A Rare Case of Polymicrobial Clostridium Difficile Bacteremia in Decompensated Liver Cirrhosis

Abstract

Introduction:Clostridium difficile(C.diff) is the most frequent cause of diarrhea in hospitalized patients. Extra-intestinal C.diff is rare, accounting for 0.2 - 0.6% of all C.diff infections. C.diff bacteremia is even more uncommon and is accompanied by high mortality rates. Case Presentation: A 68 year-old man with a history of alcoholic cirrhosis and prior episodes of spontaneous bacterial peritonitis (SBP) presented with fevers, chills, nausea, and diffuse abdominal pain without diarrhea. Physical exam was notable for: HR 99, BP 104/40 mm Hg, temperature 98.7oF, and no definite ascites. Laboratory tests showed: WBC 45,000 /μL (neutrophils, 83.3%), creatinine 3.7 mg/dL (baseline 1.1), total bilirubin 8.9mg/dl (baseline 2.8) and INR 1.52 (baseline 1.5). The MELD score was 31 (baseline 17). An abdominal ultrasound showed cirrhosis and a small amount of simple ascites. CT scan with oral contrast showed no evidence of bowel obstruction, toxic megacolon, or bowel perforation. The patient was treated with piperacillin-tazobactam for suspected SBP. Four sets of blood cultures performed on admission grew C. diff, and extended spectrum beta lactamase Escherichia coli (E.coli). Four stool studies for C.diff RNA by polymerase chain reaction were negative. The patient was treated with intravenous meropenem and metronidazole. The patient's subsequent hospital course was notable for: worsening ascites, renal failure requiring hemodialysis, myocardial infarction, worsening coagulopathy and peritoneal infection diagnosed by paracentesis on hospital day 23. The ascitic fluid polymorphonuclear leukocyte count was 1300 cells/mm3. Ascites culture was positive for Vancomycin-resistant Enterococcus and E.coli. Despite aggressive medical management, patient died on hospital day 53. Discussion:Clostridum difficile bacteremia is typically detected in the setting of polymicrobial sepsis. Mortality rates are as high as 64% in patients with liver disease. C.diff bacteremia is usually seen in the setting of C.diff diarrhea and may occur after bowel manipulation or bowel perforation. Infrequently, cases like ours - of C.diff bacteremia are seen in the absence of C.diff diarrhea or bowel manipulation. We postulate that our patient's C.diff bacteremia arose in the setting of the profound immunosuppression that may accompany end stage liver disease.