Transcript Journal Club - NYU Langone Medical Center

NYU Medical Grand Rounds
Clinical Vignette
Andy Levy, MD
PGY-2
March 26, 2013
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
Mrs. C is a 39 year old Hispanic female
patient who presents with intermittent watery
diarrhea for 1 year.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
• General: Hispanic female, lying in
stretcher, no acute distress
• Vital Signs: T: 98.6 BP:91/61 HR:86 RR:16
and O2 sat:100% on RA
•Patient was orthostatic with dry mucous
membranes and diffuse mild abdominal
tenderness
• Remainder of the physical exam was
normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
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
x2
• No fecal leukocytes, negative stool culture,
stool negative for ova and parasites
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Other Studies
• Chest X-Ray: no infiltrates, effusions,
consolidations
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Differential Diagnosis
• Recurrent C. difficile colitis
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 1:
– The patient was started on IV hydration, PO
vancomycin and IV metronidazole
• Hospital Day 2:
– Flexible sigmoidoscopy showed normalappearing colonic mucosa with no evidence of
colitis or pseudomembranes
• Hospital Day 3:
– Antibiotics were discontinued after C. diff toxin
assays and PCR were negative
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Differential Diagnosis
• Post-infectious IBS
• Microscopic Colitis
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS