Use of intravenous immunoglobulin for the treatment of severe clostridium difficile colitis

Abstract

Background: Clostridium difficile is a gram-positive, anaerobic, spore-forming, rod-shaped bacterium responsible for most of the hospital-acquired diarrhea in developed countries. The organism received its name because it was difficult to isolate and grow in culture. Infections in the elderly have been associated with significant morbidity and mortality as well as prolonged hospitalization. Case summary: A 72-year-old white male presented with a 5-day history of abdominal pain, nausea, and severe diarrhea but no fever or chills. He had had recent chemotherapy for Merkel cell carcinoma of the right ear. Medical history included hypothyroidism for 10 years and non-Hodgkin's lymphoma in remission for 4 years after a stem cell transplant. The patient was receiving oral vancomycin, levofloxacin, thyroxine, and esomeprazole. He had severe infection secondary to chemotherapy for Merkel cell carcinoma; in addition, he had failed to respond to metronidazole and vancomycin treatment, with the resulting development of colon dilatation and hypoalbuminemia. Colonoscopy showed severe ulceration with inflammation suggestive of severe persistent colitis. At that point, the patient was given 1 dose of IV immunoglobulin (IVIG) 400 mg/kg; vancomycin treatment was continued. Two days after IVIG therapy, the patient's diarrhea improved, with complete resolution after 6 days; bowel dilatation resolved completely after 7 days; and oral intake improved after 2 days. The patient continued on a tapering dose of vancomycin for 6 weeks. He was discharged home and had no recurrence despite antibiotic use for pseudomonas and staphylococcus bacteremia. Conclusions: Severe C difficile colitis has been reported more frequently in the literature recently, especially in elderly patients. Tissue culture assay is the best diagnostic test to detect the cytotoxin; enzyme immunoassay is the test used in most hospitals, but it has a sensitivity of only −75%. Treatment options remain limited to eradicate this serious infection. Antibiotic therapy, infection control measures, and early diagnosis are essential components of successful outcome for this disease. This patient's infection resolved with the addition of IVIG with no recurrence, suggesting the possible benefit of this treatment in certain patients with severe colitis who do not respond to standard therapy.