S1762 An Atypical Presentation of Fulminant Clostridioides difficile Colitis Without Diarrhea

Abstract

INTRODUCTION: Clostridioides difficile infection (CDI) occurs mostly after antibiotics use and presents almost invariably with watery diarrhea. Here, we described an unusual presentation of fulminant CDI in a middle aged woman who was admitted with altered mental status and ileus but no diarrhea. CASE DESCRIPTION/METHODS: A 62-year-old woman with a history of schizophrenia was admitted to inpatient psychiatry for treatment of schizophrenia. On hospital day 47, she was found to be severely somnolent with fecal incontinence. Vital signs were notable for tachycardia and fevers. Physical exam was remarkable for abdominal distension, tympany with hypoactive bowel sounds, and diffuse abdominal tenderness. Laboratory revealed marked leukocytosis of white blood cells (WBC) 51 × 109 cells/L, lactate 3.66 mg/dL, and acute kidney injury with creatinine 1.4 mg/dL. Abdomen and pelvis CT showed proctocolitis and distension of rectum and left colon along with significant stool burden. The patient was initially started on broad spectrum antibiotics for severe sepsis of unknown origin however without significant improvement. She was managed for constipation with oral bowel regimen, tap water enemas, suppositories, and manual disimpactions. Given persistent leukocytosis and overflow diarrhea, stool C. difficile toxin was checked and resulted positive. The patient was subsequently treated for fulminant CDI with oral vancomycin, vancomycin enemas and intravenous metronidazole. After the 14-day course of antibiotics, her abdominal pain and distension resolved and leukocyte count normalized. DISCUSSION: The most common symptom of CDI is watery diarrhea which is often associated with abdominal pain, fever, and leukocytosis. Unique features in our case include lack of diarrhea, a significantly high WBC count and no history of recent antibiotics use. The abdominal pain and distention were attributed to stool impaction. Persistent high WBC, minimal response to bowel regimen, and ileus led to further investigation with C. difficile stool test in our patient. Symptoms resolved after proper treatment of CDI. It was reported that CDI can present acutely as ileus with constipation and absence of diarrhea [1]. This is due to pooling of secretions in dilated and atonic colon. These patients are at high risk to progress rapidly to toxic megacolon and perforation if not treated promptly. CDI should be considered in the context of unexplained severe sepsis with high WBC even without diarrhea.