Presence Of Pseudomembranes Research Articles

Pseudomembrane to nodule-gamut of ligneous conjunctivitis: A case report

Ligneous conjunctivitis is a type of chronic conjunctivitis characterized by the presence of pseudomembranes on the conjunctival surface. It can present as a part of a multisystem disease with involvement of other mucous membranes. A 1-year-old girl presented with features of conjunctivitis. Local examination revealed thick exudates in left tarsal conjunctiva, which was diagnosed as an ulcer with pseudomembrane and sterile culture. The patient presented with a nodular mass in the same site after a year, which showed a pseudomembrane along with sub- epithelial hyaline lobular deposits negative for Congo red, concurring a diagnosis of ligneous conjunctivitis. The patient was prescribed topical lubricating agents and regular follow up. Ligneous conjunctivitis is attributed to a deficiency of plasminogen, which plays a vital part in wound healing. The present case highlights the progression of pseudomembrane into a ligneous lesion in a child who was resisting medication and follows up.

Risk Factors that Predict the Failure of Multiple Fecal Microbiota Transplantations for Clostridioides difficile Infection.

Fecal microbiota transplantation (FMT) is a highly effective therapy for recurrent Clostridioides difficile infection (CDI); however, a small percentage of patients fail to achieve cure even after two FMTs. This high-risk cohort remains poorly understood. We performed a multicenter, multinational retrospective review of patients that underwent at least one FMT for a CDI indication at four academic FMT referrals. Patients' data including CDI, FMT, and FMT variables were assessed. The primary outcome was FMT failure after a second FMT defined as persistent diarrhea and positive laboratory test for C. difficile (PCR or toxin) despite a second FMT within 8weeks of the first FMT. A multivariable logistic regression model was performed to determine predictors of second FMT failure. A total of 540 patients received at least one FMT during the study period, of which 432 patients had success following the first FMT, 108 had documented failure (25%). Among those who failed the first FMT, 63 patients received a second FMT, of which 36 achieved cure, and 24 had documented failure after the second FMT. Patients that failed the first FMT but did not receive a second FMT and those lost to follow-up were excluded leaving 492 patients included in the analysis. The second FMT failure rate was 4.8% (24/492). Risk factors for second FMT failure identified by multivariable logistic regression included: inpatient status (OR 7.01, 95% CI: 2.37-20.78), the presence of pseudomembranes (OR 3.53, 95% CI: 1.1-11.33), and immunocompromised state (OR 3.56, 95% CI: 1.45-8.72) at the time of first FMT. This study identifies clinically relevant risk factors predictive of failing a second FMT. Clinicians can use these variables to help identify high-risk patients and provide a better-informed consent regarding the possibility of needing multiple FMTs.

Predictors and Management of Patients who Failed Fecal Microbiota Transplantation for Recurrent C. difficile Infection

Introduction: A fraction of patients have recurrent Clostridium difficile infection (CDI) after fecal microbiota transplantation (FMT). Known predictors include severe-complicated infection and inpatient FMT. We identified predictors and describe management and clinical outcomes of patients who fail FMT in a predominantly outpatient cohort of CDI patients. Methods: A nested case-control study of patients who underwent FMT for recurrent CDI from 08/2012 to 01/2017 was performed. FMT failure was defined as recurrent diarrhea with a positive C. difficile stool test. Cases were patients who had CDI recurrence after FMT and controls were patients with no CDI recurrence. Controls were matched to cases 1:1 for gender and timing of FMT ± 1 month to ensure similar follow-up time. Data including demographics, comorbid conditions, donor information, FMT route, post-FMT antibiotic exposure and post-FMT CDI management were collected. Results: Overall, 522 patients underwent FMT and 70 (13.4%) patients (median age 53.8 years, (range (18-89), 54.3% females) had recurrence within a median of 5.6 months following FMT (range 0.2-34.9 months). There were no differences in number of prior CDI episodes, courses of metronidazole, vancomycin or fidaxomicin prior to FMT, prior CDI related hospitalizations and mode of FMT delivery between cases and controls (Table 1). The use of non-CDI antibiotics after FMT (54.3% vs 21.4%, P<0.0001), presence of IBD (34.3% vs 15.7%, P=0.01), presence of pseudomembranes at FMT (4.3% vs 0%, P=0.03) and poor quality of bowel preparation (28.5% vs 21.4%, P=0.01) were associated with FMT failure. On multivariate logistic regression, IBD (OR 5.1, 95%CI, 1.9-14.2), use of non-CDI antibiotics after FMT (OR 7.8, 95%CI, 3.3-19.8) and poor quality of bowel preparation (OR 3.7, 95%CI, 1.5-9.0) predicted FMT failure, with an area under the curve of 0.78. Of patients who failed FMT, 12 were managed with repeat FMT after 1 antibiotic course, 15 were managed with repeat FMT after 2 antibiotic courses, and 5 with repeat FMT after 3 antibiotic course; 37 (52.8%) were successfully managed with antibiotics (25 vancomycin, 11 fidaxomicin, 1 metronidazole+vancomycin), 1 patient underwent colectomy for severe complicated CDI.Table: Table. Clinical characteristics of cases and controlsConclusion: Use of non-CDI antibiotics, IBD and poor quality of bowel preparation are associated with FMT failure. Patients with FMT failure can usually be managed with repeated courses of antibiotics or repeat FMT after antibiotic therapy.

