Clostridium difficile pseudomembrane colitis

Dr.Jerin.K.John, Dr.Bhanu vikraman pillai (Dr.Anupa (Ped gastro,AIMS), Dr.Neeraj(Ped gastro,AIMS),Dr.C.Jayakumar
A 3-year-old girl with normal perinatal history presented with a 2-week history of bloody loose stools occurring 10-12 times a day, and high-grade intermittent fever.At admission her vitals were stable 
The child appeared ill with signs of some dehydration. The abdomen was soft and non-tender, but there is history of oliguria.

The patient had a history of acute diarrheal disease (ADD), pharyngitis, and oral candidiasis, for which she received ceftriaxone followed oral cefixime for 7 days. She experienced reduced oral intake and oral thrush for 2 days and was treated with injectable amikacin, oral azithromycin, and rifaximin.

Labs HB 10.1 g/dL, 
TC 14,000/cu mm P 67% L17% PLT 301,000/cu mm,CRPl68 mg/L, ESR15 mm/hr,PT) of 17.3 /1.19, 
Calprotectin 1220 µg/g. 
PS showed toxic granules in polymorphs. Serum electrolytes, liver function tests, blood urea, creatinine, and CSF studies were normal. 
Malarial parasites NIL 
Blood and urine cultures were sterile. 
Stool routine normal
Quantiferon-TB Gold test was negative.

USG Diffuse thickening of the rectosigmoid wall up to 9 mm, thickening of the left colon wall up to 5-6 mm, and inflammation of the right colon. Adjacent mesenteric fat showed thickening with small lymph nodes. 
Upper endoscopy revealed no significant findings, while flexible sigmoidoscopy showed rectal prolapse with perianal ulceration, rectal ulceration, friability, severe sigmoid inflammation with ulceration, exudates, and nodularity. The sigmoid lumen could not be visualized.

Multidetected computed Tomography (MDCT)revealed extensive colitis involving the terminal ileum, with no evidence of strictures, enteroenteric or enterocutaneous fistulas, or bowel obstruction. 
There were traces of mild right pleural effusion.

HPE -no specific pathology in the duodenum biopsy and focal erosion in the antrum of the stomach biopsy. 
Biopsies of the sigmoid colon and rectum indicated pseudomembranous colitis without chronicity. Stool culture for Clostridium difficile was negative, and a cyto-toxin assay was not performed.

The patient was initially managed with intravenous fluids and broad-spectrum antibiotics. Considering the possibility of pseudomembranous colitis, antibiotics were stopped, and metronidazole was initiated. When her symptoms persisted, treatment was escalated to include vancomycin in addition to metronidazole. The patient showed significant improvement, with a marked decrease in diarrhea and resolution of abdominal symptoms. She made a full recovery and was discharged with normal clinical and laboratory parameters. Follow-up visits confirmed her continued well-being without recurrence of symptoms.
Discussion

Clostridium difficile pseudomembranous colitis is a severe form of colitis primarily caused the bacterium Clostridium difficile (C. difficile). This condition is often associated with the use of antibiotics, which disrupt the normal intestinal flora, allowing C. difficile to proliferate and produce toxins that damage the intestinal lining.

The clinical presentation of C. difficile pseudomembranous colitis includes watery diarrhea, abdominal pain, fever, and, in severe cases, blood in the stool. In children, the symptoms can be particularly severe, and the diagnosis can be challenging due to the overlap with other gastrointestinal conditions. In this case, the patient’s prolonged diarrhea, fever, and hematochezia, following multiple courses of antibiotics, raised suspicion for pseudomembranous colitis.

Diagnosis of C. difficile infection traditionally involves stool culture, detection of toxins A and B in the stool, and molecular tests for C. difficile genes. However, these tests can have variable sensitivity, and negative results do not entirely rule out the infection. In such instances, endoscopic examination and histopathological analysis can provide crucial diagnostic information. Endoscopic findings typically include characteristic pseudomembranes—yellowish plaques on the colonic mucosa—which were observed in this patient.

The pathogenesis of pseudomembranous colitis involves the production of toxins A and B C. difficile, which cause inflammation, epithelial damage, and formation of pseudomembranes composed of inflammatory cells, fibrin, and necrotic tissue. The histopathological examination in this case confirmed the presence of pseudomembranous colitis without chronicity, supporting the diagnosis.

Management of C. difficile pseudomembranous colitis involves discontinuation of the inciting antibiotics and initiation of specific anti-C. difficile therapy. Metronidazole 30mg/kg/day and vancomycin 40mg/kg/days for total 10 days are commonly used antibiotics for treating this condition. In this case, the patient responded well to metronidazole and vancomycin, demonstrating significant clinical improvement.

This case underscores the importance of considering C. difficile infection in pediatric patients with a history of antibiotic use presenting with severe gastrointestinal symptoms. Early recognition and appropriate treatment are essential to prevent complications and ensure recovery. Regular follow-up is also necessary to monitor for potential recurrence of the infection.

Take-Home Messages

1. Excessive Use of Antibiotics: This case highlights the risks associated with the excessive and inappropriate use of antibiotics, which can disrupt the normal intestinal flora and predispose patients to severe infections like C. difficile pseudomembranous colitis.
2. Consider C. difficile in Acute Diarrhea: In patients, especially children, presenting with acute diarrheaand a history of recent antibiotic use, clinicians should have a high index of suspicion for C. difficile infection and consider appropriate diagnostic tests and treatment options.