The Journal of the Arkansas Medical Society Med Journal June 2019 Final - Page 10

SCIENTIFIC ARTICLE Clostridium Difficile Infection Can Mask Diagnosis of Other GI Infections In Immunocompromised Patients: A Tale of Co-Existing Bacteria and Fungus Naga S. Addepally, MBBS 2 ; Jagpal S. Klair, MBBS 1 ; Mohit Girotra, MD 2 ; Daniel K. Brown MD 2 Division of Gastroenterology and Hepatology, Department of Medicine, UAMS 2 Central Arkansas Veterans Health Services (CAVHS), Little Rock, Arkansas 1 INTRODUCTION C lostridium difficile infection (CDI) can occur commonly in immunocompromised pa- tients. However, lack of response to treatment should alert physicians to actively re-investigate for the pres- ence of other co-existing GI infec- tions, which our interesting case alludes to. with histoplasmosis. Patient had no co-existent pulmonary lesions or other sites of dissemina- tion. He responded well to liposomal amphoteri- cin B. DISCUSSION Diarrhea is common in patients with HIV/ AIDS; however, bloody diarrhea is not very com- mon. When present, it should be seriously inves- tigated. Hematochezia could be from both infec- tious and non-infectious causes. Non-infectious causes include hemorrhoids, IBD, anal fissures, idiopathic ulcers, and colon cancer. Though bacterial gastroenteritis like – salmonella, shi- gella, and Clostridium difficile – can present with bloody diarrhea; opportunistic infections like CMV, HSV, histoplasma, and Mycobacterium tuberculosis contribute to most of the infectious CASE PRESENTATION A 55-year-old man with HIV (CD 4 43/mm 3 , non-compliant with medications) and hepatitis- C presented with RLQ pain with fever, night sweats, and intermittent bloody diarrhea lasting two weeks. An outside hospital work-up (abdom- inal CT and stool studies) was unremarkable, ex- cept for (+) Clostridium difficile antigen. Patient was started on PO Vancomycin, to which he ini- tially responded, but was later re-admitted with worsening pain and persistent bloody stools. Re- peat CT revealed concentric bowel wall thicken- ing/edema in cecum/ascending colon along with lymphadenopathy. Antibiotics were restarted for assumed recalcitrant CDI, but after 21 days of unsuccessful therapy, patient was transferred to us. Colonoscopy divulged inflamed, edematous and friable-appearing cecum/ascending co- lon, with multiple discrete, punched-out ulcers throughout the colon. Biopsies were consistent Figure 1: Colonoscopy divulged inflamed, edematous and friable-appearing cecum/ ascending colon, with multiple discrete, punched-out ulcers throughout the colon. 274 • THE JOURNAL OF THE ARKANSAS MEDICAL SOCIETY VOLUME 115