Cases Of Pseudomembranous Colitis Research Articles

Follow-up of pseudomembranous colitis in children using colonoscopy

Pseudomembranous colitis (PC) is a common nosocomial disease. The most common etiology of the disease is Clostridium difficile and also many other causes can be having role in the occurrence of the disease. This disease is not very common in children and is mostly related to the use of antibiotics and hospitalization. Here, we report a case of PC in an 8-year-old boy who had no history of taking antibiotics and hospitalization.

Prevalence, Antibiotic Resistance, and Genetic Diversities of Clostridium difficile in Meat Nuggets from Various Sources in Isfahan, Iran

Clostridium difficile is recognized as one of the leading causes of diarrhea and is responsible for almost all cases of pseudomembranous colitis. The main aim of this study was to determine the prevalence and genetic diversities of Clostridium difficile contamination in meat nuggets in Isfahan (Iran). To achieve this, 100 samples of chicken, ostrich, quail, shrimp, fish, and beef nuggets were collected by the simple random sampling method from the market of Isfahan from July 2018 to July 2019. Microbiological analyses were performed on each collected sample to isolate and identify C. difficile strains. Susceptibility of the isolated strains to antibiotics was assessed by the Kirby–Bauer method. The PCR technique was used to identify the genes responsible for producing toxins. Of the 600 food samples, 7 C. difficile strains were found, representing a prevalence of 1.17%. Based on the obtained antibiogram results, the highest resistance was related to ampicillin (100%) and then amoxicillin (85.72%), and the highest susceptibility was related to vancomycin (100%) and metronidazole (85.72%). Concerning the identification of the genes responsible for the production of the toxins, it appears that que 4 samples (57.14%) had tcdA genes, 2 samples (14.57%) had tcdC genes, and 7 samples (100%) had tcdB genes. The cdtA and cdtB genes were observed in only one positive sample on beef. This study showed the presence of C. difficile in the analyzed food products. The isolated strains are toxigenic and resistant to antibiotics, except for vancomycin. A mutation would be the basis for the absence of the tcdC gene in the genome of all isolates.

Pseudomembranous colitis in patients infected with SARS-CoV‑2

The article presents data on cases of pseudomembranous colitis registered in the region in patients infected with SARS-CoV‑2. A preliminary analysis of 214 cases of pseudomembranous colitis was carried out, of which 99 people died. As an illustration of the significance of the problem, the medical history of a patient with coronavirus infection and pseudomembranous colitis is presented. The article presents a point of view on the reasons for the increase in the number of cases of pseudomembranous colitis during the COVID‑19 pandemic.

First Case of Pseudomembranous Colitis in a Sars-Cov-2 Patient with Chronic Cerebral Vasculopathy: A Rare Multiple Organ Involvement in the Covid-19 Era

In December 2019, an outbreak of pneumonia of unknown cause in Wuhan, Hubei province, China led to the identification of a new betacoronavirus, called Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2).

A case of pseudomembranous colitis associated with paclitaxel and carboplatin chemotherapy for vulvar cancer

A case of pseudomembranous colitis associated with paclitaxel and carboplatin chemotherapy for vulvar cancer

Тяжельій псевдомембранозньій колит – особенности течения, диагностики и лечения: описание клинического случая

Мета роботи: На підставі вивчення клінічного випадку акцентувати увагу на труднощах діагностики та лікування тяжкого псевдомембранозного коліту (ПМК).Матеріали і методи. Проспективно вивчено особливості перебігу тяжкої форми ПМК у пацієнтки, яка перебувала на лікуванні у Комунальній міській клінічній лікарні швидкої медичної допомоги м. Львова. Діагностика захворювання ґрунтувалася на клінічних даних, результатах ультрасонографії (УСГ), фібросигмоскопії (ФСС), комп’ютерної томографії (КТ).Результати досліджень та їх обговорення. У статті наведено випадок розвитку псевдомембранозного коліту у 42-річної пацієнтки після доопераційної хіміотерапії та короткого режиму застосування антибактерійного препарату (цефтріаксон) у післяопераційному періоді. Описано клінічну симптоматику тяжкого перебігу коліту, результати діагностики за допомогою ультрасонографії, сигмоскопії, комп’ютерної томографії. Проаналізовано труднощі лікування, необхідність корекції лікувальних схем залежно від перебігу процесу та ефективність тривалого призначення ванкоміцину у пульс-режимі.

