title: Fulminant colitis from Clostridium difficile infection, the epidemic strain ribotype 027, in Japan.
abstract: In December 2012, a 32-year-old woman with no previous medical history and no previous antibiotic treatment had a fever and diarrhea 2 days after a cesarean section in which cefazolin was used as a prophylactic antimicrobial agent. She was transferred to our hospital 5 days after the cesarean for severe colitis. A rapid test of stool for Clostridium difficile toxin A and B was positive. Although oral vancomycin (0.5-2.0 g/day) and intravenous immunoglobulin (5 g/day) were administered after her transfer, 7 days after admission emergency exploratory surgery was performed because of poor response to therapy. Bowel perforation was noted and a temporary colostomy was created without colectomy. Vancomycin (2.0 g/day) was administered via the colostomy, in addition to a vancomycin enema (2.0 g/day), oral metronidazole (1500 mg/day), and oral vancomycin (2.0 g/day). Three days after the operation, linezolid (1200 mg/day IV) was added. She was treated with antibiotics against C. difficile for a total of 18 days after the operation. The same strain was not isolated from other patients in the same ward. Microbiological analysis of the isolate revealed housekeeping gene (tpi), toxin A gene (tcdA), toxin B gene (tcdB), and binary toxin gene (cdtA and cdtB). DNA sequencing of tcdC revealed a base 117 deletion and contained an 18-bp tcdC deletion. PCR ribotyping showed ribotype 027 patterns. The MIC of moxifloxacin was >32 μg/ml, indicating resistance to fluoroquinolones. This isolate was considered as the epidemic strain. Our case of fulminant colitis is apparently the first case involving the epidemic strain ribotype 027 in Japan.
authors.affiliation: Department of Infection Control and Prevention, Tokyo Medical University Hospital, Japan.
authors.forename: Itaru
authors.initials: I
authors.lastname: Nakamura
authors.affiliation: Department of Infection Control and Prevention, Tokyo Medical University Hospital, Japan; Department of Microbiology, Tokyo Medical University, Japan.
authors.forename: Tetsuo
authors.initials: T
authors.lastname: Yamaguchi
authors.affiliation: Department of Infection Control and Prevention, Tokyo Medical University Hospital, Japan.
authors.forename: Ayaka
authors.initials: A
authors.lastname: Tsukimori
authors.affiliation: Department of Infection Control and Prevention, Tokyo Medical University Hospital, Japan.
authors.forename: Akihiro
authors.initials: A
authors.lastname: Sato
authors.affiliation: Department of Infection Control and Prevention, Tokyo Medical University Hospital, Japan.
authors.forename: Shinji
authors.initials: S
authors.lastname: Fukushima
authors.affiliation: Department of Infection Control and Prevention, Tokyo Medical University Hospital, Japan.
authors.forename: Yasutaka
authors.initials: Y
authors.lastname: Mizuno
authors.affiliation: Department of Infection Control and Prevention, Tokyo Medical University Hospital, Japan; Department of Microbiology, Tokyo Medical University, Japan. Electronic address: tetsuya@tokyo-med.ac.jp.
authors.forename: Tetsuya
authors.initials: T
authors.lastname: Matsumoto
mesh_terms: D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D016360:Clostridioides difficile / Q000145:classification / Q000235:genetics / Q000302:isolation & purification*; D003125:Colostomy; D004761:Enterocolitis, Pseudomembranous / Q000188:drug therapy / Q000382:microbiology* / Q000601:surgery; D058872:Epidemics; D005260:Female; D006801:Humans; D007564:Japan; D021521:Ribotyping
chemical_list: D000900:Anti-Bacterial Agents
keywords: Clostridium difficile; Epidemic strain; Fulminant colitis; Ribotype 027