Case Presentation: 52 year old female with history of stage IV invasive colorectal adenocarcinoma of sigmoid colon with multifocal bilobar liver metastasis s/p sigmoid colon resection, diverting loop ileostomy and partial hepatectomy (two stage surgery 6 weeks apart) admitted for one day of dyspnea improved by laying down and worsened by exertion/sitting up. Initially patient was admitted for concern for HCAP complicated by a small right pleural effusion noted on chest X-ray. CT of chest done on admission noted the right pleural effusion but also noted a rim containing fluid collection/abscess adjacent to right lobe of the liver. Patient was initially started on vancomycin and zosyn empirically. Two days later, patient was taken to IR for placement of pleural drain for the pleural effusion and percutaneous drain for subdiaphragmatic abscess. Cultures and fluid studies were sent from drainage from both sites. Light criteria was met as fluid LDH was >2/3 upper limit of normal serum LDH at 6, 558. Pleural fluid also demonstrated a total nucleated cell count of 35,345 with a neutrophilic predominance of 87%. Abscess culture was positive for C. difficile, which was confirmed by the laboratory. Infectious disease was consulted and they believed the infectious sites were likely polymicrobial and recommended discontinuing vancomycin and adding IV metronidazole to zosyn. Per discussion of the patient’s case, the infectious disease specialists were unsure if infection of the pleura was an empyema or the result of abdominal abscess tracking along the IR drain and transversing the pleural space. A CT of the chest later demonstrated multiple small loculations concerning for empyema. After approximately 10 days of antibiotics, repeat CT of the abdomen demonstrated improved pleural effusion with minimal output and the pleural drain was discontinued. The subdiaphragmatic drain was left in place as the abscess had not changed in size and continued to drain copious amounts of fluid. Of note, on CT of the abdomen the radiologist noted in the report marked circumferential colonic wall thickening indicative of C. difficile colitis.

Discussion: Extracolonic manifestations of C. difficile infections although rare are possible and have been documented. There have been a few case reports of appendicitis caused by C. diff infection. Additionally, there have been reports of small bowel involvement in patients with co-morbidities such as in this patient with a history of colectomy with ileostomy. In addition, there have been documented cases of cellulitis, soft tissue infections, bacteremia and reactive arthritis caused by C. difficile. Finally, upon literature review, there was a similar case report published in the Journal of Clinical Pathology in 1996 by Simpson et al., whereby a 46 year old male whereby the patient had a pleural infection by C. difficile following chest tube insertion. As expected, due to the rarity of extracolonic C. difficile infections, there are no explicit guidelines for treatment of these infections. The patient presented in this case had her infection managed by customary treatments for her presentation including percutaneous abscess drainage, tube thoracostomy drainage of empyema, and the use of the antibiotic Metronidazole, which is a typical treatment for C. difficile colitis.

Conclusions: Extracolonic manifestations of C. difficile infections although rare are possible and have been documented. The management in this case was handled in a typical standard of treatment.