Statins Improve Clostridium difficile Outcomes

Statins are increasingly recognized to have a positive outcome on a variety of infections, presumably through their anti-inflammatory effect. Does this include Clostridium difficile infection? To answer this question, researchers in Korea conducted a case-control study involving 1725 consecutive hospitalized patients with diarrhea and positive C. difficile toxin assays, C. difficile cultures, or presence of pseudomembrane on lower endoscopy. After exclusion …

The effects of statins on the clinical outcomes ofClostridium difficileinfection in hospitalised patients

An association between exposure to statin drugs and favourable treatment outcomes for various types of infections has been established.To determine the clinical characteristics and treatment outcomes of Clostridium difficile infection (CDI) among hospitalised patients taking statin drugs.The medical records were reviewed for consecutive in-patients with CDI confirmed by positive toxin assay (A or B), C. difficile culture, or the presence of pseudomembrane on endoscopy. Treatment success was defined as the resolution of diarrhoea within 6 days of therapy. The primary end points were assessed by average symptom recovery time and treatment response (success or failure).Among 949 patients, the overall response to metronidazole was 91.9%. The baseline characteristics showed some differences between statin users and statin non-users with respect to mean disease severity score. In the multivariate analysis, successful treatment response was significantly associated with the absence of exposure to proton pump inhibitors (PPIs) (OR = 0.690, 95% CI = 0.513-0.929, P = 0.014) and with exposure to statins (OR = 1.449, 95% CI = 1.015-2.070, P = 0.041). Contrary to the treatment response, univariate and multivariate analyses failed to show that exposure to PPIs or statins affected symptom recovery times. Sixty-day CDI recurrence rates for those patients with statin exposure were significantly lower compared with those patients without statin exposure (3% vs. 7.3%, respectively; RR = 0.393, 95% CI = 0.167-0.926, P = 0.033).Prior statin exposure in patients with C. difficile infection is associated with a successful response to treatment.

PCR vs “PCAren’t”

Clostridium difficile remains the most common nosocomial cause of diarrhea and is becoming an increasingly important community-acquired infection.1,2 Antibiotic resistance, as well as the recently identified BI/NAP1/027 strain, is responsible for more cases of severe C difficile –associated diarrhea worldwide.3 The diagnosis of C difficile infection is usually based on a combination of history of antibiotic use, the presence of pseudomembranes on colonoscopy, appropriate histology on biopsy, and confirmatory laboratory stool tests for either the C difficile toxin or bacterial toxin genes. Most clinical laboratories employ a C difficile –associated toxin enzyme immunoassay (EIA). These assays are technically easy to perform and have a rapid turnaround time. Although they have specificities ranging from 65% to 100%, the sensitivities are limited, ranging from 31% to 99%.4 Recently, US Food and Drug Administration–approved, polymerase chain reaction (PCR)–based molecular assays performed on stool lysates have been increasingly recognized as the most sensitive and specific methods of diagnosing C difficile . These assays target C difficile toxin genes rather than the toxins themselves, with a sensitivity from 77% to 100% and a specificity from 93% to 99%.5–7 The tissue diagnosis of C difficile in a gastrointestinal mucosal biopsy specimen is generally straightforward, although some infections (eg, enterohemorrhagic Escherichia coli , Shigella , and toxin-producing Clostridium perfringens ) may produce similar features both macroscopically and morphologically. Ischemia is frequently in the histologic differential diagnosis as well, and the distinction between the two is extremely important because the treatments are different. In their article in this issue of the American Journal of Clinical Pathology , Wiland and colleagues8 examine the degree of interobserver agreement in the histologic diagnosis of C difficile colitis and correlate the histologic findings with clinical data. They also …

