Clostridium difficile colitis: CT findings and differential diagnosis.

Clostridium difficile infection (CDI) is a severe and potentially deadly infectious colitis whose incidence is dramatically increasing in the last decades, with more virulent strains. CDI should be suspected in case of unexplained diarrhea and abdominal pain in patients with a recent history of antibiotic use and healthcare exposures; diagnosis is based on a combination of clinical and laboratory findings with demonstration of C. difficile toxins by stool test. The advantages of contrast-enhanced computed tomography (CECT) are the noninvasiveness and the ability to evaluate both the colonic wall and the adjacent soft tissues. Considerable overlap exists between the CECT findings of CDI and those of colitis of other origins, such as typhlitis, ischemic colitis, graft-versus-host disease, radiation colitis and inflammatory bowel diseases; however, some features may help distinguish between these conditions. This paper provides a comprehensive overview of the imaging features of Clostridium difficile colitis and its mimics, with a view to assist the radiologist in reaching the correct diagnosis.

Community-acquired fulminant colitis caused by binary toxin-producing Clostridium difficile in Japan.

We report a case of community-acquired fulminant colitis caused by Clostridium difficile in Japan. A 46-year-old woman was diagnosed with severe infectious enterocolitis and was admitted at another hospital. The stool culture was positive for toxigenic C. difficile. Since the patient presented with fulminant C. difficile infection (CDI) with toxic megacolon, respiratory insufficiency, and circulatory failure, she was transferred to Kyorin University Hospital for intensive care. Intubation and antibiotic therapy were performed. The general condition improved with conservative treatment, and she was discharged without sequelae. While the recovered isolate was toxin A and B-positive and binary toxin-positive, it was identified as polymerase chain reaction (PCR) ribotype ts0592 and slpA sequence type ts0592. The isolate was different from PCR ribotype 027 epidemic in Europe and North America. In Japan, binary toxin-producing strains are rare and have not caused an epidemic to date. Furthermore, there are few data on community-acquired CDI in Japan. In this case, a non-elderly woman with no major risk factors such as antibiotic use, administration of proton pump inhibitor and history of gastrointestinal surgery developed community-acquired fulminant CDI caused by the binary toxin-positive strain, and ICU treatment was required. Further studies focusing on the role of binary toxin-positive C. difficile in the severity of community-acquired CDI are necessary.

Clostridium difficile enteritis: diffuse small bowel radiological changes in a patient with abdominal sepsis.

While imaging appearances of pseudomembranous colitis are commonly recognised, radiological manifestations of Clostridium difficile-associated enteritis are poorly understood which, combined with the rarity of this infection involving small bowel, makes establishing the correct diagnosis challenging. Therefore, in order to encourage awareness of readers, we present a case of C. difficile enteritis that manifested as abdominal sepsis complicating the postoperative period in a middle-aged woman with fistulating Crohn's disease and defunctioning ileostomy. Radiological appearances are described based on three consecutive CT studies performed 5 days prior to onset of symptoms, during the peak of enteritis, corresponding with the patient's clinical deterioration, and also 35 days later following treatment and resolution.

Colite pseudomembranosa / Pseudomembranous colitis

A colite pseudomembranosa (CPM) foi descrita pela primeira vez em 1893 por Finney, sendo uma doença infecciosa que surge geralmente com o uso frequente de antibióticos, levando a um quadro de diarreia, sendo provocada por reação inflamatória intestinal às toxinas do Clostridium difficile. Apresenta-se, neste relato, o caso de uma paciente de 80 anos que, após internação, apresentou quadro de celulite nos membros inferiores (MMII), com hipertermia, rubor, dor, tratada por sete dias com ciprofloxacino 500mg de 12/12 horas com boa evolução. Trinta e cinco dias após, paciente retorna com quadro de distensão e de dor abdominal e diarreia mucosa. A retossigmoidoscopia associada à biópsia foi o método que estabeleceu o diagnóstico de colite pseudomembranosa, possibilitando tratamento clínico bem sucedido, evitando-se a intervenção cirúrgica.

