Post-Fecal Microbiota Transplantation (FMT) Constipation and Abdominal Distention Due to Methane-Predominant Bacterial Overgrowth Contracted from the Donor

Abstract

FMT is becoming increasingly used in patients with severe, recurrent and/or relapsing Clostridium difficile infections (CDI). Despite durable benefits associated complications are poorly defined. Up to 10% of patients develop bloating and constipation after FMT (Lee CH 2014); however, causality is not established as most patients undergoing FMT are ill and suffer from significant gastrointestinal (GI) symptoms. Excessive methane production (>10 ppm) is present in up to 25% of the general population and can lead to constipation and bloating. (Chang 2015) Here we report a 21 year-old female with history of recurrent sinusitis due to IgA deficiency requiring multiple courses of antibiotics and no prior GI-related complaints. She contracted CDI in Jan 2014, which persisted despite treatment with vancomycin and metronidazole. In July 2014, she underwent FMT via colonoscopy from her stepbrother. Despite eradication of CDI, she developed significant post-prandial bloating, distention, fatigue and constipation without rectal bleeding or constitutional symptoms. Her physical exam was without focal abnormalities. Laboratory evaluation showed normal IgG and IgM levels, but undetectable IgA and IgE titres. ANA was slightly elevated at 1:80, however CRP, anti-CCP, anti-tTG, C3, C4, LFTs, lipase CBC, and electrolytes were normal. Anti-vinculin and anti-CdtB antibodies were negative, as were stool for C. difficile, elastase, calprotectin and O&P. EGD and ileocolonoscopy were normal with normal gastric and duodenal biopsies. Capsule endoscopy and CT of the abdomen were normal. Antidepressants, low FODMAPs diet, peppermint, over-the-counter laxatives, linaclotide, lubiprostone and prucalopride proved to be minimally effective. Breath testing performed in Oct 2014 showed normal hydrogen levels, but significantly elevated methane peaking at 51 ppm (Figure 1). On further testing, FMT donor was also found to be an excessive methane producer, with a methane level of 35 ppm. The patient was treated with 14 days of rifaximin 550 mg TID and neomycin 500 mg BID leading to eradication of excessive methane production to 0 ppm and resolution of her GI symptoms. CDI has not recurred as of June 2016. This is the first report of methane-predominant bacterial overgrowth contracted from the FMT donor as a potential cause of post-FMT IBS-like symptoms such as bloating and constipation. Screening of FMT donors for excessive methane production may prevent such complications.Figure 1