NYU Medical Grand Rounds Clinical Vignette

Andy Levy, MD

PGY-2

March 26, 2013

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Mrs. C is a 39 year old Hispanic female patient who presents with intermittent watery diarrhea for 1 year.

Chief Complaint

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• The patient originally developed diarrhea and low-grade fever 1 year ago after completing a long course of clindamycin for a dental infection. • She was diagnosed with C. difficile colitis via PCR at an outside hospital and discharged on PO metronidazole • She continued to have watery diarrhea despite multiple courses of PO flagyl and PO vancomycin and was hospitalized at outside hospitals three times over the past year for dehydration.

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• On these admissions she was presumed to have recurrent C. difficile infection as stool PCR was positive. •She was most recently discharged 2 weeks prior to this presentation on PO vancomycin, which she took with no improvement in her diarrhea; she was still having 6-10 watery bowel movements daily w/ some diffuse abdominal pain and postprandial nausea•Pt presented to the emergency department with these symptoms

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Additional History

• Past Medical History: None • Past Surgical History: Dental surgery, appendectomy • Social History: Denies tobacco, alcohol and other illicit drug use. Originally from Mexico, came to the US 13 years ago • Family History: Denies family history of IBD • No Known Drug Allergies• Medications: Vancomycin PO 250mg four times daily

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Physical Examination

• General: Hispanic female, lying in stretcher, no acute distress

• Vital Signs: T: 98.6 BP:91/61 HR:86 RR:16 and O2 sat:100% on RA

•Patient was orthostatic with dry mucous membranes and diffuse mild abdominal tenderness

• Remainder of the physical exam was normal

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Laboratory Findings

• CBC: WBC 5.0, Hgb 10.8, Plt 350• Basic Metabolic panel: within normal limits• Hepatic panel: within normal limits• INR, PT, PTT within normal limits • C. diff toxin assay negative x 3, PCR negative x 2• No fecal leukocytes, negative stool culture, stool negative for ova and parasites

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Other Studies

• Chest X-Ray: no infiltrates, effusions, consolidations

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Recurrent C. difficile colitis

Differential Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Hospital Day 1:– The patient was started on IV hydration, PO

vancomycin and IV metronidazole

• Hospital Day 2:– Flexible sigmoidoscopy showed normal-appearing

colonic mucosa with no evidence of colitis or pseudomembranes

• Hospital Day 3:– Antibiotics were discontinued after C. diff toxin

assays and PCR were negative

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Hospital Day 4:– Colonoscopy with small area of colitis in ascending

colon and small area of proctitis in rectum, but otherwise colonic mucosa and terminal ileum appeared normal

– Biopsies revealed mucosal lymphoid aggregate throughout most of colon and rectum

• Hospital Day 5-7:– The patient was started on cholestyramine and

probiotics with some improvement in diarrhea– She was discharged on HD 7.

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Post-infectious IBS

• Microscopic Colitis

Differential Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS