[A case of disseminated tuberculosis presenting as a metastasizing tumor, complicated by toxic megacolon caused by Clostridium difficile: Difficulties in diagnosis]. / Metasztatizáló tumor képét adó disszeminált tuberkulózis Clostridium difficile okozta toxicus megacolonnal szövodött esete: a diagnózis nehézségei.

A mára ritkán eloforduló tuberkulózis (tbc) extrapulmonális manifesztációi elorehaladott rosszindulatú daganatok képét utánozhatják, jelentos diagnosztikus dilemmákat okozva. A tbc igazolása gyakorta bonyolult, komplex vizsgálatokat igényel. Egy fiatal vietnámi nobeteg esetét ismertetjük, aki idült hasi fájdalom, fogyás, fejfájás, bal oldali hemiparesis miatt jelentkezett kórházunkban. Az urgens vizsgálatok hasi folyadékgyülemek, lymphadenopathia és peritonealis carcinosis képe mellett az uterushoz asszociált ökölnyi kismedencei térfoglaló képletet, intracranialisan agyödémát és metastaticusnak tuno gócokat ábrázoltak. Neurológiai, belgyógyászati, majd pulmonológiai klinikai vizsgálatok és kezelések során eloször disszeminált gynaecologiai tumor, majd meningealis-, miliaris tüdo- és kiterjedt hasüregi-kismedencei érintettséggel járó tbc gyanúja fogalmazódott meg. Bár mycobactérium jelenléte nem volt igazolható, antituberculoticus- és komplex antibiotikus terápiát alkalmaztak. Ennek szövodményeként Clostridium difficile okozta enterocolitis alakult ki. Átmeneti állapotrosszabbodás miatti intenzív osztályos kezelést követoen a beteget visszahelyezték kórházunk belgyógyászatára. Itt toxicus megacolon, acut peritonitis alakult ki, emiatt sürgos mutétet végeztünk.A hasüregben granulomatosus peritonitis encapsulans, extrém tágult, megrepedt taeniájú colon, hyperaemiás vékonybéltraktus, tuboovarialis tályogok voltak láthatók. Oncotomiát követoen salpingo-oophorectomiát és subtotalis colectomiát végeztünk, Brooke szerinti ileostomát készítettünk. Az intenzív osztályos, majd infektológiai kezelésnek köszönhetoen a beteg reconvalescentiája sikeres volt, kielégíto állapotban emittálták. A specimenek valós ideju PCR-vizsgálata során Mycobacterium DNS nem volt detektálható, végül a hasüregi váladék és granulomák mikroszkópos vizsgálatával sikerült saválló pálcákat identifikálni.Az eset kapcsán áttekintjük az extrapulmonális tbc diagnosztikus lehetoségeit és terápiás nehézségeit.

Clostridioides difficile infection in a rural New Zealand secondary care centre: an incidence case-control study.

BACKGROUND: Clostridioides difficile infection (CDI) is a form of antibiotic-associated infectious diarrhoea resulting in significant morbidity and mortality. Community-acquired disease in low-risk individuals is increasingly recognised. There are limited New Zealand data published. AIM: To determine the incidence and location of onset of CDI cases in the Manawatu region, and further describe the demographics, risk factors and prevalent C. difficile ribotypes of the population. METHODS: We performed an incidence case-control study of CDI in the Manawatu region between September 2018 and September 2019. Cases were matched to controls with a negative test for C. difficile. Demographic and comorbidity data, location of onset, drug exposure, disease recurrence and 30-day mortality were collected. Ribotype analysis was performed on C. difficile isolates. RESULTS: Thirty-two specimens tested toxin positive over 12 months, yielding an incidence of 18.3 cases per 100 000 person-years. Twenty-five percent of cases had community onset disease. Cases were more likely to have had amoxicillin/clavulanate or ceftriaxone prescribed. Elevated blood white cell count and lower HbA1c were significantly associated with CDI. The dominant ribotype was 014/020. Two cases were RT 023. CONCLUSION: Our data are similar to previous national data. RT 023 has not been previously reported in New Zealand and has been associated with severe colitis. We demonstrated a significant proportion of community-acquired cases and the true incidence might be higher. Vigilance for community onset disease is required. These data may allow observation of temporal changes in incidence and infection patterns of CDI in New Zealand.

Clostridium difficile ribotype 033 colitis in a patient following broad-spectrum antibiotic treatment for KPCproducing Klebsiella pneumoniae infection, Italy.

