NYU Medical Grand Rounds Clinical Vignette

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NYU Medical Grand Rounds Clinical Vignette

• Andy Levy, MD
• PGY-2
• March 26, 2013

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Chief Complaint
Mrs. C is a 39 year old Hispanic female patient
who presents with intermittent watery diarrhea
for 1 year.
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History of Present Illness

• The patient originally developed diarrhea and
  low-grade fever 1 year ago after completing a
  long course of clindamycin for a dental
  infection.
• She was diagnosed with C. difficile colitis via
  PCR at an outside hospital and discharged on PO
  metronidazole
• She continued to have watery diarrhea despite
  multiple courses of PO flagyl and PO vancomycin
  and was hospitalized at outside hospitals three
  times over the past year for dehydration.

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History of Present Illness

• On these admissions she was presumed to have
  recurrent C. difficile infection as stool PCR was
  positive.
• She was most recently discharged 2 weeks prior to
  this presentation on PO vancomycin, which she
  took with no improvement in her diarrhea she was
  still having 6-10 watery bowel movements daily w/
  some diffuse abdominal pain and postprandial
  nausea
• Pt presented to the emergency department with
  these symptoms

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Additional History

• Past Medical History None
• Past Surgical History Dental surgery,
  appendectomy
• Social History Denies tobacco, alcohol and
  other illicit drug use. Originally from Mexico,
  came to the US 13 years ago
• Family History Denies family history of IBD
• No Known Drug Allergies
• Medications Vancomycin PO 250mg four times daily

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Physical Examination

• General Hispanic female, lying in stretcher, no
  acute distress
• Vital Signs T 98.6 BP91/61 HR86 RR16 and
  O2 sat100 on RA
• Patient was orthostatic with dry mucous membranes
  and diffuse mild abdominal tenderness
• Remainder of the physical exam was normal

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Laboratory Findings

• CBC WBC 5.0, Hgb 10.8, Plt 350
• Basic Metabolic panel within normal limits
• Hepatic panel within normal limits
• INR, PT, PTT within normal limits
• C. diff toxin assay negative x 3, PCR negative x
  2
• No fecal leukocytes, negative stool culture,
  stool negative for ova and parasites

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Other Studies

• Chest X-Ray no infiltrates, effusions,
  consolidations

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Differential Diagnosis

• Recurrent C. difficile colitis

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Hospital Course

• Hospital Day 1
• The patient was started on IV hydration, PO
  vancomycin and IV metronidazole
• Hospital Day 2
• Flexible sigmoidoscopy showed normal-appearing
  colonic mucosa with no evidence of colitis or
  pseudomembranes
• Hospital Day 3
• Antibiotics were discontinued after C. diff toxin
  assays and PCR were negative

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Hospital Course

• Hospital Day 4
• Colonoscopy with small area of colitis in
  ascending colon and small area of proctitis in
  rectum, but otherwise colonic mucosa and terminal
  ileum appeared normal
• Biopsies revealed mucosal lymphoid aggregate
  throughout most of colon and rectum
• Hospital Day 5-7
• The patient was started on cholestyramine and
  probiotics with some improvement in diarrhea
• She was discharged on HD 7.

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Differential Diagnosis

• Post-infectious IBS
• Microscopic Colitis