A Diagnostic and Therapeutic Challenge: Campylobacter Colitis Triggers Ulcerative Colitis and the Peril of Clostridium difficile

Abstract

Introduction: Microbial causation of inflammatory bowel disease (IBD) remains unproven. Initiation or relapse of IBD may be facilitated by infection in genetically vulnerable individuals. Diagnosis of IBD during hospitalization is more common in patients with recent positive stool culture. Distinction by exclusion of infection is critical as immunosuppressive therapies will exacerbate active infectious disease. Case Description: A previously healthy 27-year-old with no family history of IBD presented to his family doctor after four weeks of profuse watery bowel movements and fever. He had no known allergy and did not take medication. Campylobacter jejuni stool culture was positive and metabolic panel revealed severe hypokalemia. He was admitted for severe sepsis [tachycardia (124 bpm), fever (39.5-degrees Celsius) and infectious diarrhea]. Exam was benign and skin was without lesion. Laboratory studies revealed potassium 1.9 mmol/L (3.5-5.1 mmol/L, leukocytosis, anemia, and hypoalbuminemia. Stool culture, ova and parasite, and Clostridium difficile PCR were negative. Serology for celiac disease was negative and upper endoscopy was unremarkable. Colonoscopy revealed pancolitis with diffusely bleeding ulcers and endoscopically normal terminal ileum. Histopathology revealed chronic inflammatory disease and diagnosis of UC was established. The patient was treated with mesalamine and finished azithromycin course; corticosteroids and azathioprine were avoided in setting of active infection. At six weeks, the patient had no relapse and continued mesalamine. Nine months after initial episode, he presented to the hospital with dyspnea and diagnosed with alcoholic hepatitis. Steroids were administered. Shortly after, he developed severe Clostridium difficile colitis and was transferred to the intensive care unit in multiple system organ failure (APACHE-II score of 25, 65.3% hospital mortality). To date, he remains dialysis dependent in liver failure (MELD score of 40). Discussion: UC diagnosis requires bloody diarrhea with cramping, fecal urgency, anemia, low albumin, negative stool culture, endoscopic evidence and tissue sampling. Clinically and endoscopically, it can be indistinguishable from other causes. Post-infectious diagnosis considers negative stool culture, histology, and course of disease. Clostridium difficile associated disease is prevalent in UC patients and is associated with poor clinical outcome. This clinical scenario exposes the diagnostic and therapeutic challenges of UC in the setting of infectious colitis and emphasizes microbial consideration in the natural history of inflammatory bowel disease.