Antibiotic-associated diarrhea in children: how to identify, what to do and how to treat?

Rational antibiotic therapy is one of the most important components in the treatment of children with various infectious and inflammatory diseases. However, wide and sometimes unjustified use of AB in pediatric practice often leads to the development of a variety of complications. Children receiveing AB, especially during the first 5 years of life, are at a very high risk of developing antibiotic-associated diarrhea (AAD) which manifests itself in three or more episodes of unformed stools for two or more consecutive days or for 8 weeks after withdrawal. The most relevant pathogen of AAD is C. difficile which, according to various data, causes from 10 to 25% of AAD cases and 90 to 100% of all cases of pseudomembranous colitis (PMC). Given the high probability of developing dangerous complications such as PMC, special attention should be paid to the prevention of the infection associated with C. difficile by reducing the frequency of uncontrolled and unjustified use of AB. A new generation of eco-antibiotics can be recommended which allow to maintain diversity of the intestinal microbiota and are less likely to cause complications.

Genomic study of the Type IVC secretion system in Clostridium difficile: understanding C. difficile evolution via horizontal gene transfer.

Clostridium difficile, the etiological agent of Clostridium difficile infection (CDI), is a gram-positive, spore-forming bacillus that is responsible for ∼20% of antibiotic-related cases of diarrhea and nearly all cases of pseudomembranous colitis. Previous data have shown that a substantial proportion (11%) of the C. difficile genome consists of mobile genetic elements, including seven conjugative transposons. However, the mechanism underlying the formation of a mosaic genome in C. difficile is unknown. The type-IV secretion system (T4SS) is the only secretion system known to transfer DNA segments among bacteria. We searched genome databases to identify a candidate T4SS in C. difficile that could transfer DNA among different C. difficile strains. All T4SS gene clusters in C. difficile are located within genomic islands (GIs), which have variable lengths and structures and are all conjugative transposons. During the horizontal-transfer process of T4SS GIs within the C. difficile population, the excision sites were altered, resulting in different short-tandem repeat sequences among the T4SS GIs, as well as different chromosomal insertion sites and additional regions in the GIs.

Pseudomembranous colitis: Not always Clostridium difficile.

Although Clostridium difficile infection is the cause of most cases of pseudomembranous colitis, clinicians should consider less common causes, especially if pseudomembranes are seen on endoscopy but testing remains negative for C difficile or if presumed C difficile infection does not respond to treatment. Histologic review of colonic mucosal biopsy specimens can provide clues to the underlying cause.

中毒性巨大結腸症を併発した偽膜性腸炎に結腸瘻造設術が有効であった1例

症例は69歳，男性．腎機能障害で当院内科に通院中であった．感冒症状に対してCefcapene（CFPN）を11日間内服していたところ嘔吐下痢が出現した．細菌性腸炎を合併した急性腎不全と診断され当院内科に入院となった．その後，腹部膨満が増悪し，入院第5病日に偽膜性腸炎と診断された．入院時に中毒性巨大結腸症を合併し，当科紹介時はすでに重篤化していたため結腸瘻造設術により結腸を減圧したのち，結腸瘻からVancomycin（VCM）の結腸内投与を開始した．術後5日目の便培養でClostridium difficileは陰性となり，入院第63病日に退院となった．本症例は重篤な状態であったが，結腸の減圧とVCMの結腸内投与を迅速かつ確実に施行したことが救命につながったと考えられた．

The Clostridium difficile Protease Cwp84 Modulates both Biofilm Formation and Cell-Surface Properties.

Clostridium difficile is responsible for 15-20% of antibiotic-associated diarrheas, and nearly all cases of pseudomembranous colitis. Among the cell wall proteins involved in the colonization process, Cwp84 is a protease that cleaves the S-layer protein SlpA into two subunits. A cwp84 mutant was previously shown to be affected for in vitro growth but not in its virulence in a hamster model. In this study, the cwp84 mutant elaborated biofilms with increased biomass compared with the parental strain, allowing the mutant to grow more robustly in the biofilm state. Proteomic analyses of the 630Δerm bacteria growing within the biofilm revealed the distribution of abundant proteins either in cell surface, matrix or supernatant fractions. Of note, the toxin TcdA was found in the biofilm matrix. Although the overall proteome differences between the cwp84 mutant and the parental strains were modest, there was still a significant impact on bacterial surface properties such as altered hydrophobicity. In vitro and in vivo competition assays revealed that the mutant was significantly impaired for growth only in the planktonic state, but not in biofilms or in vivo. Taken together, our results suggest that the phenotypes in the cwp84 mutant come from either the accumulation of uncleaved SlpA, or the ability of Cwp84 to cleave as yet undetermined proteins.

