An Adjunctive Role for Intravenous Steroids in Refractory C. Difficile Colitis

Abstract

The clinical spectrum of Clostridium Difficile infection often includes severe and refractory forms of pseudomembranous colitis. Definitive antibiotic treatment of the infection is the mainstay of management rather than treatment of the colitis as a separate inflammatory entity. We report a case that highlights the potential utility of intravenous steroids in the management of refractory C. Diff colitis. A 77 year old female with significant co-morbidities presented with recurrent abdominal pains, nausea, vomiting, diarrhea and fevers. She had been treated for recurrent C. Difficile infection and proven pseudomembranous colitis over the preceding 5 months with multiple agents including Flagyl PO and IV, Vancomycin PO at doses ranging from 125 mg qid to 500 mg qid, vancomycin retention enemas, Bacitracin 25000 units qid, rifampin 600 mg daily, cholestryramine up to 16 grams daily, and Sacccharomyces boulardii. Intravenous gamma globulin (300 mg/kg) was also used without improvement. Despite these interventions, she had persistent and refractory severe pseudomembranous colitis with stool toxin assays positive for C. Difficile. Her clinical course was complicated by sepsis, profound hypoalbuminemia, ascites, leukomoid reaction with a WBC count over 63000, and peritonitis requiring laparoscopy to rule out non-colitis pathology including ischemia. She was deemed to ill to tolerate a total colectomy. TPN was instituted with continued use of vancomycin and multimodality therapy. The patient had serial toxin assays which eventually came back negative as did a stool culture for C. Difficile. Despite this, the patient had continued clinical complications due a persistent and severe pseudomembranous colitis. She was placed on intravenous Solumedrol 40 mg bid with a significant clinical and endoscopic improvement in as short as 6 days and near resolution of the colitis by total colonoscopy within two weeks. She has remained stable following discharge. This case illustrates and highlights the potential utility of IV steroids in treating the colitis associated with Clostridium Difficile infection. It is postulated that some patients may develop a UC-like immune response triggered by C. Difficile, even after clearance of the toxin. The clinician should consider IV steroids as an adjunctive option for refractory colitis after aggressive anti-microbial treatments have not lead to optimal clinical resolution, especially if the patient is not an optimal surgical candidate.