Creighton University School of Medicine
Pseudomembranous colitis (PMC) is characterized by yellow-white nodules or plaques on the endoscopic exam and is most commonly a manifestation of severe Clostridium difficile infection (CDI). However, several other causes of PMC have been reported in the literature. Here, we describe a rare presentation of PMC associated with ischemic colitis (IC) from amphetamine use that was initially treated like CDI reminding one to have a high index of suspicion for other causes of PMC.
A 40-year-old male with polysubstance use was admitted for acute abdominal pain. He was tachycardic, tachypneic, and febrile on admission and noted to be in significant distress with diffuse rebound tenderness on exam. Labs were remarkable for elevated white cell count at 55k and lactic acid of 4.8. Urine drug screen confirmed polysubstance abuse. Abdominal CT scan revealed thickening of the splenic flexure, left colon wall, with inflammatory stranding and mild dilatation of the transverse colon and hepatic flexure raising concerns for toxic megacolon from CDI. General surgery recommended conservative management. He was started on vancomycin oral and enema therapy and stool studies were negative for C. difficile. Due to lack of clinical improvement, sigmoidoscopy was performed which showed diffuse dense pseudomembranes involving entire examined colon. Biopsies revealed fibropurulent debris but samples did not have colon mucosa. Based on these findings, treatment for CDI was continued but repeat assay for CDI was negative. A week later, repeat sigmoidoscopy showed improving PMC and biopsies revealed fibropurulent, ulcerated granulation tissue. CMV was negative. Given endoscopic improvement, CDI therapy was continued. Subsequently, patient developed fevers, leukocytosis, and repeat abdominal CT revealed persistent colitis and colon perforation requiring emergent exploratory laparotomy that showed diffusely inflamed colon and necrosis at the splenic flexure and underwent total colectomy. Pathology showed global ischemia with perforation and serosal adhesions.
PMC has a classic endoscopic appearance and commonly associated with CDI. However, several other causes of PMC have been reported including uremia, sepsis, obstruction, chemotherapy and ischemic disease. History of amphetamine use, negative CDI toxin and biopsies should serve as clinical clues to increasing suspicion for IC and to assess for alternate causes of pseudomembranes on colonoscopy in the absence of CDI.
CT Abdomen and Pelvis showing thickening of splenic flexure, left colon wall, with inflammatory stranding and mild dilatation of the transverse colon and hepatic flexure raising concerns for toxic megacolon from CDI
Pseudomembranes involving entire examined colon up to the distal transverse colon
Avanija Buddam indicated no relevant financial relationships.
Meghana Vellanki indicated no relevant financial relationships.
Subhash Chandra indicated no relevant financial relationships.
Rajani Rangray indicated no relevant financial relationships.