Fatal Clostridium difficile-associated toxic megacolon following unrelated stem-cell transplantation

Biebl, Matthias; Stelzmüller, Ingrid; Nachbaur, David; Wolf, Dominik; Suman, G.; Bonatti, Hugo

doi:10.1007/s10353-006-0224-1

Cited by 7 publications

(10 citation statements)

References 24 publications

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“…At our center, a single case of CD-associated toxic megacolon requiring colectomy was diagnosed during the past year. This patient had undergone stem cell transplantation, had prolonged neutropenia and CMV disease, and ultimately died from multiorgan failure [17]. This is in contrast to the three SORs who had colectomy for megacolon described in the current study, two of whom are currently alive with good graft function.…”

Section: Discussioncontrasting

confidence: 82%

“…In this patient population it may be difficult to diagnose and have a more complicated clinical course than in non-immunocompromised patients [10][11][12][13][14][15][16][17]. CD infection can progress into a life-threatening complication requiring surgical intervention, in particular, in lung recipients as also recently reported by Yates et al [15].…”

Section: Discussionmentioning

confidence: 81%

“…However, solid organ recipients (SORs) are among the group of highest risk for this infection [9]. CD-associated diarrhea has been described in all types of SOT and after stem cell transplantation [10][11][12][13][14][15][16][17]. Rapid detection of enteric pathogens is essential in order to initiate timely treatment, since diarrhea during the early posttransplant period can cause severe secondary complications [18,19].…”

Section: Introductionmentioning

confidence: 99%

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Clostridium difficile Colitis in Solid Organ Transplantation—A Single-Center Experience

et al. 2007

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Clostridium difficile (CD) is one of the most common causes of diarrhea in solid organ transplantation (SOT). Between 1996 and 2005, a total of 2474 solid organ transplants were performed at our institution, of which 43 patients developed CD-associated diarrhea. There were 3 lung, 3 heart, 20 liver, 8 kidney-pancreas, 6 kidney, 1 composite tissue, and 2 multivisceral recipients. Onset of CD infection ranged from 5 to 2453 days posttransplant. All patients presented with abdominal pain and watery diarrhea. Toxins A and B were detected using rapid immunoassay or enzyme immunoassay. Treatment consisted of reduction of immunosuppression, fluid and electrolyte replacement, metronidazole (n=20), oral vancomycin (n=20), and a combination of metronidazole and vancomycin (n=2). Toxic megacolon was seen in five patients. Two of them had colonoscopic decompression, and the remaining three required colonic resection. One of these patients died due to multiorgan failure after cured CD enteritis. The remaining patients were discharged with well-functioning grafts and all are currently alive. CD colitis was a rare complication prior to 2000; 38 of the 43 cases occurred thereafter. We conclude that CD colitis represents a severe complication following SOT. Recently, a dramatic increase in the incidence of this complication has been observed. The development of life-threatening toxic megacolon must be considered in solid organ recipients.

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Section: Discussioncontrasting

confidence: 82%

Section: Discussionmentioning

confidence: 81%

Section: Introductionmentioning

confidence: 99%

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Clostridium difficile Colitis in Solid Organ Transplantation—A Single-Center Experience

et al. 2007

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“…As Clostridium difficile associated colitis (CDAC) is a well-known nosocomial infection affecting 1-4% of general surgery patients and our patient had received a prolonged course of antibiotics before he was referred to us, we considered the possibility of Clostridium difficile colitis. Biebl et al reported TM due to CDAC in a patient following unrelated stem cell transplantation [18]. We excluded the possibility of CDAC by consecutive negative CD toxin assays, negative cultures, and absence of typical findings on endoscopy.…”

Section: Discussionmentioning

confidence: 99%

Cytomegalovirus associated toxic megacolon in an immunocompetent host. A case report