Pseudomembranous colitis was inicially described in 1893 by Finney, resulting in an infectious disease which arises in the daily antibiotic consume, leading basically to diarrhea symptons, induced by Clostridium difficile toxin inflammatory reations. This case report exibits a 80th-year patient who, after being treated of an limb cellulitis, with pain, blush and heat, with ciprofloxacin 500mg 12/12h, being curable. Thirty five days later, patient returns presenting abdominal pain and distention, and volumous mucosal diarrhea. Submited to a retossigmoisdocopy followed by a biopsy, diagnosing a difuse pseudomembranous colitis, clinically treated, avoiding the surgical treatment.

Cephalosporins Associated Pseudomembraneous Colitis in an Elderly Male Patient - A Case Report.

INTRODUCTION: Incidence of antibiotic- associated diarrhoea is a common (10-30%) but pseudomembranous colitis (PMC) is less frequent (1-5%). Fluoroquinolones, clindamycin, penicillins, cephalosporins (mostly third generation) are commonly associated with PMC. The association between cephalosporins and PMC is now well established. CASE PRESENTATION: A 78 year old male patient developed pseudomembraneous colitis after administration of Ceftriaxone and Cefazoline for the treatment of pleural effusion. The reaction was confirmed by ultrasonography and CT scan. Causative agents were stopped and patient was managed by systemic therapy. Patient was expired due to respiratory complications as there was complexity in management of disease due to development of pseudomembraneous colitis. CONCLUSION: Increase awareness of prescribers for high-risk drugs, close monitoring, with immediate withdrawal of the culprit drug can reduce the complexity of management that occur due to development of such adverse drug reaction.

Nodular colitis: endoscopic image an unusual finding.

An 82-year-old male with a history of high blood pressure, COPD, chronic myeloid leukemia, and stage-4 chronic renal failure. Admitted to hospital for lower-limb cellulitis and severe COPD exacerbation, he received antibiotic therapy and bronchodilators. During his hospital stay he developed severe anemia and had an hematochezia event with no diarrhea. A complete colonoscopy found small (4-7 mm) nacreous elevated lesions, circumferential in shape, in the cecum and ascending colon with some bleeding stigmata and submucosal bleeding suggestive of infectious colitis; stool culture was negative and Clostridium difficile toxins were positive. The condition was histologically confirmed.

Clostridium difficile ileitis in a patient, after total colectomy.

This is a case of a 63-year-old, post total colectomy patient, who presented to the hospital with watery diarrhoea, abdominal cramping and fevers. On admission, the patient was haemodynamically stable and febrile. Clostridium difficile PCR was sent and tested positive. CT of the abdomen revealed diffuse thickening of the distal small bowel to the level of the anastomosis and mesenteric oedema consistent with infectious enteritis. The patient was started on vancomycin orally as well as flagyl intravenously. Because of an ileus, he initially was treated with bowel rest and a NG tube. Surgical consult was obtained early with no intervention. The patient's symptoms progressively resolved over the next 7 days of hospitalisation, and he was discharged home.

Multidetector computed tomography features of positive endoscopic or toxin assay Clostridium difficile colitis.

BACKGROUND: Pancolonic colonic wall thickening is a common CTfeature in patients diagnosed with Clostridium difficile colitis (CDC). OBJECTIVE: To illustrate CT appearances of CDC in hospitalized patients with toxin assay indicant or endoscopic proven CDC. MATERIAL AND METHOD: Two reviewers independently evaluated the colonic abnormalities in the retrospectively identified patients with toxin assay indicant or endoscopic proven CDC that underwent abdominal CT between January 2006 and June 2009. The colonic abnormalities included wall thickening, wall enhancement, the "accordion sign, pericolonic stranding, lymphadenopathy, ascites, gut obstruction, and associatedfindings such as small bowel involvement. They then compared the CT diagnostic findings with lab result and endoscopic findings RESULTS: Fifteen patients (in 897 patients) with toxin assay indicant or endoscopic proven CDC and underwent abdominal CT were included in the study. Colonic wall thickening (0.5 -1.6 cm) and mild degree of pericolonic fat stranding are commonly found in this study. Eleven (73.3%) patients had pancolonic wall thickening and the remaining four (26.6%) had segmental involvement. Accordion sign was demonstrated in 11 (73.3%) patients. No small bowel thickening was detected Contrast enhanced CT showed superior result to non-contrast enhanced CT for colonic wall thickness evaluation. Accordion sign were not different between contrast enhanced CT in patients that did not received oral/rectal contrast medium administration and non-contrast enhanced CT in patients that received adequate rectal contrast medium administration. CONCLUSION: Patients taking a broad spectrum of antibiotic were found to have colonic wall thickening, a mild degree of pericolonic fat stranding, and accordion sign on CT scan. The doctor should be concerned with CDC.