Follow-up of Pseudomembranous Colitis in Children Using Colonoscopy: A Case Report.

Pseudomembranous colitis (PMC) occurs mainly in adults and is believed to be caused almost exclusively by toxins produced by Clostridium difficile. Colonoscopy found that PMC occurs mainly in the colon, sigmoid colon and rectum in up to 80% ~ 100% of cases. Colonoscopy is simple and fast. It has the significance of making a definite diagnosis and can be used as the main examination method of diagnosis. Reports of children suffering from PMC are rare. Herein, we report a case of PMC in a child. This report has some clinical value for the study of the spectrum of PMC in patients.

A case of pseudomembranous colitis associated with antituberculosis therapy in a patient with tuberculous meningitis

Pseudomembranous colitis (PMC) is known to be associated with the long-term administration of antibiotics, which alter normal gastrointestinal flora and allow overgrowth of Clostridium difficile. However, antituberculosis agents are rarely reported as a cause of this disease. Besides, most cases of antituberculosis agent-induced PMC have been observed in patients with pulmonary tuberculosis but not with tuberculous meningitis. This report presents a case of PMC associated with antituberculosis therapy in a patient with tuberculous meningitis. A 29-year-old female patient was admitted due to headaches and diplopia that had lasted for 2 weeks. She had not recently received antimicrobial therapy. She was diagnosed with tuberculous meningitis by cerebrospinal fluid findings and neurologic examination, including brain imaging study. She was treated with standard antituberculosis agents (HERZ regimen: isoniazid, ethambutol, rifampicin, and pyrazinamide). After 11 days of HERZ, she developed a fever, sudden widespread skin eruption, and elevation of liver enzymes. Considering adverse drug reactions, antituberculosis agents were stopped. One week later, her symptoms were relieved. Thus, antituberculosis agents were reintroduced one at a time after liver function returned to normal. However, she presented with frequent mucoid, jelly-like diarrhea, and lower abdominal pain. Sigmoidscopy revealed multiple yellowish plaques with edematous mucosa, which were compatible with PMC. She was treated with oral vancomycin considering drug interactions. Symptoms were relieved and did not recur when all antituberculosis agents except pyrazinamide were started again. Therefore, when a patient complains of abdominal pain or diarrhea after initiation of antituberculosis therapy, the physician should consider the possibility of antituberculosis agent-associated PMC.

Unusual case of ascites

<i>Clostridium difficile</i> infection is very commonly related to antibiotic therapy. The spectrum of clinical manifestation of C. difficile infection may include, in an increasing order of severity, absence of symptoms, colitis without formation of pseudomembranes and pseudomembranous colitis (PMC). PMC is a severe but rare complication of the infection. It is related to the bacterial production of enterotoxin A and B. Its clinical features include diarrhea, abdominal tenderness and fever. In the worst case, it may progress to toxic megacolon and colonic perforation. Ascites is an infrequent direct complication of most severe cases of PMC. We report a case of ascites arising two weeks after the resolution of <i>C. difficile</i> infection, in which hypoalbuminemia, caused by protein losing enteropathy, was the most likely pathogenetic mechanism. The patient recovered completely after human albumin intravenous support and diuretics. Protein losing syndrome represents a group of disorders in which hypoproteinemia and edema occur in the absence of either proteinuria or defects in protein synthesis. It is a consequence of the intestinal epithelial cell damage and increased mucosal permeability induced by <i>C. difficile</i> enterotoxin. The clinical manifestations are ascites and low serum albumin levels. The treatment requires human albumin intravenous integrations and diuretics. Ascites could be a direct complication of antibiotic-associated pseudomembranous colitis, but it could also be the manifestation of a protein-losing enteropathy, caused by inflammatory damage of gastrointestinal mucosa.

