For several days, a 50-year-old man has had copious green stools, vomiting, and fever. His symptoms began shortly after he was discharged from a regional burn center, where he was treated for full-thickness burns that covered 60% of his body surface.
For several days, a 50-year-old man has had copious green stools, vomiting, and fever. His symptoms began shortly after he was discharged from a regional burn center, where he was treated for full-thickness burns that covered 60% of his body surface. While at the center, he was given third-generation cephalosporins and fluoroquinolones for pneumonia and a urinary tract infection.
The patient is acutely hypotensive and tachypneic. He has generalized tenderness and moderate distention of the abdomen. A central venous catheter is placed for aggressive fluid resuscitation, and a chest film is obtained.
What abnormality is evident on this radiograph-and what further action is warranted?
(Answer on next page.)
The chest radiograph revealed subdiaphragmatic free air (arrow),which prompted immediate surgical consultation.
The patient underwent a subtotal colectomy, ileostomy, and the Hartmann pouch procedure. A grossly edematous and boggy colon, 3 L of peritoneal fluid, and a 2-cm transverse colonic perforation were noted during surgery. Pathological examination of surgical specimens revealed diffuse pseudomembranous colitis with multiple areas of full-thickness ischemia.
Diarrhea is a well-known complication of extended antibiotic therapy. Clostridium difficile infection accounts for 15% to 25% of cases.1
Symptoms of C difficile-associated pseudomembranous colitis range from mild diarrhea to toxic megacolon, colonic perforation, and overwhelming sepsis. In patients who have a colonic perforation, mortality is 32% to 50%.2 This patient had severe sepsis and pneumoperitoneum after acute colonic perforation secondary to C difficile infection.
Fluoroquinolones and clindamycin have been associated with pseudomembranous colitis; however, any recent antibiotic use can be a contributing factor.3 Other risk factors include prolonged hospitalization and use of narcotics or proton pump inhibitors.4,5
Virulence is related to the production of endotoxins A and B. Both cause severe mucosal inflammation and degradation of colonic epithelial cells, which lead to pseudomembrane formation and watery diarrhea.6 An enzyme-linked immunosorbent assay for the detection of endotoxins A and B in stool is required for diagnosis and has 80% to 90% sensitivity.7 In this patient, results were positive for endotoxin A.
Typically, mild disease is treated with oral metronidazole and moderate disease with oral vancomycin. Severe disease-as in this case-requires both oral vancomycin and intravenous metronidazole.1,8,9 This patient's postoperative course was uneventful, and he was discharged within 15 days of admission.
Recurrent C difficile diarrhea occurs in 5% to 50% of cases.1 Prevention of Clostridium-induced infections includes appropriate antibiotic use, contact precautions for exposed patients, cleaning environmental surfaces with bleach-containing solutions, and good hand-washing habits.10,11
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