This report describes a case of Clostridium difficile ribotype 033 colitis in a patient treated with multiple antibiotics for KPC-producing Klebsiella pneumoniae pancreatitis. Diagnostic, clinical and therapeutic features are discussed. To the best of our knowledge, this is the first case of C. difficile ribotype 033 clinical infection reported from Italy.

Molecular characterisation of Klebsiella oxytoca strains isolated from patients with antibiotic-associated diarrhoea.

BACKGROUND AND STUDY AIM: Colitis is a common complication after treatment with antibiotics such as ß-lactams, quinolones, and aminoglycosides. Recently, Klebsiella oxytoca has been implicated in this type of diarrhoea. The prevalence and characterisations of K. oxytoca isolated from patients with antibiotic-associated diarrhoea were investigated. The K. oxytoca isolates were also tested for cytotoxin production. PATIENTS AND METHODS: This study was conducted from May 2011 to Dec 2013. Faecal samples were collected from hospitalised patients receiving antibiotic treatment. Initial cultivation was performed on specific media. The clinical isolates were confirmed by polymerase chain reaction (PCR) using the specific K. oxytoca polygalacturonase (pehX) gene. The double-disc diffusion test was used to detect extended-spectrum beta-lactamase (ESBL)-producing strains. Tracking of ESBL-encoding genes was performed via PCR. The organism was cultured on Hep-2 cell lines for cytotoxin production. RESULTS: Out of 331 samples collected from patients, 40 were confirmed molecularly to be clinical isolates of K. oxytoca. Fourteen (35%) ESBL-producing strains were isolated using the double-disc diffusion method. Among the molecularly confirmed K. oxytoca isolates, seven (17.5%) tested positive for the blaSHV gene, 12 (30%) for blaTEM, 10 (25%) for blaCTX-M, three (7.5%) for blaOXA, nine (22.5%) for blaCTX-M-15, and seven (17.5%) for blaTEM-1. Five (12%) isolates showed cytotoxin activity below 30%, 12 (30%) strains showed moderate cytotoxin activity between 30% and 60%, and 23 (58%) strains showed cytotoxin activity ⩾60%. CONCLUSIONS: The cytotoxin-producing K. oxytoca is found to be one of the causes of antibiotic-induced colitis. Discontinuing treatment and allowing normal intestinal flora to be established or prescribing appropriate medication after antibiogram can help patients with antibiotic-induced haemorrhagic colitis in a timely manner.

Vancomycin Treatment Alters Humoral Immunity and Intestinal Microbiota in an Aged Mouse Model of Clostridium difficile Infection.

BACKGROUND: The elderly host is highly susceptible to severe disease and treatment failure in Clostridium difficile infection (CDI). We investigated how treatment with vancomycin in the aged host influences systemic and intestinal humoral responses and select intestinal microbiota. METHODS: Young (age, 2 months) and aged (age, 18 months) C57BL/6 mice were infected with VPI 10463 after exposure to broad-spectrum antibiotics. Vancomycin was given 24 hours after infection, and treatment was continued for 5 days. At select time points, specimens of serum and intestinal tissue and contents were collected for histopathologic analysis, to measure antibody levels and the pathogen burden, and to determine the presence and levels of select intestinal microbiota and C. difficile toxin. RESULTS: Levels of disease severity, relapse, and mortality were increased, and recovery from infection was slower in aged mice compared to young mice. Serum levels of immunoglobulin M, immunoglobulin A, and immunoglobulin G against C. difficile toxin A were depressed in aged mice, and vancomycin treatment reduced antibody responses in both age groups. While baseline levels of total bacterial load, Bacteroidetes, Firmicutes, and Enterobacteriaceae were mostly similar, aged mice had a significant change in the Firmicutes to Bacteroidetes ratio with vancomycin treatment. CONCLUSIONS: Vancomycin treatment decreases the systemic humoral response to CDI. Increased mortality from and recurrence of CDI in the aged host are associated with an impaired humoral response and a greater susceptibility to vancomycin-induced alteration of intestinal microbiota.

Atypical presentation of pseudomembranous colitis localized in adenomatous polyps.

The most frequent cause of pseudomembranous colitis is Clostridium difficile (C. difficile) infection. This type of colitis is characterized by an endoscopic pattern of numerous small, yellowish or whitish plaques diffusely distributed, which typically compromises the rectum extending to proximal colon. Occasionally, the pseudomembranes compromise only the transverse or right colon, but their exclusive localization over polyps has not been reported. In this case report we have described a patient with symptoms compatible with C. difficile infection and positive for C. difficile toxigenic culture. Colonoscopy examination showed two small polyps with a whitish surface, and histopathological analysis confirmed them to be pseudomembranes over tubular adenomas. The rest of the colonic mucosa was normal and no other cause was demonstrated. We suggest that this particular distribution might be due to a higher affinity for dysplastic cells such as adenomatous polyps of colon by C. difficile and/or its toxins.

