Abstract
Immunocompromised patients undergoing chemotherapy for hematologic malignancy and hematopoietic stem cell transplant (HSCT) recipients are at increased risk of Clostridium difficile (C. difficile) infection (CDI). The recurrence of infection and its associated morbidity and mortality are due to multiple risk factors. Diarrhea is common in HSCT recipients, but the diagnosis of diarrhea caused by CDI is a therapeutic challenge due to frequent Clostridium difficile colonization with diarrhea secondary to non-infectious causes. The high recurrence rate is a significant challenge in the treatment of immunocompromised patients. Close monitoring of the patients, timely diagnosis, preventive measures, treatment with antibiotics, and the removal of offending agents can help in the management and cure of the disease. We review the literature on management and describe a patient with acute lymphoblastic leukemia (ALL) with multiple recurrences of CDI during leukemia therapy and allogeneic stem cell transplantation for leukemia.
Highlights
Clostridium difficile (C. difficile) is recognized as the most common healthcare-associated infection in the United States
The risk of developing C. difficile infection (CDI) is high in patients with hematologic malignancy and solid tumors and in hematopoietic stem cell transplant (HSCT) recipients due to the presence of multiple risk factors, including immunocompromised status, prolonged hospital stay during chemotherapy, and transplantation along with exposure to multiple antibiotics, chemotherapy-related disruption of the enteric mucosal barrier, the frequent use of proton pump inhibitors, histamine type 2 blockers, and gut involvement with graft versus host disease (GVHD) along with the immunosuppressive medication used to treat it [1]
The etiology of diarrhea is often multifactorial in HSCT recipients and prominent causes include the adverse effects of chemotherapy, gastrointestinal graft versus host disease (GVHD) and gastrointestinal infections, while C. difficile is among the leading causes of infectious diarrhea in HSCT recipients
Summary
Clostridium difficile (C. difficile) is recognized as the most common healthcare-associated infection in the United States. A diagnostic bone marrow biopsy showed 65.1% blasts (by aspirate morphology), 90% marrow cellularity, myeloid erythroid ratio (M:E) 14.04, megakaryocytes 0.9/high power field (HPF), along with complex abnormal female cytogenetics 45, XX, del (9)(p21), -20(11)/46 XX, del(9), del(20)(q11.1) She was treated with an intensive chemotherapy ALL protocol (E1910) and achieved complete remission by day 27 of remission induction therapy. During the period of inpatient care for allogeneic HSCT, the patient developed a second recurrence of CDI confirmed by the presence of negative NAP1/BI/027 C. difficile toxin PCR in the stool. At this point, the patient received 10 days of fidaxomicin and transitioned back to oral vancomycin taper therapy over the following four weeks. The post-transplantation evaluation after one month was negative for any morphologic or immunophenotypic evidence of leukemia and the patient had 100% donor chimerism, which is consistent with successful engraftment and leukemia remission
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