More Than Just Clostridium difficile Infection: The Potential Role of Fecal Microbiota Transplantation in Patients with Inflammatory Bowel Disease

Abstract

Introduction: Patients with inflammatory bowel diseases (IBD) experience a significant impact on quality of life. Nearly one third ultimately require colectomy for symptom relief, while others suffer from unexpected flares or complications such as superimposed infections. Despite the development of local and systemic pharmaceutical agents, varying conditions, including pregnancy, may preclude their use. This report reviews the clinical course of a patient with indeterminate colitis and superimposed Clostridium difficile infection who experienced relief of symptoms following fecal microbiota transplantation (FMT). Case Presentation: A 30 year old woman suffered gastrointestinal symptoms for years before being diagnosed with ulcerative colitis at age 16. She was maintained on a variety of medications including oral and topical aminosalicylate, steroids, and immunosupressants with minimal success. After a severe flare and development of perianal and vaginal fistulae at age 23, she was diagnosed with indeterminate colitis and started on infliximab. At age 25, infliximab lost efficacy and she switched to adalimumab, which required increased weekly dosing to achieve symptom relief. She had recurrent C. difficile infections, usually treated with oral vancomycin. A recent infection, unresponsive to antibiotics, was treated with FMT. She had complete resolution of symptoms one week after colonoscopy and FMT. Adalimumab administrations were tapered down and discontinued, allowing her time to conceive. During pregnancy she had a minor relapse that responded well to topical and systemic steroids. She delivered at full term and breastfed for several months before experiencing relapse of IBD symptoms and resuming adalimumab. Her clinical remission lasted approximately two years after FMT. Discussion: FMT has demonstrated efficacy for treatment of recurrent C. difficile infections, but its role in IBD is under investigation. This case suggests a potential benefit of FMT in special populations of patients with IBD. Our young patient with indeterminate colitis desired pregnancy which limited the pharmaceuticals available to manage her IBD. Following FMT for recurrent C. difficile infection, she was able to carry a pregnancy and breastfeed safely before experiencing another relapse of IBD symptoms. She had never experienced such a break from her disease before. Studies addressing the potential of FMT in specific patients with relapsing IBD may prove beneficial.