CLOSTRIDIUM DIFFICILE COLITIS MIMICKING ACUTE APPENDICITIS!

Abstract

Pseudomembranous colitis associated with Clostridium difficile rarely manifests as an acute abdomen and even more rarely as an acute abdomen without abnormal radiological studies. We are presenting a case of 71-year-old female nursing home resident who was sent to the emergency department for evaluation of fever and dysuria. Review of systems was unremarkable. Patient was started on gatifloxacin for a possible urinary tract infection. However, she soon developed abdominal pain. On physical examination, she was febrile with temperature of 103°F and tachycardiac. Abdominal examination revealed a significant right lower quadrant tenderness with signs of peritoneal irritation. Her white count was surprisingly normal (8700 cells/mcl). A presumptive diagnosis of acute appendicitis was made. CT scan of her abdomen at this time was normal. In view of her clinical signs and symptoms and suspicion of a possible appendicitis, urgent exploratory laprotomy was performed. The laprotomy was essentially benign with no evidence of appendicitis or intestinal perforation. A plasma Clostridium difficile toxin assay sent during hospitalization was found to be positive. She was started on metronidazole postoperatively and showed dramatical improvement over next 48 hours. Patient had a follow up colonoscopy, which showed diffuse pseudomembranes with typical histologic lesions. Cultures of the colonic tissue sample grew clostridium difficile. Pseudomembranous colitis may present as acute abdomen mimicking bowel perforation or peritonitis and in our case as acute appendicitis. Emergency colonoscopy maybe useful for diagnosis and treatment especially when there are no radiological signs. Treatment with metronidazole is effective. Colitis due to C. difficile should be considered in the differential diagnosis of acute abdomen in patients treated with prior antibiotics or living in nursing homes. A high index of suspicion is the key.