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
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