Pseudomembranous colitis in a pregnant woman

Pseudomembranous colitis in association with pregnancy has not been well described in English literature. Recent studies show a drastic increase in the incidence and severity of Pseudomembranous colitis in pregnant women, who were once thought to be at low risk. We report here a case of Pseudomembranous colitis in a young healthy immunocompetent pregnant lady. An early suspicion of this entity with the characteristic appearance of pseudomembranes on colonoscopy and histology confirmed the diagnosis enabling prompt treatment and complete recovery without any serious consequences.

A Case of Pseudomembranous Colitis in Old Age which was Misdiagnosed as Acute Appendicitis with Perforation

Pseudomembranous colitis is mostly related to antibiotics and it presents symptoms of diarrhea, abdominal pain, fever, hypoalbuminemia and hypovolemia. Diarrhea is the most common manifestation, but in geriatric patients, symptoms of pseudomembranous colitis can be different from those of usual cases and the course of disease can be more aggressive. For these reasons, it can be misdiagnosed. So physicians must take pseudomembranous colitis into consideration in older patients with acute abdominal pain, who have been treated with antibiotics. We reported a case of an older patient with pseudomembranous colitis which was misdiagnosed as acute appendicitis with perforation.

Need for Clinicopathologic Correlation of Clostridium difficile Colitis in View of Molecular Diagnosis

TO THE EDITOR—We read with interest the review titled “Effective utilization of evolving methods for the laboratory diagnosis of Clostridium difficile infection” [1]. The article mentioned that the Infectious Diseases Society of America/Society for Healthcare Epidemiologoy of America guidelines stipulate that once diarrhea is present, histopathologic presence of pseudomembranes is one test that can be used to define C. difficile colitis [2]. We performed a correlation of pathology with C. difficile toxin enzyme immunoassay (EIA) and molecular-based assay (polymerase chain reaction [PCR]) in stool while validating the latter. Of the 56 patients used in the laboratory validation, only 7 had a colonoscopy with biopsies performed. In these 7 patients, 2–4 stool samples had been obtained, and at least 1 sample had been positive for the toxin in each of the patients. The C. difficile gene was detected by PCR in only 3 of the 7 patients. The biopsies had been obtained within a range of 1–60 days of the positive stool sample. Only 1 patient showed pseudomembranous colitis in the colonoscopy and by histopathology 16 days after the toxin and gene were detected. The other 2 patients in which the toxin and gene were detected showed focal active colitis and an enterocutaneous fistula. The pathology in the 4 patients with presence of toxin (positive EIA) but no evidence of the gene (negative PCR) varied from minimal inflammation to active ulcerative colitis. Our colonoscopic and histopathologic results underscore the great variability found when C. difficile is detected by EIA and PCR in stool. There have been few studies that correlate the presence of C. difficile and endoscopic and histopathologic findings [3–6]. In adults with C. difficile–associated diarrhea, pseudomembranes were detected in 51%–89% of patients by endoscopy and in 63% by histology; the remainder showed normal endoscopies or erythema [2, 3]. In a study by Mogg et al [6], only 31% of patients with diarrhea had pseudomembranous colitis histologically and presence of C. difficile toxin in stool, 27% had positive histology and negative C. difficile toxin, and 42% had suspicious histology with positive toxin in stool. The presence of pseudomembranes may not occur in patients with evidence of C. difficile–associated diarrhea in patients who are neutropenic or immunosuppressed, have received hematopoietic stem cell transplantation, or have ulcerative colitis [4]. The majority of cases of pseudomembranous colitis are due to C. difficile; however, some are due to other pathogens [7–9]. El-Gammal et al [10] looked at the use of C. difficile toxin results by clinicians and found that results had minimal impact on treatment decisions. At our institution, there was skepticism of the C. difficile PCR results even though the validation showed better sensitivity and specificity than the toxin (EIA) assays and need for testing fewer samples. Due to the increased sensitivity of the PCR test, clinicians have raised concerns about potential colonization with a toxin-producing strain. Studies that address the clinical usage of the different test results as well as studies that correlate signs, symptoms, colonoscopy, and histopathology with the newer tests are needed.

