Transcript Journal Club

NYU Medical Grand Rounds
Clinical Vignette
Matthew Johnson MD, PGY-2
May 5, 2010
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
A 54-year-old man with diabetes
presents with watery diarrhea for 5 days.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• The patient was in his usual state of health until several
months prior to admission when he noted an ulcer on the
lateral aspect of his right foot.
• Though he is unsure exactly when it developed, the ulcer
persisted over several months.
• When associated swelling and drainage developed, the
patient sought medical attention, and eventually underwent
surgical debridement.
• Additional wound care and antibiotics were continued and
the patient was eventually discharged home.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• Two weeks after discharge, the patient began to experience
10-15 episodes of profuse, non-bloody diarrhea.
• The diarrhea persisted over the next several days, and the
patient began feeling increasingly weak.
• Concerned, he sought further care in the emergency room.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
Past Medical History
• Diabetes mellitus
Past Surgical History
• Ulcer debridement
• Right foot
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Family History
• Mother: Diabetes
• Father: Prostate cancer
Social History
• Lives alone
• Currently unemployed
• Denies tobacco use
• Denies alcohol use
• Denies illicit drug use
Outpatient Medications
Glipizide 5mg Daily
Pioglitazone 15mg Daily
Metformin 1000mg BID
Allergies: NKDA
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
General: Well-appearing middle-aged man in no acute distress
Vitals: T 98.4F, BP 101/52, HR 107, RR 16
O2 saturation: 99% on room air
Abdominal: Mildly distended, non-tender, hyperactive bowel sounds
Extremities: 3 x 4 cm ulcer with a clean base and margins on lateral
aspect of the right foot
The remainder of the physical exam was normal.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Initial Studies
• CBC:
• WBC 39,300 with 35% bands
• The remainder was within normal limits
• Basic Metabolic Panel:
• Sodium 130
• BUN 37, Cr 1.7
• The remainder was within normal limits
• Hepatic Panel: Within normal limits
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
CT Abdomen and Pelvis
• Diffuse marked symmetric pan-colonic wall
thickening up to 1.3 cm involving the entire colon
• Thickened haustral folds with associated free
fluid in the paracolic gutters
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working Diagnosis
Clostridium difficile Colitis
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Treatment was initiated with metronidazole and oral
vancomycin, but without significant clinical improvement.
• The patient’s WBC count continued to rise over the next
several days, and peaked at 58,800.
• Vancomycin per rectum was added, but the patient’s
diarrhea persisted.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• The patient was transferred to the ICU for several
days after developing hypotension, acute renal failure
and increasing oxygen requirements, concerning for
sepsis due to his colitis.
• The patient’s diarrhea slowly improved and he was
eventually transferred back to the medical ward.
• He is currently in the process of being discharged to
a rehabilitation facility.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
Pan-colitis secondary to a severe, antibioticassociated Clostridium difficile infection
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS