Stool Ball Impaction and Obstipation: An Atypical Presentation of Clostridium difficile Infection

Abstract

The hallmark manifestation of Clostridium difficile infections (CDI) has always been diarrhea and is a key point in identifying patients who may be infected. Throughout the years, a number of risk factors have been associated with CDI including antibiotic use and hospitalizations. Here we present an unusual case of CDI where a healthy patient without any identifiable risk factors presented with obstipation, and, whose diagnosis of CDI was critical to her improvement. A 35-year-old female with no significant past medical history of constipation, recent hospitalization, use of antibiotics or medications, or sick contacts, presented with left lower quadrant abdominal pain and constipation for four days. An abdominal X-ray was negative for obstruction and was initially prescribed magnesium citrate and enemas. Her symptoms worsened, as she developed a fever and leukocytosis of 19k/ul. A CT scan of the abdomen showed a 4cm circular mass in the sigmoid colon with proximal colon distended with stool, distal decompression, and fat stranding around the sigmoid colon (Img2). A flexible sigmoidoscopy showed sigmoid colitis with pseudomembranes, along with a dense, impacted stool ball that was not able to be moved or fragmented. A stool specimen taken was positive for clostridium difficile antigen and PCR toxin, confirming CDI. Biopsies also confirmed pseudomembranes colitis (Img1). Metronidazole was started with quick resolution of obstipation and leukocytosis. She was safely discharged home to complete the course of antibiotics. Our case seems to be the first of its kind in reporting this atypical presentation of community acquired CDI in a healthy young patient with obstipation related to a stool ball impaction without diarrhea or classical risk factors. While it is acknowledged that ileus is a complication of CDI and occasionally formed stool or a rectal swab may be needed to confirm the diagnosis, guidelines still focus on testing patients with diarrhea. Physicians should have an appreciation of the spectrum in which CDI may present and be prepared to initiate a work up even in the absence of diarrhea. Sigmoidoscopy was instrumental in this case and should also be considered as part of the diagnostic armamentarium. As our understanding of CDI is rapidly evolving, we hope to contribute to the current literature with this uncommon presentation of a common disease, thus increasing the role of physicians in making a timely diagnosis and delivering effective treatment.Figure: Mucosal biopsy fragment showing patchy mucosal injury with necrosis, and separate fragments of necroinflammatory debris suggesting pseudomembranous colitis.Figure: 4cm stool ball identified in the sigmoid colon with fat stranding along with proximal distension and distal compression.