An 84-year-old Caucasian female presented with 3 days of profuse, watery diarrhea and right knee pain. She had been hospitalized for bronchitis a few weeks ago, treated with amoxicillin-clavulanic acid and discharged. There was no history of trauma or travel. Her past medical history included CKD stage IIIa and diverticulosis. She was afebrile and her clinical exam was normal except for dry oral mucosa and minimal swelling of the right knee. She had a normal WBC count, UA and LFTs, but had a GFR of 27 (baseline 45-55 ml/min/1.73m2, and creatinine of 1.9 ( baseline 1). Stool was positive only for Clostridium difficile toxin. She was diagnosed with acute kidney injury from C. Difficile associated diarrhea and started on IV fluids with oral vancomycin. Her diarrhea and renal function improved but the pain and swelling of her right knee increased and flexion became restricted. Work up showed CRP of 118 mg/dL, and ESR of 18 mm/hr., while X-rays, Rheumatoid Factor, anti-CCP, Anti-Nuclear Antibodies and uric acid were normal. The knee joint was aspirated and showed 12090 leukocytes with 85% PMNs. Gram staining, crystals and eventually cultures were also negative.
Methylprednisolone was added and knee symptoms rapidly improved. Patient was discharged on oral prednisone and oral vancomycin for 2 weeks. On follow-up her renal insufficiency, diarrhea and knee pain had resolved. ESR and CRP had decreased to 12.2 mg/dL and 9 mm/hr. respectively.
Discussion:
Reactive Arthritis (ReA) is a syndrome of sterile asymmetrical autoimmune oligo-arthritis following infection. Preceding infections are usually Chlamydia, Campylobacter, Shigella, Salmonella, Yersinia, and Mycoplasma but CDI is distinctly uncommon. Only 50 CDI related ReA cases have been reported since the first case report in 1976. With increasing incidence of CDI, clinicians should expect to see more extra-gastrointestinal morbidity from CDI. CDI associated ReA has been mostly reported in younger people, with positive HLA-B27, with excellent prognosis. Although traditionally NSAIDs have been the first line of treatment, we used corticosteroids to avoid the well-known nephrotoxic effects of NSAIDs, since our patient had acute kidney injury. Even though conventional knowledge is that usage of corticosteroids in patients with CDI have worse outcomes, there is anecdotal evidence of refractory CDI being treated with corticosteroids. A recent study of elderly adults with pneumonia or COPD showed decreased incidence of CDI when treated with steroids. As demonstrated in this case, judicious use of corticosteroids in clinically appropriate situations may decrease morbidity in patients with CDI.
Conclusions:
With the rapidly increasing incidence of Clostridium Difficile Infection (CDI), clinicians are becoming more aware of atypical presentations and complications. Judicious use of corticosteroids in clinically appropriate situations may decrease morbidity in patients with Refractory CDI.