9/L and abdominal/pelvic CT showed thickened small bowel loops in the right lower quadrant with free fluid and soft tissue stranding. Colonoscopy revealed a normal colon and a 10-cm segment of erythematous mucosa in the terminal ileum with normal histology. Stool cultures were negative, but C. difficile PCR returned positive. He improved on metronidazole and was discharged. Three weeks later, he presented with worsening abdominal pain and diarrhea, WBCs 18.1 x 10ˆ9/L, positive C. difficile PCR, and interval worsening of diffuse terminal ileal inflammation on CT scan. He improved rapidly on oral vancomycin. MRE/MRA on hospital day 3 was negative for large vessel vasculitis and showed resolution of the ileal thickening seen on admission CT. Work-up also included normal complement levels, HIV and TB testing, and autoimmune serologies. Repeat colonoscopy and small bowel enteroscopy were normal, and capsule endoscopy showed slight ileal patchy erythema. One month after completing his vancomycin taper, he again presented with abdominal symptoms, WBCs of 23 x 10ˆ9/L, circumferential thickening of the entire ileum on CT, and positive C. difficile PCR. He improved on IV metrondiazole and oral vancomycin, which was continued until 3 days prior to outpatient fecal microbiota transplant (FMT) via colonoscopy. On the day of the procedure, he endorsed mild abdominal pain. Terminal ileum at time of FMT appeared mildly erythematous. After FMT, he experienced rapid and complete resolution of abdominal pain and remained symptom free 6 weeks later. Discussion: It is hypothesized that CDE develops from intestinal metaplasia and intestinal flora changes triggered by prior gastrointestinal surgery, chronic immunosuppression, or antibiotic exposure. While CDE has been reported in patients after colectomy, it is exceptionally rare in immunecompetent patients with no previous bowel surgery. This case demonstrates a rare case of CDE in a patient without predisposing conditions. This case also highlights the utility of FMT in recurrent C. difficile infection and represents the first case of CDE treated by FMT. Disclosure - Dr. Colleen Kelly - Site investigator for a clinical trial for Seres Health. Drs Freeman, Mao, Shah have no relevant financial relationships to disclose.