Recurrent Clostridium difficile Colitis in a Patient with Concurrent Diverticulitis

Abstract

Background:Clostridium difficile infection (CDI) and diverticulitis both cause inflammation of the colon and mimic each other radiographically. Distinguishing between the two entities is essential, as the treatment for diverticulitis (fluoroquinolone or cephalosporin, in addition to an antibiotic with anaerobic activity) can be a harbinger for CDI. Although rare, both diseases can present simultaneously, making diagnosis and treatment difficult. Case Presentation: A 76-year-old man with a history of recurrent diverticulitis subsequently developed CDI and was referred to us with recurrent symptomatic colitis. In May and November, 2011, he developed left lower quadrant abdominal pain and was treated with ciprofloxacin and metronidazole for 10 days with resolution of symptoms each time. Another episode occurred in December, 2011, but he now developed bloody, watery diarrhea. His stool C. difficile toxin assay was positive, and he was treated with metronidazole for two weeks with resolution of his diarrhea. Three months later, he again developed watery diarrhea, and his stool was positive for C. difficile. He responded to treatment with oral vancomycin followed by a prolonged taper, but within a week of discontinuing the taper, his diarrhea returned and he became dehydrated, requiring hospitalization. His WBC was 15.6 x 10ˆ3/μl. CT scan (June 4, 2012) showed thickening of the distal transverse, descending, and sigmoid colon. Given these findings, he was treated for recurrent sigmoid diverticulitis (ciprofloxacin and metronidazole) and CDI (fidaxomicin followed by a vancomycin taper). Review of his follow-up abdominal CT (June 29, 2012) showed resolution of colitis in the transverse and descending colon, but residual abnormalities in the sigmoid colon. As his symptoms resolved, he continued only a suppressive dose of vancomycin (125 mg once daily). He again became symptomatic (July, 2012) with bloody stools, abdominal cramps, and fever, and was treated for both entities. Although his vancomycin regimen was empirically increased to 250 mg QID, his stool C. difficile assay was negative, and this episode likely represented simple diverticulitis. The patient successfully underwent resection of the sigmoid colon two months later and has had no further symptoms. Conclusion: Management of recurrent CDI and diverticulitis becomes difficult as the antibiotics used to treat the latter are often the culprit in the development of the former. Prior studies suggest that patients with diverticulosis who develop CDI are more prone to CDI, as the diverticula themselves serve as a reservoir for C. difficile spores. In patients with recurrent CDI and concurrent diverticulitis, surgical resection of the latter should be considered.