Case Presentation:
A 26 year‐old female with history of Ulcerative Colitis (UC), status‐post partial colectomy and ileostomy five years ago presented with nausea, vomiting and abdominal pain for one day. She developed severe pain around her umbilicus area within few hours of eating a burger, associated with constant bilious vomiting. She also noticed increased output in her ileostomy bag, which got filled with yellow loose watery stools. She had associated fever and chills. She denies having any blood in her stools or any recent acute flare up of her UC. Physical examination revealed increased heart rate, fever and diffusely tender abdomen with normal bowel sounds, but no rigidity or guarding. Blood tests showed increased white cell count of 19.2 with 17% bands. CAT scan of her abdomen was unremarkable except for previous surgical changes. Initially empirical treatment was started with IV Ciprofloxacin and Flagyl and stool was sent for gram stain, culture, ova and parasites and fecal leukocyte stain. Stool culture came back positive for Methicillin‐resistant Staphylococcus aureus (MRSA). Clostridium difficile toxin, ova or parasites were not detected. Her blood cultures were negative. After MRSA was detected in stool, antibiotics were switched to IV Vancomycin dosed appropriately and PO Vancomycin 250mg every six hours. After 9 days of inpatient stay, she improved clinically, with resolution of her symptoms and normalization of white cell count. She was discharged home on 7 more days of PO Vancomycin 250mg QID.
Discussion:
A vast majority of gastroenteritis caused by Staphylococcus aureus is toxin induced and treatment is supportive with no role for antibiotics. In contrast to that, MRSA enteritis/enterocolitis is rare but serious illness presenting with fever, nausea, vomiting, diarrhea and abdominal pain and treatment with Oral Vancomycin is recommended. Patients with Inflammatory Bowel Disease (IBD) are predisposed to having increased incidence of infections caused by resistant organisms. A recent study by Nguyen et al showed a 1.4 times increased MRSA colonization in hospitalized IBD patient versus general medical floor patients; along‐with a seven fold increase in mortality. There are only a few published case‐reports of MRSA enterocolitis in patients with acute exacerbation of Ulcerative Colitis (UC). Our patient did not have any clinical evidence of acute exacerbation of her UC.
Conclusions:
MRSA is known to cause many, predominantly hospital‐acquired infections including bloodstream infections, surgical‐site infections, skin and soft tissue infections and pneumonia. Enteritis caused by MRSA is a very uncommon clinical entity. We presented our unique experience with a rare case of MRSA enteritis in a patient with Ulcerative Colitis (UC) without any acute flare of UC per se. With the newer data suggesting higher incidence of drug‐resistant organisms in IBD patients, we should have a high index of suspicion and prompt treatment with appropriate antimicrobial therapy should be initiated for favorable clinical outcomes.