Case Presentation: A 59-year-old male presented to the ED with tachycardia, hypotension, and three days of vomiting and abdominal pain. He was recently hospitalized for acute hypoxic respiratory failure after several missed hemodialysis sessions. His comorbidities include end-stage renal disease (ESRD) on hemodialysis, peripheral neuropathy on tramadol, and peritoneal mesothelioma not on treatment. Initial labs were notable for a neutrophilic leukocytosis to 10.1 x10^9/L (normal 3.4-9.6) and electrolyte abnormalities consistent with ESRD. An abdominal CT obtained in the ED demonstrated diffuse ileus and known abdominopelvic carcinomatosis. The patient was made NPO, and a nasogastric tube was placed with 1.5 liters of bilious output.The patient’s leukocytosis increased to 16.3 x10^9/L, and his tachycardia continued. Chest x-ray was unremarkable. A repeat abdominal CT redemonstrated diffuse ileus with no evident source of infection. Blood cultures were negative. The patient reported ongoing abdominal pain and distention and had not yet had a bowel movement. Overnight, he became increasingly hypotensive and was transferred to the ICU where vancomycin, piperacillin/tazobactam, and vasopressors were initiated. The patient continued to worsen, requiring higher doses of vasopressors. He leukocytosis increased to 31.6 x10^9/L and his CRP was 350 mg/L (normal < 5) despite multiple days of antibiotics. Infectious diseases was consulted and recommended further workup with fungal studies and a transthoracic echocardiogram, which were unremarkable.On day 9 of hospitalization, the patient passed a small stool. Polymerase chain reaction (PCR) testing of the stool for Clostridioides difficile toxin producing gene was positive. Oral vancomycin and IV metronidazole were administered, with resolution of his leukocytosis, ileus, and shock over the next 48 hours. The patient stabilized and returned to the medical floor.
Discussion: It is important to be aware of varied presentations of C diff infection (CDI). C. diff testing is generally only recommended when there are ≥ 3 bowel movements over the past 24 hours. The testing method used at our institution is stool PCR for the C. diff toxin-producing gene. However, asymptomatic carriers can also test positive for this gene. Another common testing method includes a screening test for glutamine dehydrogenase (GDH), an enzyme produced by C. diff and similar bacteria, followed by an enzyme immunoassay (EIA) that detects toxins A/B in stool. EIA testing is highly specific for CDI but not very sensitive. Frequently, patients test positive for GDH and have a negative EIA, which can confuse clinicians.Although this patient likely had a CDI on presentation, suspicion was initially low given the lack of diarrhea. In fact, the electronic medical record and the microbiology lab discouraged ordering C. diff testing for this reason. One feature of fulminant CDI is paralytic ileus, as seen in this patient, which explains his lack of diarrhea. There should be high suspicion for CDI in patients who have relevant risk factors and who meet many criteria for CDI, even in the absence of diarrhea. In these cases, ACG guidelines suggest sending rectal swabs for testing.
Conclusions: In rare cases, Clostridioides difficile infection can present without diarrhea. Providers should not withhold C. diff testing solely due to lack of diarrhea if other clinical evidence points to a CDI diagnosis . Rectal swabs can be used if no stool sample is available.