title: Clostridium difficile small-bowel enteritis after total proctocolectomy: a rare but fatal, easily missed diagnosis. Report of a case.
abstract: OBJECTIVE
  Clostridium difficile enteritis is a rare infection, with less than a dozen cases reported in the literature. We present a case of a patient with total proctocolectomy and ileostomy, developing Clostridium difficile infection of small bowel. We discuss the role of Clostridium difficile toxins and review previously reported cases of Clostridium difficile enteritis after total colectomy.
  
  
  METHODS
  A 65-year-old male with a history of total proctocolectomy and ileostomy 30 years previously had purulent ileostomy drainage and septic shock. The patient was recently treated with intravenous piperacillin, tazobactam, and levofloxacin for aspiration pneumonia in the previous admission. Ileostomy stool cultures tested positive for Clostridium difficile toxin A, and the patient was promptly treated with intravenous metronidazole.
  
  
  RESULTS
  The patient was aggressively resuscitated and treated, recovered from the enteritis and shock, but died of pulmonary complications after a prolonged hospitalization.
  
  
  CONCLUSIONS
  Review of previously reported cases of Clostridium difficile enteritis showed a high mortality rate. We attribute this to delayed diagnosis secondary to rarity of this illness. Some patients were diagnosed only after pseudomembranes in small-bowel segments were found at autopsy. This rare disease entity is firmly established among the differential diagnosis to clinicians treating patients with total proctocolectomy.
authors.affiliation: Department of Surgery, Graduate Hospital, Philadelphia, Pennsylvania 19146, USA.
authors.forename: Kiup A
authors.initials: KA
authors.lastname: Kim
authors.forename: Philip
authors.initials: P
authors.lastname: Wry
authors.forename: Eugene
authors.initials: E
authors.lastname: Hughes
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Butcher
authors.forename: Donna
authors.initials: D
authors.lastname: Barbot
mesh_terms: D000368:Aged; D000890:Anti-Infective Agents / Q000627:therapeutic use; D016360:Clostridioides difficile / Q000302:isolation & purification*; D004751:Enteritis / Q000188:drug therapy / Q000382:microbiology*; D004761:Enterocolitis, Pseudomembranous / Q000175:diagnosis* / Q000188:drug therapy; D017809:Fatal Outcome; D006801:Humans; D007081:Ileostomy; D007262:Infusions, Intravenous; D008297:Male; D008795:Metronidazole / Q000627:therapeutic use; D011183:Postoperative Complications; D016737:Proctocolectomy, Restorative; D012772:Shock, Septic / Q000188:drug therapy / Q000382:microbiology
chemical_list: D000890:Anti-Infective Agents; D008795:Metronidazole