et al. 2010

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Zusammenfassung. Grundlagen: Das Zytomegalievirus (CMV) ist erwiesenermaßen eine Ursache letaler Infektionen bei Patienten mit einer Immundysfunktion, wohingegen es bei nicht immungeschwächten Personen vielfach asymptomatisch verläuft oder zu leichten, selbst begrenzenden Infektionen führt.Methodik (Fallbeschreibung): Wir beschreiben den Fall eines durch CMV hervorgerufenen fulminanten toxischen Megakolons bei einem immunkompetenten Patienten. Trotz umfassender Aufarbeitung blieb die ätio-logische Diagnose unklar. Da bei dem Patienten eine schwere Sepsis vorlag, hatte er sich einer notfallmäßigen subtotalen Kolektomie und Splenektomie aufgrund einer Milzentzündung und einer Verwachsung mit dem Kolon zu unterziehen. Der histopathologische Befund zeigte eine CMV-Kolitis mit akuter septischer Splenitis. Postoperativ erholte sich der Patient nach einem längeren Krankenhausaufenthalt gut und wurde entlassen. Ergebnisse und Schlussfolgerungen: Eine CMV-Kolitis ist bei immunkompetenten Individuen ein seltenes Ereignis. Zeigt ein Patient die typischen Manifestationen einer Kolitis und bleibt die Diagnose nach der üblichen Aufarbeitung unklar, besteht der Verdacht auf CMV-Kolitis. Auch nach einer endoskopischen Biopsie, die diesbezüglich als Goldstandard erachtet wird, kann die Diagnose unklar bleiben, da die Biopsie, wie in unserem Fall, möglicherweise nicht in einem repräsentativen Bereich durchgeführt wurde. In einer derartigen Situation sollte man die CMV-Untersuchung von Plasma und Gewebe mittels PCR-Tests in Erwägung ziehen, um zu einer gesicherten Diagnose zu kommen. So kann die antivirale Therapie zum frühestmöglichen Zeitpunkt eingeleitet werden, da die Mortalität bei verzögerter Diagnose inakzeptabel ist. Schlüsselwörter: Zytomegalievirus, Kolitis, toxisches Megakolon, immunkompetent.Summary. Background: Cytomegalovirus (CMV) has been proven to cause lethal infections in patients with immune dysfunction, whereas in normal individuals it is mostly asymptomatic or leads to mild self-limiting infections.Methods (case report): We describe a case of fulminant toxic megacolon caused by CMV in an immunocompetent patient. Etiologic diagnosis remained elusive despite comprehensive workup. As the patient presented with severe sepsis, he underwent emergency subtotal colectomy and splenectomy due to splenic inflammation and adhesion to the colon. Histopathology showed CMV colitis with acute septic splenitis. Postoperatively patient recuperated well after a prolonged hospital course and was discharged.Results and conclusions: CMV colitis in immunocompetent hosts is a rare entity. It should be suspected when a patient has typical manifestations of colitis and the diagnosis remains uncertain after the usual workup. Diagnosis may remain elusive even after endoscopic biopsy, which is considered to be the gold standard, as the biopsy may not be from a representative area, as happened in our case. In such a situation, consideration should be given to plasma or tissue PCR testing for CMV in order to establish the diagnosis, so that...

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“…Although some of the immunosuppressive agents may cause diarrhea themselves and other noninfectious causes must be considered, infectious diarrhea should be assumed until otherwise proven [13]. Many pathogens have been found in this patient population, including cytomegalovirus (CMV), EpsteinBarr virus, and rotavirus as well as Cryptosporidium parvum, among many others [22][23][24][25][26]. Nevertheless, in transplant recipients with diarrhea, CDAC should always be very high in the suspected diagnoses.…”

Section: Introductionmentioning

confidence: 95%

Solid organ recipients are at increased risk for recurrent Clostridium difficile colitis

et al. 2014

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Background Solid organ transplant (SOT) recipients carry a high risk of developing Clostridium difficileassociated colitis (CDAC) and an increased risk for recurrence.Patients and methods Between December 1996 and September 2007, a total of 227 patients with CDAC were identified when querying our institutional surgical infection database. This included 169 nontransplant patients and 58 SOT recipients, including 1 cardiac, 19 renal, 2 pancreas, 5 renal/pancreas, and 31 liver recipients.Results Overall, we recorded 556 infectious episodes at any site in the 227 patients analyzed who eventually developed CDAC (2.4 episodes/patient); the total number of CDAC episodes was 255: 204 patients had a single episode and 23 patients had multiple episodes of CDAC.There were 19 patients with two episodes, 3 with three episodes, and 1 with four episodes. Of the 23 patients with recurrent CDAC, 11 (48 %) were SOT recipients. A total of 19 % of SOT recipients had recurrent CDAC as compared with only 7 % for nontransplant patients (p = 0.0197). Time to first CDAC recurrence was a median of 58 (range, 17-1372) days for SOT recipients and a median of 30 (range, 6-108) days for nontransplant patients (p = 0.047).Conclusions SOT recipients at our institution were found to be a high-risk group for CDAC and had an almost threefold risk for recurrent disease. Double-drug coverage, extended application of metronidazole, and profound reduction in the level of immunosuppression may help to cope with this emerging problem.

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Fatal Clostridium difficile-associated toxic megacolon following unrelated stem-cell transplantation

Cited by 7 publications

References 24 publications

Clostridium difficile Colitis in Solid Organ Transplantation—A Single-Center Experience

Clostridium difficile Colitis in Solid Organ Transplantation—A Single-Center Experience

Cytomegalovirus associated toxic megacolon in an immunocompetent host. A case report

Solid organ recipients are at increased risk for recurrent Clostridium difficile colitis

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