Case Presentation: 53 year old male was admitted for treatment of acute alcohol intoxication and multiple facial bone fractures after an assault. He underwent surgical repair and was started on Unasyn for post-op prophylaxis. After the surgery, patient exhibited signs of alcohol withdrawal (delirium, tachycardia and agitation) and was started on benzodiazepines. During the next two days, he developed tachycardia, tremors, diaphoresis along with altered mental status. He was transferred to the medical intensive care unit (MICU) for closer monitoring where he was transitioned to phenobarbital. He developed a low grade fever and diarrhea although abdominal exam was reassuring. Chest x-ray revealed bibasilar infiltrates raising concern for aspiration pneumonia. Patient was started on broad spectrum antibiotics. The etiology of diarrhea was thought to be alcohol withdrawal and phenobarbital. While in MICU, patient’s mentation and vitals improved and he was transferred to medical floors. Due to persistence of diarrhea however, Clostridium difficile stool antigen was sent but was found negative. Unfortunately, the following day, patient once again developed tachycardia, hypotension, lethargy and high grade fever. Given new hemodynamic instability, he was readmitted to MICU where he was continually resuscitated with fluids. However, he was noted to have worsening foul smelling diarrhea. On exam, diffuse abdominal tenderness was noted and patient appeared to be in general distress. Given this presentation, Clostridium difficile stool antigen testing was resent, despite negative results from one day before. This time, the results came back positive. Patient was swiftly started on oral and rectal vancomycin along with IV metronidazole. CT abdomen was remarkable for extensive thickening of colon extending from the cecum to the rectum consistent with pseudomembranous colitis. Repeat lab studies showed severe leukocytosis and worsening lactic acidosis. Patient eventually required pressor support and was intubated for airway protection. He was urgently taken to the OR where his colon was found to be diffusely dilated, thickened and necrotic. He underwent total colectomy with end ileostomy.
Discussion: Clostridium Difficile is a colonizing microbe in the gut flora. It is competitively suppressed by other microbes. Its infective character is only seen when it overgrows and starts to produce one of its two toxins. Prevalence of infection is about half a million cases per year in the US alone. The mortality rates for individuals over the age of 65 are quite high with rates of death approaching 1 out of 11 cases. There are multiple risk factors that predispose a person to CDI. These include proton pump inhibitors, immunosuppression and use of broad spectrum antibiotics. Clostridium difficile PCR has become the gold standard for diagnosis with extremely high sensitivity and specificity. Regrettably, due to cost reasons, many institutions still send immunoassay as the initial screening test. Sensitivity of immunoassay is quite variable, ranging from 33% to 93.7%. Our patient initially tested negative on stool Clostridium stool antigen testing but was positive the very next day.
Conclusions: Although repeat testing for CDI within short intervals is generally frowned upon by experts, we contend that if there is a high clinical suspicion, repeat testing should be resent regardless. This is especially true in severely sick patients in whom the outcome of this test can make a real difference.