Insight into Fecal Microbiota Transplant in an Immunocompromised Patient

Abstract

Clostridium difficile infection (CDI) is a significant cause of morbidity and mortality. Fecal microbiota transplant (FMT) is effective for treatment of recurrent CDI, but has not been well studied in immunocompromised (IC) patients. New data shows that FMT may be safe in this population, but has not gained widespread acceptance. This is the case of a 67-year old male with recurrent CDI and immunocompromised state due to myelodysplastic syndrome transformed to acute myeloid leukemia, who was treated with FMT. This case contributes to the growing body of evidence on the outcomes of FMT on CDI in IC patients. The patient is a 67-year old male with past medical history significant for clostridium difficile colitis who was diagnosed with myelodysplastic syndrome with progression to acute myeloid leukemia. He developed diarrhea with ten loose, bloody bowel movements a day. Vitals on admission were unremarkable. On exam, he displayed left lower quadrant tenderness. Labs displayed WBC 1.43, hemoglobin 8.1, and platelets 126. He was treated initially with vancomycin, with the addition of metronidazole after minimal improvement. Stool studies were negative for infectious cause. Flexible sigmoidoscopy revealed the presence of pseudomembranes. Figures 1 and 2 show the heaped, necrotic epithelium characteristic of pseudomembranes in CDI. Due to the refractory CDI, the patient underwent FMT with improvement in his bowel movement frequency to three loose bowel movements a day. Conditioning therapy in preparation for stem cell transplant was initiated, but the patient suffered cardiorespiratory distress and died. FMT is an established treatment for recurrent CDI. One population in which FMT has not been well studied is in IC patients due to the high theoretical risk of complications. Recent studies have shown that FMT in IC patients results in resolution or decrease in diarrhea frequency with few adverse effects. Our patient met inclusion criteria for many of these studies with his history of immunosuppression and refractory CDI. After FMT, the patient's diarrhea frequency decreased from ten loose bowel movements to three a day. The patient was able to undergo conditioning therapy in preparation for stem cell transplant. Although our patient succumbed to cardiorespiratory distress, this case provides valuable insight into a patient population that is not normally treated with FMT and furthers the discussion on FMT in IC patients.1464_A Figure 1. Heaped, necrotic epithelium characteristic of pseudomembranes in clostridium difficile infection1464_B Figure 2. Magnification of Image 1