An Unusual Presentation of Clostridioides Difficile Colitis in a Patient on Opioids.

Clostridioides difficile colitis is an inflammation of the colon due to toxins produced by a gram-positive bacterium called Clostridioides difficile (also known as Clostridium difficile). Clostridioides difficile colitis is associated with an increased risk of morbidity and mortality in elderly patients. The infection develops because of the disruption of the microbiome that usually suppresses the overgrowth of Clostridioides difficile. Testing for Clostridium difficile infection is routinely recommended in patients with at least three loose bowel movements in a day. We present an unusual case of a 74-year-old woman on chronic opioids who presented with a three-day history of lower abdominal pain, constipation, hematochezia, with no diarrhea. Radiologic imaging showed evidence of colitis, and the patient was found to have Clostridium difficile colitis.

Listeria Bacteremia Presenting With Cerebral Abscess and Endocarditis in an Elderly Patient With Chronic Immune Thrombocytopenia.

Central nervous system involvement by Listeria monocytogenes usually presents as meningitis, meningoencephalitis or, less frequently, rhombencephalitis. Listerial brain abscesses are rare. Moreover, only 5-8% of listerial bacteremia is complicated by infective endocarditis (IE). A 70-year-old man with chronic immune thrombocytopenia (ITP) presented to our emergency department with acute onset of altered mental status and right-sided weakness. He was afebrile, with no heart murmurs or peripheral IE stigmata. Neurologic examination showed disorientation, expressive aphasia, and right-sided hemiparesis. Laboratory findings were unremarkable except for leukocytosis and hyponatremia. Brain MRI showed an irregular rim-enhancing lesion in the left frontal lobe, suspicious for a high-grade glial neoplasm. The lesion was excised, and he was started empirically on vancomycin, ceftriaxone, and metronidazole. After blood cultures grew Listeria monocytogenes, antibiotics were de-escalated to ampicillin and gentamicin. Echocardiography showed mitral valve vegetation. By Day 6, his mental status had improved. On Day 9, he was discharged to our inpatient rehabilitation center to complete six weeks on IV ampicillin and IV gentamicin. Pathology of the brain mass was subsequently reported as a listerial brain abscess. Chronic treatment with high-dose oral glucocorticoids and pre-existing ITP have been independently implicated as predisposing factors in listerial brain abscess. There is a propensity to misdiagnose listerial brain abscess as an intracranial neoplasm due to similar clinical/imaging findings. In addition, Listeria monocytogenes is an atypical cause of IE. Therefore, a high index of suspicion is necessary for early recognition and successful treatment of listerial brain abscess and listerial endocarditis in high-risk patients.