Images in Clinical Medicine
Pseudomembranous Colitis Associated with Clostridium difficile
N Engl J Med 2005; 353:2491December 8, 2005
- Article
A 75-year-old man with peripheral vascular disease, chronic obstructive pulmonary disease, and diabetes mellitus presented with gangrene of the right fourth toe and underwent tarsal–metatarsal amputation to manage the progression of gangrene, followed by amputation of the right leg below the knee. His hospital course was complicated by a myocardial infarction and pneumonia. During hospitalization, he was treated with multiple antimicrobial agents, including imipenem, vancomycin, piperacillin, tazobactam, and gatifloxacin. During the sixth week of hospitalization, abdominal pain, nausea, diarrhea, fever, and leukocytosis characterized by 48,000 leukocytes per microliter developed. A stool culture and toxin screen were both positive for Clostridium difficile. Radiologic imaging (Panel A) showed a dilated small intestine and colon with thumbprinting (arrows) but no free air. The patient was treated with metronidazole and vancomycin, but toxic megacolon developed. The patient refused further intervention and died during the eighth week of hospitalization.
At autopsy, the colon showed evidence of pseudomembranous colitis with multiple yellow plaques (Panel B) and a grossly thickened bowel wall (Panel C; bowel wall of normal thickness from a different patient is shown in Panel D). Prolonged hospitalization associated with the use of broad-spectrum antimicrobial agents is an important risk factor for the development of C. difficile infection. Thickening of the bowel wall associated with colonic mucosal ulceration may lead to perforation or secondary sepsis.
Paul L. Wolf, M.D.
Armen Kasyan, M.D.
University of California Veterans Affairs Healthcare Medical Centers, San Diego, CA 92103- Citing Articles (1)
Citing Articles
1
Lynne V. McFarland, Henry W. Beneda, Jill E. Clarridge, Gregory J. Raugi. (2007) Implications of the changing face of Clostridium difficile disease for health care practitioners. American Journal of Infection Control 35:4, 237-253
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