27 October 2023: Articles
Unusual clinical course, Challenging differential diagnosisManuel A. Garza 1ABCDEF*, Braden Thomas1ABCDEF, Adam Saleh 2ABCDEF, Lara Nabbout1ABCDEF, Eamonn M.M. Quigley1234ABCDEF, Neha Mathur123ABCDEFG
Am J Case Rep 2023; 24:e940923
BACKGROUND: Clostridioides difficile (C. difficile) is a bacterium that is well known for causing serious diarrheal infections and can even lead to colon cancer if left untreated. Disruption of the normal healthy bacteria in the colon can lead to development of C. difficile colitis. Risk factors for C. difficile infections (CDI) include recent antibiotic exposure, hospital or nursing home stays, inflammatory bowel disease (IBD), or impaired immunity. There is an increasing incidence of community-associated CDI (CA-CDI) in individuals without the common risk factors, which has implicated natural reservoirs, zoonoses, originating from animals such as domestic cats and dogs, livestock, shellfish, and wild animals.
CASE REPORT: A previously healthy 31-year-old woman with recurrent CA-CDI suspected to be acquired from a household cat represents a novel presentation. The patient had an initial case of severe diarrhea following recent antibiotic exposure, was briefly monitored in hospital, and was diagnosed with CDI. She was trialed on oral vancomycin, which resulted in temporary resolution of her symptoms. Her symptoms recurred, however, and did not improve despite treatment with multiple therapeutic options over a period of months. Ultimately, the patient was not able to achieve long-term resolution of her symptoms until her newly adopted pet cat was treated by a veterinarian.
CONCLUSIONS: In conclusion, this case report explores the epidemiologic risk factors of zoonotic CA-CDI and the importance of early identification, evaluation, and prevention of disease. This case demonstrates the significance of thorough history taking, contact (pet) tracing, and proper treatment of recurrent CA-CDI.
Keywords: Bacterial Zoonoses, Clostridium Infections, diarrhea, Disease Reservoirs
The increasing incidence of community-associated
A 31-year-old woman presented with a 1-week history of fever and diarrhea. She reported passing 4 loose, non-bloody bowel movements daily, associated with abdominal cramps, nausea, and vomiting. Medical history included endometriosis and recurrent urinary tract infections (UTIs). Her most recent UTI was treated with a 7-day course of ciprofloxacin, completed 3 days prior to admission. This was her only antibiotic exposure within the previous 3 months. She denied any previous hospitalizations, surgeries, prior CDI, other enteric infections, or family history of immune-mediated conditions or IBD. Pertinent negatives were dysuria, melena, or hematochezia. She did not smoke or drank alcohol socially, and had only 1 male sexual partner.
On physical examination, she was febrile (38.89°C), tachycardic (133 beats/min), and tachypneic (respiratory rate 22 breaths/min), but normotensive. There was minimal abdominal tenderness and no guarding. The white blood cell count was 13 950 cells/μL, lactic acid 2.8 mg/dL, and urinalysis revealed trace leukocyte esterase. The urine culture was negative, but she received 2 days of intravenous antibiotics for a suspected urinary tract infection (UTI). Computed tomography of her abdomen and pelvis with contrast suggested left pyelonephritis; the colon was normal. The stool polymerase chain reaction (PCR) was positive for
As demonstrated in Figure 2, 2 months later, she presented to a primary care clinic with recurrence of her symptoms, including profuse watery diarrhea associated with abdominal pain, nausea, fever, and chills. Her stool PCR was again positive for
Environmental factors play a significant role in the pathogenesis of recurrent community-acquired CDI. A study in Houston, Texas identified pathogenic
There is a general lack of data on the prevalence of pathogens in household pets and on the incidence of human infections that can be attributed to pets . However, it has been hypothesized before that a patient who experiences CDI could transmit
This study was limited by the fact that whole genome sequencing was not performed on stool isolates. As such, resolution of the patient’s stool microbiota was limited. Additionally, the patient was exposed to ciprofloxacin prior to her initial CDI which is a risk factor for CDI.
In conclusion, given the temporal relationship between the patient’s symptom onset and the adoption of the cat, and given the resolution of the patient’s symptoms following treatment of the cat, it is possible that the patient acquired
FiguresFigure 1.. This graphic depicts the epidemiological triangle of infectious disease. Focusing on the interaction between the host, the environment, and the pathogen can help us understand this rare case of community-acquired C. difficile. Figure 2.. This graphic depicts the timeline of the patient’s treatment and symptoms, and the cat’s diagnosis and treatment.
1.. Tsai CS, Hung YP, Lee JC: Expert Rev Anti Infect Ther, 2021; 19(12); 1543-52
2.. Garza M, Thomas B, Saleh A: Am J Gastroenterol, 2022; 117(10S); e1407
3.. Marra AR, Perencevich EN, Nelson RE: JAMA Netw Open, 2020; 3(1); e1917597
4.. Brown AWW, Wilson RB: Gastroenterol Rep (Oxf), 2018; 6(3); 157-66
5.. Alam MJ, Anu A, Walk ST, Garey KW: Anaerobe, 2014; 27; 31-33
6.. Damborg P, Broens EM, Chomel BB, Bacterial zoonoses transmitted by household pets: State-of-the-art and future perspectives for targeted research and policy actions: J Comp Pathol, 2016; 155(1 Suppl. 1); S27-40
7.. Redding LE, Kelly BJ, Stefanovski D: Open Forum Infect Dis, 2020; 7(1); ofz541
8.. Loo VG, Brassard P, Miller MA: Infect Control Hosp Epidemiol, 2016; 37(11); 1342-48
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