Case Reports
Clostridium difficile is a spore-forming, gram-positive bacillus that produces exotoxins that are pathogenic to humans. C. difficile--associated disease (CDAD) ranges in severity from mild diarrhea to fulminant colitis and death. Antimicrobial use is the primary risk factor for development of CDAD because it disrupts normal bowel flora and promotes C. difficile overgrowth. C. difficile typically has affected older or severely ill patients who are hospital inpatients or residents of long-term--care facilities. Recently, however, both the frequency and severity of health-care--associated CDAD has increased; from 2000 to 2001, the rate of U.S. hospital discharge diagnoses of CDAD increased by 26%.[1] One possible explanation for these increases is the emergence of a previously uncommon strain of C. difficile responsible for severe hospital outbreaks.[2] Although individual cases of CDAD are not nationally reportable, in 2005, the Pennsylvania Department of Health (PADOH) and CDC received several case reports of serious CDAD in otherwise healthy patients with minimal or no exposure to a health-care setting. An investigation was initiated by the Philadelphia Department of Public Health (PDPH), PADOH, and CDC to determine the scope of the problem and explore a possible change in CDAD epidemiology. This report summarizes the results of the investigation in Pennsylvania and three other states, which indicated the presence of severe CDAD in healthy persons living in the community and peripartum women, two populations previously thought to be at low risk. The findings underscore the importance of judicious antimicrobial use, the need for community clinicians to maintain a higher index of suspicion for CDAD, and the need for surveillance to better understand the changing epidemiology of CDAD.
A woman aged 31 years who was 14 weeks pregnant with twins went to a local emergency department (ED) after 3 weeks of intermittent diarrhea, followed by 3 days of cramping and watery, black stools 4--5 times daily. Stools specimens tested positive for C. difficile toxin, and the patient was admitted. Her only antimicrobial exposure during the preceding year was trimethoprim-sulfamethoxazole (for a urinary tract infection) approximately 3 months before admission. She was treated with metronidazole and discharged but was readmitted the next day for 18 days with severe colitis, receiving metronidazole, cholestyramine, and oral vancomycin. She improved on vancomycin and was allowed to return home. However, 4 days later she was readmitted with diarrhea and hypotension. She spontaneously aborted her fetuses. Despite aggressive treatment including a subtotal colectomy, intubation, and inotropic medication, the patient died on the third hospital day. Histopathologic examination of the colon demonstrated megacolon with evidence of pseudomembranous colitis.
A girl aged 10 years (unrelated and without contact with case 1) went to a children's hospital ED because of intractable diarrhea, projectile vomiting, and abdominal pain. She had not taken antimicrobials during the preceding year. Stool specimens were positive for C. difficile toxin. The child had been healthy until 2 weeks before the ED visit, when she became symptomatic within days of her younger brother having a febrile diarrheal illness. The boy was not on anti-microbials when he became ill. His symptoms resolved within 2--3 days without medical treatment, but his sister had fever as high as 102°F (39°C), abdominal pain, and diarrhea. One week into her illness, she was examined by a clinician, who performed a rapid streptococcal antigen test on a swab from her oropharynx; the result was positive. The patient was prescribed amoxicillin but was unable to take it because of her stomach cramps and diarrhea; her symptoms worsened until she was having liquid stools up to 14 times daily. Symptoms resolved with hospital admission and the administration of intravenous fluids, electrolytes, and metronidazole.
Morbidity and Mortality Weekly Report. 2005;54(47):1201-1205. © 2005 Centers for Disease Control and Prevention (CDC)
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Cite this: Severe Clostridium difficile-Associated Disease in Populations Previously at Low Risk - Four States, 2005 - Medscape - Dec 01, 2005.
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