S3402 Toxic Megacolon Disguised as Fecal Impaction

Abstract

INTRODUCTION: Clostridium difficile colitis is a disease rising in incidence over the years with increasing mortality, especially with complications such as toxic megacolon which can affect 0.4-3% of cases. This case report shows the need to keep a high index of suspicion, especially with atypical presentations to help reduce the mortality rate. CASE DESCRIPTION/METHODS: A 77 year old male with a history of Alzheimer’s Disease had a prolonged hospital course after admission for a fracture requiring surgery after a ground level fall. One and a half month into the hospital course, the patient was diagnosed with suppurative parotitis with associated leukocytosis up to 33,000. He was begun on empiric antibiotics which were eventually de-escalated to daptomycin & zosyn with subsequent resolution in leukocytosis one week into the planned two week antibiotic course. On the last day of antibiotics, patient was noted to having uptrending leukocytosis up to 24,000 despite staying afebrile, vitally stable, and with no symptoms reported including abdominal pain or diarrhea. His antibiotics were escalated with continued worsening of leukocytosis up to 42K. At that time, patient began complaining of abdominal pain with subsequent CT scan noting significant colonic stool with possible fecal impaction. Given the leukocytosis and imaging, he was evaluated by surgery due to concern of possible perforation. Surgery had low concern for perforation and recommended aggressive bowel regimen after which patient began stooling frequently. Shortly thereafter, he became hypotensive requiring vasopressor support. He subsequently tested positive for clostridium difficile and was begun on treatment for fulminant C. difficile with toxic megacolon. However, the patient died a few days later. DISCUSSION: C. difficile colitis and its complications, including toxic megacolon, are important to recognize early to ensure prompt treatment of this potentially fatal disease. There are the known expected signs and symptoms including abdominal pain, diarrhea, fevers, lactic acidosis, elevated creatinine, significant leukocytosis. However, it is important to not be confounded by unusual presentations such as in this case. Other rare case reports include Burke et al. who describe a patient with toxic megacolon from C. difficile without diarrhea. Malkan et al. also describe a case series of uncommon presentations though most are noted to have known risk factors including prolonged hospital or antibiotic courses.