11/481. Necroqizing enterocolitis with pneumatosis intestinalis in systemic lupus erythematosus and polyarteritis. Pneumatosis intestinalis was encountered in association with fatal necrotizing enterocolitis in systemic lupus erythematosus (SLE) and polyarteritis nodosa. The radiologic identification of mottled, bubbly, and linear collections of intramural intestinal gas distinguish this ominous complication from benign pneumatosis cystoides intestinalis. In the setting of intestinal vasculitis due to SLE or polyarteritis nodosa, these characteristic radiologic features indicate necrotizing enterocolitis. Since corticosteroids may mask clinical progression of the intestinal lesion, radiologic evaluation is essential in the overall management of the patient with intestinal vasculitis. ( info) |
| clostridium difficile is the leading cause of nosocomially acquired intestinal infection in the united states, affecting virtually all cases of pseudomembranous colitis and up to 20% of cases of antibiotic-associated diarrhea. Even after receiving antibiotic treatment with either metronidazole or vancomycin, 20% of patients will have recurrent clostridium difficile diarrhea. An innovative approach to the problem involves the introduction of competing, nonpathogenic (probiotic) organisms into the intestinal tract to restore microbial balance. The theoretical premise behind this approach is that the protective intestinal microflora is damaged by antibiotic treatment; the initial antibiotic exposure thus leaves the host susceptible to colonization and subsequent infection by clostridium difficile. A so-called "second-hit" to the intestinal microflora occurs when the infected host is treated with flagyl or vancomycin, further destroying susceptible bacterial flora. Probiotic agents, such as lactobacillus GG and saccharomyces boulardii, have been studied for the treatment of clostridium difficile. We are currently running a prospective, randomized, placebo-controlled trial of lactobacillus GG in combination with standard antibiotics for the treatment of clostridium difficile infection. Although it is too early to draw statistically significant conclusions, two patterns seem to be emerging: lactobacillus GG is effective in reducing the 3-wk recurrence rate of clostridium difficile, and patients feel better when taking lactobacillus GG, as compared with the placebo, with early disappearance of abdominal cramps and diarrhea. In conclusion, the use of probiotics for the treatment of primary and recurrent clostridium difficile diarrhea looks promising. patients seem to have less recurrent clostridium difficile diarrhea and early symptomatic improvement when using the probiotic lactobacillus GG. ( info) |
13/481. Pseudomembranous colitis: report of a severe case with unusual clinical signs in a young nurse. We describe the case of a young and otherwise healthy nurse who developed pseudomembranous colitis ten days after receiving oral clindamycin for dental infection. Her clinical course was particularly stormy and was characterized by severe diarrhea and vomiting, profuse ascites, pleural effusion, abdominal tenderness, peritoneal irritation, and systemic toxicity. The clostridium difficile assay was negative on two occasions. Features compatible with pseudomembranous colitis were seen at sigmoidoscopy, and the diagnosis was confirmed by biopsies. ( info) |
14/481. Disseminated fatal human cytomegalovirus disease after severe trauma. OBJECTIVE: Disseminated human cytomegalovirus (HCMV) disease is considered to be uncommon in critically ill but otherwise not immunosuppressed patients. We describe the case of a trauma victim who developed fatal HCMV disease that initially presented as pseudomembranous colitis and resulted in sudden cardiac death. DESIGN: Case report of fatal HCMV disease in a previously healthy patient after multiple trauma. SETTING: Surgical intensive care unit (ICU). PATIENT: A 63-yr-old male patient with multiple injuries. INTERVENTIONS AND MEASUREMENTS: Under ICU treatment, symptoms of HCMV reactivation presenting as pseudomembranous colitis appeared 32 days after trauma. Detailed laboratory examinations for HCMV infection were performed, including complement fixation titer, immunoglobulin g and M, polymerase chain reaction, and virus isolation. RESULTS: The intravital detection of HCMV dna in serum, leukocytes, and a colonic biopsy specimen indicated HCMV reactivation. Postmortem examination findings, including positive viral cultures, showed severe disseminated HCMV disease with involvement of the colon and myocardium. CONCLUSIONS: The lack of specific clinical symptoms of HCMV disease and the delay until viral culture results are available make an exact and timely diagnosis of HCMV disease difficult. Its prevalence in critically ill but otherwise not immunosuppressed patients is currently unknown and possibly underestimated. Because severe illness or trauma can cause immunodysfunction and, thus, may contribute to an increased rate of HCMV disease, detailed studies are warranted to evaluate the real risk in the ICU setting. ( info) |
