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166 SEVERE PSEUDOMEMBRANOUS COLITIS IN AN ADULT CYSTIC FIBROSIS (CF) TRANSPLANT RECIPIENT H Chaun, J Telford, E Lam, R Enns, P Vos, PT Phang, P Zetler Carrier rates of Clostridium difficile (CD) in CF patients are high, up to 50% (normal adults 2%), but pseudomembranous colitis (PC) is rare. Only three cases of severe antibiotic-associated colitis have been reported in adult CF patients, in one a cause of acute abdomen after lung transplantation. This is the first reported case of a post-transplant adult CF patient requiring emergency colectomy for intractable severe PC.
Departments of Medicine (Gastroenterology), Radiology, Surgery and Pathology, St Paul's Hospital and University of British Columbia, Vancouver, British Columbia
CASE REPORT: A 47-year-old man, diagnosis of CF aged 11, was the first CF patient to have bilateral lung transplantation in Canada in 1985. In 1998, he had kidney transplant for cyclosporine-induced end-stage disease, and aortic aneurysm repair. He was a known CD carrier. He was maintained on prednisone, azathioprine, cyclosporine and pancrealipase MT16. He received iv ciprofloxacin and piperacillin for cholecystectomy (cholelithiasis) and bile duct exploration with stone extractions October 2004. During admissions for debilitation, abdominal pain and diarrhea in December 2004 and February 2005, ultrasound showed diffusely thickened colonic wall, flexible sigmoidoscopy nodular lesions throughout distal colon, biopsies demonstrating PC, stool positive for CD toxin, treated with metronidazole. He received moxifloxacin and later cefuroxime for lung infections, and fluconazole for candida esophagitis. Colitic symptoms persisted despite colonoscopy and biopsies showing improving CD colitis. On readmission March 23 with progressive abdominal pain (morphine prn and Tylenol #3 taken at home), anorexia, weight loss and frequent small formed nonbloody stools, temperature was 38°C, pulse 101, BP 99/55, abdomen tender, WBC 28.8 (neutrophils 26.1), creatinine 278, Na 125, K 5.6, albumin 11, stool positive for CD toxin, CT gross abnormalities compatible with PC. He failed to respond to vancomycin po and metronidazole po then iv. He underwent total colectomy and ileostomy April 1, postoperative course uneventful. Pathology revealed extensive PC involving the entire large bowel, with microscopic features typical of PC.
CONCLUSION: Although CD carrier rates in CF patients are high, PC is extremely rare. This patient had PC which was distinctly intractable and severe, it might have been due to his markedly immunocompromised state, significantly altering his host defence mechanism.