The host immune response to Clostridium difficile infection.

Clostridium difficile infection (CDI) is the most common infectious cause of healthcare-acquired diarrhoea. Outcomes of C. difficile colonization are varied, from asymptomatic carriage to fulminant colitis and death, due in part to the interplay between the pathogenic virulence factors of the bacterium and the counteractive immune responses of the host. Secreted toxins A and B are the major virulence factors of C. difficile and induce a profound inflammatory response by intoxicating intestinal epithelial cells causing proinflammatory cytokine release. Host cell necrosis, vascular permeability and neutrophil infiltration lead to an elevated white cell count, profuse diarrhoea and in severe cases, dehydration, hypoalbuminaemia and toxic megacolon. Other bacterial virulence factors, including surface layer proteins and flagella proteins, are detected by host cell surface signal molecules that trigger downstream cell-mediated immune pathways. Human studies have identified a role for serum and faecal immunoglobulin levels in protection from disease, but the recent development of a mouse model of CDI has enabled studies into the precise molecular interactions that trigger the immune response during infection. Key effector molecules have been identified that can drive towards a protective anti-inflammatory response or a damaging proinflammatory response. The limitations of current antimicrobial therapies for CDI have led to the development of both active and passive immunotherapies, none of which have, as yet been formally approved for CDI. However, recent advances in our understanding of the molecular basis of host immune protection against CDI may provide an exciting opportunity for novel therapeutic developments in the future.

Infección por Clostridium difficile: enfrentamiento de la crisis grave y recurrencia / Clostridium difficile infection: management of severe and recurrent disease

Clostridium difficile has become an important healthcare-associated infection due to increased frequency, mortality and recurrence rate. These facts, associated in part to the appearance of epidemic strains have driven changes in diagnostic and therapeutic approaches. The clinical spectrum of C. difficile infection (CDI) ranges from mild diarrhea without systemic compromise to life-threatening pseudomembranous colitis. Metronidazole is the first line treatment in mild CDI; however, the response rate is lower in severe disease, therefore in patients with clinical markers of unfavorable outcome, the first line treatment is oral vancomicin. On the other hand, the increased recurrence rate seen in the last decade with its clinical and economic consequences has forced the development of new therapies that allow change the course of this disease. In this line, the fecal microbiota transplantation and new antibiotics as fidaxomicin has proved to decrease the recurrences.

Clostridium difficile es actualmente una de las principales infecciones asociadas a la atención de salud debido al aumento de su frecuencia, letalidad y capacidad de recurrencia. Estos hechos en parte asociados al surgimiento de cepas conocidas como epidémicas han determinado grandes cambios en el enfrentamiento diagnóstico y terapéutico. El espectro clínico de la infección por C. difficile (ICD) abarca desde una diarrea leve sin compromiso sistémico hasta cuadros de colitis pseudomembranosa que pueden ocasionar la muerte. Metronidazol es el tratamiento de elección de la ICD leve; sin embargo, la tasa de respuesta es inferior en cuadros graves, por lo tanto, en pacientes con marcadores de mal pronóstico vancomicina oral es la terapia de primera elección. Por otro lado, la mayor tasa de recurrencia observada en la última década con sus consecuencias clínicas y económicas ha obligado al desarrollo de nuevas terapias que permitan alterar el curso de la enfermedad. En esta línea, el trasplante de microbiota fecal y nuevos antibióticos como fidaxomicina han mostrado efectividad en reducir las recurrencias.

Colite por clostridium difficile e Doença Crohn: relato de caso / Clostridium difficile colitis and Crohn's Disease: a case report

A infecção pelo Clostridium difficile é a principal causa de diarréia associada ao uso de antibióticos. Os pacientes com doença inflamatória intestinal apresentam um aumento na incidência e na gravidade da infecção, além de um maior tempo de hospitalização e maior taxa de mortalidade. Uma história prévia de colite parece ser o fator de risco mais importante para a aquisição da infecção. Apresentamos um caso de um paciente jovem, do sexo masculino, com ileíte de Crohn em uso de azatioprina e ciprofloxacino que evoluiu com colite nodular causada pelo Clostridium difficile.