15/481. Pseudomembranous colitis caused by a toxin A(-) B( ) strain of clostridium difficile. We report a case of severe pseudomembranous colitis due to a toxin A(-) B( ) strain of clostridium difficile in an immunosuppressed patient and discuss the implications for diagnostic testing in suspected C. difficile-associated diarrhea. ( info) |
16/481. Pseudomembranous colitis in a patient treated with paclitaxel for carcinoma of the breast: a case report. INTRODUCTION: The concomitant antimicrobial properties of antineoplastic agents may play a role in causing pseudomembranous colitis, which has been documented for cisplatin, cyclophosphamide and 5-fluorouracil. CLINICAL PICTURE: We describe the first case reported in the English literature of severe pseudomembranous colitis occurring in a patient given paclitaxel as adjuvant chemotherapy for breast cancer. There was no prior antibiotic therapy. Stool culture confirmed clostridium difficile. TREATMENT: Oral vancomycin, metronidazole and cholestyramine led to prompt improvement of intestinal symptoms, which resolved in two weeks. OUTCOME: Repeat colonoscopy performed 3 months later showed total resolution of the colitis. CONCLUSIONS: awareness of pseudomembranous colitis after paclitaxel chemotherapy can avert life-threatening complications. ( info) |
17/481. Pseudomembranous enteritis after proctocolectomy: report of a case. Intestinal pseudomembrane formation, sometimes a manifestation of antibiotic-associated diarrheal illnesses, is typically limited to the colon but rarely may affect the small bowel. A 56-year-old female taking antibiotics, who had undergone proctocolectomy for idiopathic inflammatory bowel disease, presented with septic shock and hypotension. A partial small-bowel resection revealed extensive mucosal pseudomembranes, which were cultured positive for clostridium difficile. Intestinal drainage contents from an ileostomy were enzyme immunoassay positive for C. difficile toxin A. Gross and histopathologic features of the small-bowel resection specimen were similar to those characteristic of pseudomembranous colitis. The patient was treated successfully with metronidazole. These findings suggest a reservoir for C. difficile also exists in the small intestine and that conditions for enhanced mucosal susceptibility to C. difficile overgrowth may occur in the small-bowel environment of antibiotic-treated patients after colectomy. Pseudomembranous enteritis should be a consideration in those patients who present with purulent ostomy drainage, abdominal pain, fever, leukocytosis, or symptoms of septic shock. ( info) |
18/481. Synchronous occurrence of collagenous colitis and pseudomembranous colitis. Synchronous collagenous and pseudomembranous colitis has not been previously reported. A 73-year-old woman presented with chronic watery diarrhea and abdominal cramping of six weeks' duration. Biopsies of the colon revealed findings of collagenous colitis involving the endoscopically normal right colon, and superimposed collagenous and pseudomembranous colitis involving the rectosigmoid colon. Endoscopically, the left colon revealed discrete ulcerative plaques, and clostridium difficile toxin A assay was positive. The patient partially responded to a three-week regimen of metronidazole, and symptoms resolved completely with subsequent steroid therapy. At follow-up endoscopy four months later, colon biopsies demonstrated persistence of subepithelial collagen but no pseudomembranes. The patient remained asymptomatic during this interval. Collagenous colitis has been reported in association with other inflammatory bowel diseases, including lymphocytic colitis, sprue and idiopathic inflammatory bowel disease. This unique association of collagenous colitis with an endotoxigenic inflammatory bowel disease is presented with a review of related disease features. ( info) |
19/481. Convulsions induced by metronidazole treatment for clostridium difficile-associated disease in chronic renal failure. clostridium difficile-related diarrhea and colitis are common health problems, especially in elderly, frail hospitalized patients. The drug of choice is metronidazole, which can be associated, in long or high doses, with neurotoxic side effects. We report convulsions induced by short-term metronidazole therapy used in conventional doses for clostridium difficile colitis in an elderly patient with chronic renal failure. ( info) |
20/481. amiodarone pulmonary, neuromuscular and ophthalmological toxicity. amiodarone is an iodinated benzofuran derivative class III antiarrhythmic that is highly effective in suppressing ventricular and supraventricular arrhythmias. It is also associated with an imposing side effect profile, which often limits its use. Numerous adverse effects have been documented including skin discolouration, photosensitivity, hepatitis, thyroid dysfunction, corneal deposits, pulmonary fibrosis, bone marrow suppression and drug interactions. These side effects are thought to be correlated with the total cumulative dose of amiodarone, but idiopathic reactions have been reported. The majority of adverse reactions resolve with discontinuation of the drug; however, rapid progression may occur, which may be fatal. The present report documents a patient who had a combination of serious amiodarone toxicities that, once recognized, were treated and eventually resulted in a good outcome. ( info) |