The impact of pseudomembrane formation on the outcome of Clostridium difficile-associated disease

Although pseudomembranes are the hallmark manifestation of Clostridium difficile-associated diarrhea (CDAD), there are scant data specifically addressing their impact on the clinical outcome. We investigated whether the formation of pseudomembranes predicts a worse CDAD outcome. CDAD patients hospitalized during 2010 underwent sigmoidoscopy and were followed prospectively. In addition, all hospitalized CDAD patients in the period 01/2000-12/2009 who underwent lower endoscopy were retrospectively identified and their charts reviewed. Patients with detectable pseudomembranes on endoscopy were compared to those in whom pseudomembranes were absent. Thirty-day mortality and a composite outcome comprised of mortality within 30 days of diagnosis, admission to the intensive care unit (ICU), colectomy, peritonitis, hemodynamic instability, or respiratory insufficiency were addressed. Additional clinical outcomes used for comparison between the two groups were 60-day mortality, duration of hospitalization, and the failure of metronidazole and vancomycin. A total of 117 CDAD patients (mean age 62.9 ± 19 years) who underwent lower endoscopy were included; 46 with pseudomembranes and 71 without. Seven out of the 46 patients with pseudomembranes died within 30 days compared to 9/71 in the non-pseudomembrane group [odds ratio (OR) 1.2, 95% confidence interval (CI) 0.4-3.6, P = 0.8]. Similarly, there was no correlation between the occurrence of pseudomembranes and the rate of the composite adverse outcome (P = 0.6). In contrast, acute renal insufficiency (OR 15, 95% CI 3.2-72, P < 0.001) and hypoalbuminemia (OR 5.7, 95% CI 1.8-18, P = 0.002) were both independently predictive of a severe clinical outcome. Our findings suggest that the presence of pseudomembranes is not associated with an adverse outcome in CDAD patients.

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.

Traqueobronquitis aspergilar en paciente sometido a trasplante pulmonar

Background : Aspergillus tracheobronchitis is an uncommon cause of pulmonary aspergillosis and almost exclusively affects lung transplant recipients. There is no lung tissue involvement, thus the tracheobron-chial tree is only affected. Patients are asymptomatic, so it is important to make an early diagnosis to prevent progression of the infection and airway complications. Several prophylaxis and treatment strategies have proven to improve the prognosis. Clinical case : This is the case of a 56 year-old man who underwent bilateral lung transplant for chronic obstructive pulmonary disease (COPD) and developed Aspergillus tracheobronchitis. He received the usual prophylaxis with nebulized liposomal amphotericin B every 48 h. Routine bronchoscopy performed 2 weeks after transplantation showed inflammation with the presence of pseudomembranes that produced a 50% stenosis of the right bronchial anastomosis. Biopsy of the pseudomembranes and bronchial aspirate yielded Aspergillus fumigatus. The patient started treatment with voriconazole twice a day, bronchial debride-ment through bronchoscopy was carried out, and the treatment with nebulized liposomal amphotericin B was continued every other day. Ten weeks later, there were no endobronchial lesions and the bronchial aspirate cultures were negative. Conclusions : Aspergillus tracheobronchitis is a complication of the lung transplant recipient. Early diagnosis and prompt antifungal therapy, including new antifungal agents and local debridement, may significantly improve the outcome.

Faecal toxin and severity of antibiotic-associated pseudomembranous colitis.

The relationship between faecal toxin titre, histological evidence of pseudomembrane in the rectum, and severity of antibiotic-associated colitis has been analysed from data on 62 patients whose faeces contained Clostridium difficile toxin. There was a significant correlation between a toxin titre of 6400 or more and the presence of pseudomembrane (p less than 005). There was no correlation between toxin titre, duration of diarrhoea, total white cell count, temperature, serum albumin or serum orosomucoid concentrations. There was, however, a significant correlation between the presence of rectal pseudomembrane and duration of diarrhoea (p less than 0.005). Exposure to clindamycin or lincomycin was also associated with a significantly higher toxin titre than that seen in patients who were given other antibiotics. The duration of diarrhoea of diarrhoea was not longer and rectal pseudomembrane did not occur more often in the patients who had received clindamycin or lincomycin.