Extracolonic Clostridium difficile Infection with Peri-rectal Abscesses: A Rare Occurence

Abstract

Introduction:Clostridium difficile (C.difficile) is the agent implicated for pseudomembranous colitis. It is responsible for 10% - 25% of cases of antibiotic associated diarrhea. Extracolonic manifestations of clostridium difficile infections are rare and very few reports have been published in the literature. We present a case of recurrent clostridium difficile colitis in a patient with rectal adenocarcinoma treated surgically, presenting with multiple peri-rectal abscesses with polymicrobial clostridium difficile infection. Case: 74 y/o female with past medical history significant of rectal adenocarcinoma s/p neoadjuvant chemotherapy and surgery, hypertension, CVA, seizure disorder and recurrent C.difficile colitis presented to the hospital with intermittent diarrhea for 3 weeks. The diarrhea was associated with intermittent rectal bleeding for 10 days, right lower quadrant abdominal pain, nausea and vomiting. The patient was started on iv metronidazole and PO vancomycin. CT abdomen and pelvis revealed 1.9 x 4.8 x 1.9 cm fluid collection in the left peri-rectal fossa, 2.1 x 3.3 x 2.8 cm fluid collection in the right peri-rectal fossa with air and a 2.3 cm collection of air in the left pelvic wall muscle. MRI of the pelvis revealed heterogenous signal and contrast enhancement in the sacrum consistent with post treatment changes or fibrosis. IR guided bone biopsy was negative for osteomyelitis or metastasis. IR guided drainage of the perirectal abscesses was also performed with placement of a drain. The culture was positive for candida dubliniensis, streptococcus milleri and clostridium difficile. She was hence started on fluconazole, iv vancomycin for streptococcus milleri and oral vancomycin was switched to fidaxomicin along with iv metronidazole for treatment of C.difficile. Patient eventually had resolution of symptoms along with improvement in nutritional status. Discussion: Extracolonic manifestations of clostridium difficile infection include osteomyelitis, bacteremia, visceral abscesses, empyema, pyelonephritis, prosthetic infection, reactive arthritis, skin and soft tissue infections. It is more common in patients with significant comorbidities and relative immunosuppression. Studies have also shown that increased extracolonic infections are seen in patients with intestinal surgery as evident in our patient. Most of the cases are polymicrobial in nature and treatment has been directed towards all organisms as described in our case.Figure 1Figure 2