Poster 174: Clostridium difficile toxin-negative, severe, acute colitis presenting as fever and leukocytosis without diarrhea in a patient with a total hip revision during inpatient rehabilitation: a case report.

Abstract

Setting: A comprehensive inpatient rehabilitation unit. Patient: An 83-year-old man after right total hip arthroplasty revision. Case Description: Shortly after transfer to inpatient rehabilitation, he became febrile (38.4°C) and developed an elevated white blood count (WBC) of 16,600/μL with 80% polys. He was treated with antibiotics for incision cellulitis, a urinary tract infection, and bacteremia. He became afebrile and his WBC returned to normal (8900/μL). 18 days later, he became febrile again (38.9°C) and his WBC rose to 17,400/μL with 78% polys. He did not develop abdominal pain, distention, or diarrhea. Repeat blood and urine cultures were negative and stool cultures did not reveal enteric pathogens or Clostridium difficile toxin. However, an indium-labeled WBC scan revealed extensive uptake throughout the colon consistent with colitis. No evidence of an infected hip prosthesis or an adjacent soft tissue abscess was detected. A colonoscopy revealed severe, acute colitis extending from the sigmoid colon to the cecum. Biopsy specimens revealed an active, inflammatory colitis without evidence of pseudomembranes or ischemia. The patient was treated with oral vancomycin for 10 days. He became afebrile, his WBC decreased to 11,600/μL, and he was discharged to subacute rehabilitation on hospital day 31. Discussion: Severe, acute, bacterial colitis is a common complication during inpatient rehabilitation. Clinical signs include fever, abdominal pain, diarrhea, and leukocytosis. Our patient only had fever and leukocytosis. Clostridium difficile toxin was negative. The Clostridium difficile toxin is positive in only 60% to 75% of cases of colitis without pseudomembranes. Conclusions: Severe, acute colitis should be considered in the differential diagnosis of a rehabilitation inpatient with fever and leukocytosis even in the absence of abdominal pain, diarrhea, or a positive Clostridium difficile toxin. Colonoscopy is needed to confirm the diagnosis and antibiotics are the appropriate treatment in such a patient.