Title : Clostridium difficile Bacteremia in a case of Acute Appendicitis
Abstract:
Background
Clostridium difficile is the principal agent of nosocomial diarrhea. C. difficile is not intrinsically invasive and rarely infects extraintestinal sites. The bacterium, therefore, is not commonly detected in blood cultures. Herein, we report a case of C. difficile bacteremia in a patient with acute appendicitis.
Case presentation
A 53-year-old female with past medical history of type 2 diabetes mellitus presented with same day onset of severe right lower quadrant pain. On admission, her vitals were temperature 37.1°C, heart rate 109, and blood pressure 166/93. Physical exam revealed significant right lower quadrant tenderness. Initial lab workup revealed WBC count of 21.8k and lactic acid 4.6. CT scan of the abdomen revealed appendicitis with appendicolith without evidence of perforation or abscess. The patient was started empirically on piperacillin-tazobactam and underwent laparoscopic appendectomy where appendiceal perforation was noted which required extensive washout for contamination and lysis of adhesions. Blood cultures taken postoperatively, on day 3 of admission grew Clostridium difficile on anaerobic broth. Stool testing was also positive for C. difficile toxin. Interestingly, patient had no complaint of diarrhea. Antibiotics were switched from piperacillin-tazobactam to IV ceftriaxone and IV Flagyl based upon culture results and susceptibility testing. On susceptibility testing, the strain was sensitive to Ampicillin/Sulbactam, Clindamycin, Meropenem, Metronidazole and resistant to Imipenem and Penicillin. Repeat blood cultures collected after two days were clear. She was discharged on a 14 day course of IV ceftriaxone and PO Flagyl from the day of
her washout.
Conclusion
Clostridium difficile bacteremia is rare but carries a high mortality rate, often occurring in the context of polymicrobial infections. Interestingly, this case presents a monomicrobial C. difficile bacteremia without the typical gastrointestinal symptoms such as diarrhea or colitis. Given that Clostridium species are normal inhabitants of the gastrointestinal tract, most extracolonic C. difficile infections are preceded by gastrointestinal events, such as C. difficile colitis or surgical and anatomical disruptions of the colon. In our case, the bacteremia likely resulted from bacterial translocation following appendix perforation or surgical intervention, emphasizing the need to consider C. difficile as a potential pathogen in patients with gastrointestinal perforations or surgical disruptions, even in the absence of classic symptoms like diarrhea or colitis.
