Clostridium difficile Small Bowel Enteritis in a Patient with IgG Deficiency

Abstract

Purpose:Clostridium difficile (C. difficile) infection has been infrequently reported as a cause of diarrhea in the ileostomy patient, often with high morbidity and mortality due to delayed diagnosis. We present a case of C. difficile small bowel enteritis in an immunosuppressed patient successfully treated after early diagnosis and aggressive medical management. Case: A 44-yearold female patient with a history of immotile cilia syndrome, asthma, chronic bronchiectasis, and IgG deficiency was admitted with increased ostomy output. Three months prior, she had a subtotal colectomy with diverting loop ileostomy secondary to a sigmoid colon obstruction. In addition, she had multiple admissions for pulmonary issues and was treated with glucocorticoid tapers and antibiotics. At the time of admission, she was on prednisone 25 mg daily and had received a dose of IVIG one month prior for a low IgG level. On exam, she was afebrile with normal vital signs and an unremarkable physical exam. Pertinent labs included a WBC of 6.4 K/ul with a normal differential. Stool from her ostomy was found to be positive for C. difficile. During previous hospitalizations, her stools were negative for C. difficile. She was started on oral vancomycin and IV metronidazole and was discharged home on oral metronidazole. After missing 3 doses, she was readmitted for increased ostomy output and volume depletion. She was treated with IV metronidazole and oral vancomycin. She received a total of 23 days of antibiotics and did well after discharge. Her loop ileostomy was taken down five months later and the patient has done well. Discussion: C. difficile is a toxin-producing, anaerobic, gram-positive rod previously thought to be pathogenic only in the colon. Animal models have demonstrated that its toxins can generate a severe inflammatory response in small bowel mucosa. A recent review identified a total of 56 cases of C. difficile small bowel enteritis in the literature by 2010, with 48 reported after 2001. The vast majority were associated with colectomy or other bowel surgery. Additional pre-disposing factors included inflammatory bowel disease, immunosuppression, and antibiotic exposure. The mortality rate was 32% for the previously described cases, but our patient had a benign clinical course, likely due to early diagnosis and aggressive treatment. Since C. difficile small bowel enteritis is rare, there are no established guidelines on treatment. In our patient, we opted for dual therapy due to previously reported poor outcomes. Clinicians should consider C. difficile enteritis in any patient with increased ostomy output, especially those with prior antibiotic exposure or immunosuppression.