Recurrent Clostridium difficile colitis in cystic fibrosis: an emerging problem.

OBJECTIVE: To examine the incidence of recurrent Clostridium difficile infection in patients with cystic fibrosis (CF), including patients who had undergone lung transplantation, and review clinical findings in hospitalized patients with C. difficile colitis. METHODS: A retrospective chart review was performed to examine the clinical presentation and management of patients with cystic fibrosis (CF) who received care at the University of Wisconsin Hospital and Clinics (UWHC) from 1994 to 2011 and were prospectively identified with C. difficile colitis. RESULTS: Ten cases of C. difficile associated disease (CDAD) occurred in patients with CF followed by our Adult CF Center over a period of 17 years, and 4 patients were bilateral lung transplant recipients. Two of the lung transplant recipients had recurrent CDAD that lead to fulminant pancolitis, surgical intervention, and shock. Two patients in the non-transplant group experienced recurrent C. difficile infection that led to fulminant pancolitis with associated systemic inflammatory response syndrome and required colectomy. CONCLUSIONS: C. difficile colitis can cause life threatening illness in patients with CF, and symptoms may be subtle and/or atypical and lead to significant delay in diagnosis. Patients with recurrent C. difficile colitis are at high risk of fatal outcome, and empiric therapy should be considered for patients with previous C. difficile colitis even in the absence of disease when broad-spectrum antibiotics are given to treat bacterial infection.

[Successful treatment of life-threatening, treatment resistant Clostridium difficile infection associated pseudomembranous colitis with faecal transplantation]. / Életet veszélyezteto, terápiarefrakter Clostridium difficile fertozés okozta pseudomembranosus colitis sikeres kezelése széklettranszplantációval.

Due to world-wide spread of hypervirulent and antibiotic resistant Clostridium difficile strains, the incidence of these infections are dramatically increasing in Hungary with appalling mortality and recurrence rates. Authors present a case of a 59-year-old patient who developed a severe, relapsing pseudomembranous colitis after antibiotic treatment. Life-threatening symptoms of fulminant colitis were successfully treated with prolonged administration of metronidazole and vancomycin, careful supportive therapy and weeks of intensive care. However, a well-documented, severe relapse developed within a week and this time faecal bacteriotherapy was performed. This treatment resulted in a complete cure without any further antibiotic treatment. In relation to this life-saving faecal transplantation, methodology and indications are briefly discussed. In addition, microbiological issues, epidemiological data and threats associated with antibiotic treatment of Clostridium difficile infections are also covered. Finally, relevant professional societies are urged to prepare a national protocol for faecal transplantation, which could allow introduction of this valuable, cost-effective procedure into the routine clinical practice.

Intravenous immunoglobulin in treatment of Clostridium difficile colitis.

Clostridium difficile infection is the most common infectious cause of healthcare-acquired diarrhoea. Severe infections cause therapeutic challenges for healthcare providers. Various novel treatment modalities are currently being explored for treatment of severe disease. The authors report a 70-year-old female who presented to the emergency room with 1 week history of fever, watery diarrhoea, diffuse abdominal pain and weakness. C difficile toxin was detected in the stool and abdominal CAT scan showed extensive colonic wall thickening. The patient was started on intravenous metronidazole along with oral vancomycin. Due to the severity of the infection the patient was given intravenous immunoglobin for 4 consecutive days. The patient had vast improvement in her clinical symptoms with resolution of the multi-organ system failure. It is currently considered that the predominant intravenous immunoglobin's mechanism of action is through binding and neutralisation of toxin A by IgG antitoxin A antibodies.

[CT imaging features of colitis in neutropenic patients]. / Aspects tomodensitométriques des colites chez les patients neutropéniques.

Colitis in neutropenic patients presents with non-specific clinical findings including abdominal pain, fever, diarrhea and abnormal liver function tests. Four diagnoses are relatively more frequent: neutropenic enterocolitis, pseudomembranous colitis, intestinal GVHD and CMV colitis. Knowledge of their respective imaging features combined with epidemiological data frequently leads to the correct diagnosis. The purpose of this paper is to illustrate the imaging features of colitis in neutropenic patients.