Medline ® Abstracts for References 29-31
of 'Clostridium difficile infection in adults: Clinical manifestations and diagnosis'
Extracolonic manifestations of Clostridium difficile infections. Presentation of 2 cases and review of the literature.
Jacobs A, Barnard K, Fishel R, Gradon JD
Medicine (Baltimore). 2001;80(2):88.
Clostridium difficile is most commonly associated with colonic infection. It may, however, also cause disease in a variety of other organ systems. Small bowel involvement is often associated with previous surgical procedures on the small intestine and is associated with a significant mortality rate (4 of 7 patients). When associated with bacteremia, the infection is, as expected, frequently polymicrobial in association with usual colonic flora. The mortality rate among patients with C. difficile bacteremia is 2 of 10 reported patients. Visceral abscess formation involves mainly the spleen, with 1 reported case of pancreatic abscess formation. Frequently these abscesses are only recognized weeks to months after the onset of diarrhea or other colonic symptoms. C. difficile-related reactive arthritis is frequently polyarticular in nature and is not related to the patient's underlying HLA-B27 status. Fever is not universally present. The most commonly involved joints are the knee and wrist (involved in 18 of 36 cases). Reactive arthritis begins an average of 11.3 days after the onset of diarrhea and is a prolonged illness, taking an average of 68 days to resolve. Other entities, such as cellulitis, necrotizing fasciitis, osteomyelitis, and prosthetic device infections, can also occur. Localized skin and bone infections frequently follow traumatic injury, implying the implantation of either environmental or the patient's own C. difficile spores with the subsequent development of clinical infection. It is noteworthy that except for cases involving the small intestine and reactive arthritis, most of the cases of extracolonic C. difficile disease do not appear to be strongly related to previous antibiotic exposure. The reason for this is unclear. We hope that clinicians will become more aware of these extracolonic manifestations of infection, so that they may be recognized and treated promptly and appropriately. Such early diagnosis may also serve to prevent extensive and perhaps unnecessary patient evaluations, thus improving resource utilization and shortening length of hospital stay.
Johns Hopkins University School of Medicine, Baltimore MD, USA.
Ileal perforation secondary to Clostridium difficile enteritis: report of 2 cases.
Hayetian FD, Read TE, Brozovich M, Garvin RP, Caushaj PF
Arch Surg. 2006;141(1):97.
Two cases of small-bowel perforation secondary to Clostridium difficile enteritis are described and compared with the 8 cases of C difficile enteritis reported in the medical literature. The cause of small-bowel involvement with C difficile is unknown, but prior antibiotic use, prior colectomy, chronic alterations in small-bowel flora, and other host factors are discussed.
Division of Colon and Rectal Surgery, The Western Pennsylvania Hospital, Clinical Campus of Temple University School of Medicine, 4800 Friendship Avenue, Pittsburgh, PA 15224, USA.
Pseudomembranous enteritis after proctocolectomy: report of a case.
Vesoulis Z, Williams G, Matthews B
Dis Colon Rectum. 2000;43(4):551.
Intestinal pseudomembrane formation, sometimes a manifestation of antibiotic-associated diarrheal illnesses, is typically limited to the colon but rarely may affect the small bowel. A 56-year-old female taking antibiotics, who had undergone proctocolectomy for idiopathic inflammatory bowel disease, presented with septic shock and hypotension. A partial small-bowel resection revealed extensive mucosal pseudomembranes, which were cultured positive for Clostridium difficile. Intestinal drainage contents from an ileostomy were enzyme immunoassay positive for C. difficile toxin A. Gross and histopathologic features of the small-bowel resection specimen were similar to those characteristic of pseudomembranous colitis. The patient was treated successfully with metronidazole. These findings suggest a reservoir for C. difficile also exists in the small intestine and that conditions for enhanced mucosal susceptibility to C. difficile overgrowth may occur in the small-bowel environment of antibiotic-treated patients after colectomy. Pseudomembranous enteritis should be a consideration in those patients who present with purulent ostomy drainage, abdominal pain, fever, leukocytosis, or symptoms of septic shock.
Department of Pathology, Akron City Hospital (Summa Health Systems), Ohio 44304, USA.