Tests for the diagnosis of Clostridium difficile infection: The next generation

Clostridium difficile ( C. difficile) causes 25–30% of cases of antibiotic associated diarrhea and most cases of pseudomembranous colitis. Patients presenting with diarrhea after hospitalization for 3 or more days should be tested for C. difficile. There are many options available for testing, each of which has inherent advantages and disadvantages. Most laboratories perform toxin testing using an enzyme immunoassay method. In general these tests have sensitivities ranging from 60 to 70% and specificities of 98%. When using these methods, symptomatic patients with negative tests should be tested by another more sensitive method. Until recently, cell culture cytotoxicity neutralization assays (CCNAs) were considered the gold standard in the U.S. A two-step algorithm using an EIA for glutamate dehydrogenase detection followed by testing positives using CCNA, offered an improved alternative until the availability of molecular assays. Although early studies that compared the GDH assay to CCNA demonstrated high sensitivity and negative predictive values, more recent comparisons to toxigenic culture and PCR have shown the sensitivity to be in the mid to high 80’s. When testing using a sensitive assay, repeat testing is not cost-effective. Outbreaks caused by a toxin variant epidemic strain have renewed interest in bacterial culture. Toxigenic culture has emerged as the new gold standard against which newer assays should be compared. However, there is no agreed upon standard method for culture performance. At least 4 FDA cleared nucleic acid amplification assays are available to clinical laboratories and several of these have been well evaluated in the literature. Because these assays detect a gene that encodes toxin and not the toxin itself it is important that laboratories test only patients with diarrhea. These molecular assays have been shown to be superior to toxin EIAs, CCNA and 2-step algorithms, but not to toxigenic culture. More studies are needed to assess the impact of molecular tests on treatment and nosocomial spread of Clostridium difficile infections.

Post-Esophagectomy Pseudomembranous Inflammation of the Interposed Colon

Pseudomembranous colitis (PMC) usually is caused by antibiotic-related changes in colonic anaerobic microflora, leading to Clostridium difficile overgrowth and overproduction of toxins. We present the first reported case of PMC affecting the intrathoracic, interposed colon of an esophagectomy patient in the absence of inflammation of the in situ colon. Case report and review of pertinent English-language literature. A 47 year-old male developed Clostridium difficile-related colitis after in Ivor-Lewis esophagectomy for carcinoma of the esophagus, and rendered asymptomatic after 10 days of therapy with oral vancomycin. Postoperatively, the patient developed a broncho-esophageal fistula, and was reconstructed with a two-stage colonic esophageal colonic interposition three months after the fistula was closed surgically. On postoperative day nine, the patient developed symptomatic PMC of the interposed colon segment, whereas the in situ colon was spared. Therapy with oral vancomycin for three weeks eradicated the infection. Pseudomembranous colitismay develop in the interposed colon after a esophageal colonic interposition, even absent inflammation of the in situ colon. Previous infection with C. difficile may have increased the risk in this patient.

PSEUDOMEMBRANOUS COLITIS COMPLICATING ULCERATIVE COLITIS

Clostridium difficile toxin (CD toxin) causes antibiotic-associated colitis, or pseudomembranous colitis (PMC). Although CD toxin is sometimes found in the stools of patients with ulcerative colitis (UC), UC is rarely complicated by PMC. We report herein a case of PMC complicating UC, and present a review of the literature. A 71-year-old woman was diagnosed as having UC of the left colon, and treated with prednisolone and mesalazine. Later, however, lumbar spinal stenosis was also detected. After surgery for lumbar spinal stenosis, she suffered postoperative infection of the lumbar region. After 3-week treatment with antibiotics, she developed diarrhea, bloody stools, and abdominal pain. Colonoscopy revealed PMC of the cecum, ascending colon, sigmoid colon, and rectum. Stools were positive for CD toxin. As cefotiam hydrochloride, levofloxacin hydrate (LVFX), and prednisolone were suspected as the causative agents, she was treated with 1.5 g vancomycin (VCM) daily for 2 weeks without ceasing LVFX. Her symptoms improved, and colonoscopy confirmed resolution of PMC. The possibility of PMC should be considered in UC patients treated with antibiotics, immunosuppressive agents or corticosteroids who complain of gastrointestinal symptoms. These patients should be thoroughly investigated by several modalities, including colonoscopy and CD toxin testing.