Case Presentation: A 79-year-old man with a past medical history of congestive heart failure, hypertension, hyperlipidemia, prior Clostridium difficile ( C. difficile ) infection presents with multiple episodes of foul smelling diarrhea. Physical examination revealed a well-nourished, well developed male with a normal exam. Vital signs were remarkable for a blood pressure of 84/47 mm hg. Laboratory findings included a white blood cell count of 12 with 87 % neutrophils, potassium of 3.1, and chloride of 115. Computed Tomography (CT) scan of the abdomen and pelvis was remarkable for colitis of the sigmoid and descending colon, acute thrombosis of the inferior mesenteric artery (IMA) and associated distal branches and stenosis of the superior mesenteric artery. Recurrence of C. difficile infection was suspected with initiation of empiric oral vancomycin. C. difficile infection was confirmed via polymerase chain reaction testing. Serial review of prior CT images confirmed new IMA thrombus when compared to a CT scan from 2.5 months prior without evidence of mesenteric ischemia. In the setting of an acute IMA thrombus, therapeutic anticoagulation was initiated. The patient’s hospital course was otherwise uncomplicated with achievement of hemodynamic stability, resolution of diarrhea and discharge on a tapering course of oral vancomycin.

Discussion: With widespread use of antibiotics, C. difficile colitis has become a relatively common occurance, however associated thrombosis is an uncommon and less understood phenomenon. The rapid development of the IMA thrombosis suggests recurrent and active C. difficile infections potentially accelerate mesenteric artery thrombus formation. Mesenteric arterial thrombosis is most commonly the result of slowly progressive atherosclerotic disease which allows for the development of collateral blood vessels over time. Bowel ischemia occurs with gradual occlusion of these vessels. Infection is a rare but reported cause of mesenteric thrombosis. Patients with C. difficile infections are at increased risk of venous thromboembolic events. C. difficile generates toxins that upregulate pro-thrombotic inflammatory markers. A common pathway activated by pro-inflammatory biologic stimuli has been proposed in the development of both arterial and venous thrombosis. Clinicians should maintain a high clinical suspicion for bowel ischemia from arterial thrombosis in patients with C. difficile infections with worsening abdominal pain. Asymptomatic acute mesenteric artery thrombosis as in our patient also warrants therapeutic anticoagulation to prevent future bowel ischemia and infarction.

Conclusions: Bowel ischemia caused by arterial mesenteric thrombosis may lead to rapid mortality, making disease recognition paramount. In addition to multiple well described complications of C. difficile infections, the possibility of mesenteric artery thrombosis formation and propagation should be considered in patients with predisposing cardiovascular risk factors.

IMAGE 1: Thrombosed Inferior Mesenteric Artery