Clostridium difficile infection is the leading cause of antibiotic associated diarrhea. Patients with inflamatory bowel are high incidence and have worse outcomes with higher rates of hospitalization, surgery, and mortality as compared to non-IBD CDI patients. Also they have increased rates of hospitalization, surgery, and mortality as a result of this infection. A prior history of colitis appears to be the most significant risk factor for acquiring this infection. We report a case of young man patient with ileitis Crohn disease in use of azathioprine and ciprofloxacin which has nodular colitis caused by Clostridium difficile.

Colitis pseudomembranosa asociada al uso de antibióticos

La colitis asociada a antibióticos es una inflamación aguda de la mucosa intestinal que algunas veces ocurre a continuación del tratamiento con antibióticos y es causada por toxinas producidas por la bacteria Clostridium difficile. El diagnóstico está basado en el cuadro clínico y en cultivos y pruebas inmunológicas para detectar las toxinas. Cuando no hay respuesta al tratamiento conservador (retiro del antibiótico y terapia de apoyo), el Metronidazol o la Vancomicina deberían ser suministrados. Recurrencias hasta de un 20% son frecuentes. Medidas preventivas contra su extensión son esenciales, debido a la elevada transmisión a través del cuidado personal y de los instrumentos.

Antibiotic-associated colitis is an acute inflammation of the intestinal mucosa that sometimes occurs following antibiotic treatment and is caused by toxins produced by the bacterium Clostridium difficile. Diagnosis is based on culture and immunological tests to detect its toxins. When there is no response to conservative treatment (withdrawal of the antibiotic and support therapy), metronidazole or vancomycin should be given. Recurrences, up to 20%, are frequent. Preventive measures of its spreading are essential due to the elevated transmission through health care personnel and instruments.

Clostridium difficile colitis.

Clostridium difficile enterocolitis is endemic in most modern hospitals. The spectrum of clinical presentation varies from the asymptomatic carrier state to fulminant colitis with toxic megacolon and perforation. Highly toxigenic and lethal strains of C. difficile have emerged worldwide. Medical treatment consists of discontinuing the precipitating antibiotic, supportive measures and bowel rest, and antibiotic treatment with metronidazole or vancomycin. Surgical treatment may be necessary in cases of fulminant disease. Subtotal colectomy with end ileostomy is the operation of choice.

Disease Burden of Antibiotic Associated Colitis in Patients with Severe Traumatic Brain Injury / 中国药房

OBJECTIVE:To analyze disease burden of antibiotic associated colitis(AAC)in patients with severe traumatic brain injury,and to explore prevention and treatment countermeasures. METHODS:Retrospective analysis method was used to analyze the relationship between the occurrence of AAC in 157 cases of severe traumatic brain injury and application duration,dosage and category of antibiotics. RESULTS:Overuse of antibiotics was closely associated with the occurrence of AAC,especially cephalosporins(P

A Case of Amoxicillin-induced Segmental Hemorrhagic Colitis / 대한소화기내시경학회지

Clinically, we often encounter patients who have symptoms of loose stool or diarrhea due to the use of antibiotics. Psuedomembranous colitis is the most frequent, but hemorrhagic colitis is rare. Penicillin-like-antibiotics-induced hemorrhagic colitis was infrequently reported in abroad, but in Korea, quinolone-induced colitis was reported. We found a case that the patient had the hematochezia after use of amoxicillin for eradication of H. pylori. Colonoscopic abnormalities showed superficial ulceration and mucosal edematous change without pseudomembrane on the ascending and transverse colon. We diagnosed the amoxicillin-induced hemorrhagic colitis by clinical course, colonoscopic findings, histologic findings and other laboratory results for differential diagnosis. This disease is rare but rapidly recovered after the withdrawal of the antibiotics and has a good prognosis. Therefore, we should differentiate this disease from hemorrhagic colitis of other causes by history taking.

A Case of Amoxicillin-induced Segmental Hemorrhagic Colitis / 대한소화기내시경학회지

Clinically, we often encounter patients who have symptoms of loose stool or diarrhea due to the use of antibiotics. Psuedomembranous colitis is the most frequent, but hemorrhagic colitis is rare. Penicillin-like-antibiotics-induced hemorrhagic colitis was infrequently reported in abroad, but in Korea, quinolone-induced colitis was reported. We found a case that the patient had the hematochezia after use of amoxicillin for eradication of H. pylori. Colonoscopic abnormalities showed superficial ulceration and mucosal edematous change without pseudomembrane on the ascending and transverse colon. We diagnosed the amoxicillin-induced hemorrhagic colitis by clinical course, colonoscopic findings, histologic findings and other laboratory results for differential diagnosis. This disease is rare but rapidly recovered after the withdrawal of the antibiotics and has a good prognosis. Therefore, we should differentiate this disease from hemorrhagic colitis of other causes by history taking.