Persistent Clostridium difficile Infection in a Patient with Decompensated Liver Disease: “Double Transplant” Saves a Life!

Abstract

Background: Over the past several years, Clostridium difficile Infection (CDI) has become more frequent and virulent. Patients hospitalized with severe liver disease are at increased risk for CDI. Persistent or recurrent CDI poses a dual threat in the pre-transplant setting- continued CDI leads to further morbidity and perhaps death. Importantly, the presence of any active infection precludes consideration for a potentially life saving liver transplant. Case Report: We report a 39-year-old white male with chronic hepatitis C infection and decompensated cirrhosis with a MELD score of 19- who developed diarrhea and abdominal pain. Stool tested positive for C. difficile toxin. Despite treatment with oral Vancomycin, Rifaximin and Saccharomyces boulardii, he continued to have frequent watery stools and was positive for C. diff toxin on repeat stool examination. He developed increasing jaundice and MELD score increased to 28, but because of his ongoing C. diff. infection he had to be made inactive on the liver transplant list. Because of the high risk of death and the ongoing CDI, a decision was made to perform fecal microbiota transplantation (FMT). His wife consented to be the “donor” and after appropriate fecal and serological testing, the patient underwent polyethylene glycol (PEG) bowel preparation and the following morning had FMT performed via colonoscopy. Colonoscopy revealed mild inflammatory changes, without psudomembranes. Over the next several days, diarrhea resolved and stool for C. diff toxin A&B was negative on day seven post FMT. Diarrhea did not recur, he was re-activated on the transplant list, and underwent successful deceased donor liver transplant six weeks later. He remains well, active as a truck driver, over one year post transplants. Conclusions: FMT should be considered if persistent or recurrent CDI occurs in patients with decompensated liver disease awaiting liver transplantation. FMT is effective (90% cure rate for colonoscopic FMT in most series). Response to FMT is typically rapid, unlike alternative treatment such as pulse-tapered vancomycin. This rapidity of response can be lifesaving, as active CDI precludes liver transplantation.