Pseudomembranous colitis

Vignette says a 55 year old female presents to the emergency department with chief complaints of abdominal cramping, watery diarrhea, and a low-grade fever for the past 5 days; She was recently diagnosed with cystitis and was treated with ciprofloxacin; She denies any recent travel or known exposures to contaminated food or water; Abdominal examination is soft, mild tenderness on palpation and hyperactive bowel sounds on auscultation; Vital signs show blood pressure of 120/80 mm of Hg, pulse rate of 108 bpm, respiratory rate of 18 breaths/min, oxygen saturation of 92% in RA and temperature of 100.2 F; CBC shows WBC count of 12,000 cells/mm3; PCR test for Clostridium difficile toxin A and B are positive; Diagnosis?

Diagnosis is Pseudomembranous colitis.

Pseudomembranous colitis is caused by Clostridium difficile; often secondary to antibiotic use, especially clindamycin, ampicillin/amoxicillin, cephalosporin, fluoroquinolones; These antibiotics alter the normal intestinal flora favoring the growth of the clostridium difficile.

Clostridium difficile produces toxins A and B that damages the enterocytes; Toxin A (enterotoxin) damages the brush border whereas Toxin B (cytotoxin) damages the cytoskeleton.

Presents with fever, abdominal cramping, watery diarrhea, leukocytosis and toxic megacolon.

Diagnosis:- 

1. PCR or antigen detection of one or both toxins in stool; Clostridium difficile produces toxins A and B that damages the enterocytes.

Treatment:-

1. Stop the offending drugs.

2. Supportive measures like intravenous fluids and probiotics.

3. Antibiotics (e.g. oral vancomycin or fidaxomicin).

4. Fecal microbiota transplant in refractory cases. 

5. Monitor for complications such as toxic megacolon, perforation.

Figure:- Antibiotic Associated Diarrhea