A severe and complicated case of recurrent Clostridium difficile colitis in a 27- month-old boy: A rare entity in young children

We present a case of a 27-month-old boy with severe Clostridium difficile infection complicated by toxic megacolon, rectal prolapse, hypoalbuminemia, and ascites. The patient improved with antibiotics but later presented with recurrent Clostridium difficile colitis. Antibiotic therapy for recurrent Clostridium difficile infection was given and after recovery, fecal microbiota transplantation was performed to prevent further recurrence of disease. The patient did well on follow-up. Severe Clostridium difficile disease is rare in young children and colonization is common. Correspondence to: Dr. Maribeth Nicholson, MD, MPH, Division of Pediatric Gastroenterology, Hepatology, and Nutrition. Monroe Carell Jr. Children’s Hospital, Vanderbilt University, 2200 Children’s Way, Nashville, TN 37232, USA; Tel: (615)322-7449; Fax: (615)936-8128, E-mail: maribeth.r.nicholson@ vanderbilt.edu Uzma Rani, MBBS, Vanderbilt University, 2200 Children’s Way, Nashville, TN 37232, USA; Tel: (315) 560-9915; [email protected] Received: February 02, 2017; Accepted: February 26, 2017; Published: February 28, 2017 Case report A 27-month-old male patient presented to the pediatric emergency department with complaints of diarrhea and vomiting for 4 days. He had large, watery, non-bloody, non-mucoid stools with a frequency of 10-12 episodes/day. The patient was reported to be febrile at home with a temperature of 102oF. His oral intake was significantly decreased, and he had minimal urine output. Past medical history included a recent hospitalization for respiratory syncytial virus bronchiolitis for 3 days and the use of antibiotics during this stay. On physical examination, the patient appeared ill and fussy with dry mucous membranes. He was tachycardiac on initial evaluation with a heart rate of 156 beats/min. His abdominal examination showed a distended but soft abdomen with mild diffuse tenderness to palpation. His initial laboratory studies were significant for a white blood count of 21.8 cells per microliter (μL), sodium of 122 mEq/L, potassium of 5.2 mEq/L, and a chloride of 95 mEq/L. He was also hypoalbuminemic with an albumin of 2.6 gm/ dL. The patient was admitted to the hospital for supportive care and correction of electrolyte imbalances. Stool studies were positive for Clostridium difficile (C. difficile) via DNA amplification testing and the patient was started on oral metronidazole, which was later switched to the intravenous route due to vomiting. Oral vancomycin was later added due to persistent symptoms. The patient developed peripheral edema with pleural effusion and ascites. On repeat laboratory evaluation, his albumin and total protein both were low at 1.6 g/dl and 3.5 gm/dl respectively. The patient underwent therapeutic paracentesis along with an infusion of 25% albumin. His upper gastrointestinal endoscopy revealed esophagitis, gastritis and a duodenal ulcer. Flexible sigmoidoscopy showed bowel wall edema and pseudomembranous colitis (Figure 1). Colonic biopsies demonstrated fragments of edematous colonic mucosa and fragments of hyperplastic-appearing colonic mucosa with abundant associated mucin; negative for active inflammation or granuloma. An abdominal x-ray revealed dilated bowel loops concerning for toxic megacolon (Figure 2) which was confirmed on subsequent CT scan of abdomen. Meanwhile, the patient developed rectal prolapse. Toxic megacolon was treated conservatively with nothing per oral, intravenous antibiotics and total parental nutrition. No surgical intervention was required. The patient was continued on antibiotics and total parenteral nutrition for 3 weeks. His condition improved gradually and he was discharged home after completion of antibiotics. Figure 1. Endoscopic image of pseudo-membranes in colon. Rani U (2017) A severe and complicated case of recurrent Clostridium difficile colitis in a 27month-old boy: A rare entity in young children Gastroenterol Hepatol Endosc, 2017 doi: 10.15761/GHE.1000136 Volume 2(1): 2-3 One week later, the patient again presented with watery, nonbloody diarrhea, accompanied by vomiting, fever and loss of appetite. His stool studies were positive for C.difficile and he was found to have hypoalbuminemia (2.5 g/dl) and mild ascites. He was started on intravenous metronidazole and oral Vancomycin to which he responded. As the patient presented with recurrent and complicated CDI, fecal microbial transplantation (FMT) was discussed with his family and was performed when a healthy related donor was identified. The donor was screened for transmissible infections per guidelines [1]. Antibiotics were held approximately 24 hours prior to the procedure. FMT was performed with 50g of donor stool homogenized with 100cc of normal saline and instilled via nasoduodenal tube. The procedure was well tolerated without complication. Post-transplantation, the patient did well with complete resolution of symptoms and no further recurrences on follow-up 2 months post-procedure.