Vancomycin Treatment for Pneumobilia in Clostridioides difficile Infection: A Case Analysis

Introduction

Pneumobilia is defined as the presence of air in the biliary system. It can be detected on abdominal ultrasound, computed tomography (CT) or magnetic resonance imaging (MRI). It is a rare condition. Pneumobilia indicates an underlying pathological condition or a previous medical procedure. Procedures such as endoscopic retrograde cholangiopancreatography (ERCP), biliary stenting, or surgical biliary reconstruction can introduce air into the biliary system. Infections like emphysematous cholecystitis, caused by gas-forming bacteria (eg, Clostridium perfringens), can lead to pneumobilia. Obstruction of the bile ducts (eg, by a tumor or gallstone) can occasionally cause air to be trapped in the biliary tree. Dysfunction or abnormal relaxation of the sphincter of Oddi (the muscle controlling the flow of digestive juices through the bile and pancreatic ducts) can allow intestinal air to enter the biliary system [1,2].

Case Report

A 20-year-old man presented to Gennimatas General Hospital in Athens Greece due to multiple episodes of diarrhea starting 1 week before presentation at our hospital. He had a medical history of suffocation 3 years ago, being bedridden afterwards and fed through a feeding tube, receiving sachet esomeprazole 10 mg ×1 and lacosamide tablets 50 mg ×2. A year ago, he suffered obstructive ileus, which was surgically treated. Fifteen days before presentation, he was diagnosed with lung infection, for which he received oral levofloxacin.

Upon admission, he had axillary temperature 38.3°C, blood pressure 100/60 mmHg, heart rate 95 bpm, oxygen saturation 95% on ambient air, and respiratory rate 20 breaths per minute. Lung auscultation was normal on both lungs.

Routine laboratory blood results showed neutropenia, thrombocytopenia, low potassium serum levels, and elevated inflammation markers (Table 1). The neutropenia and thrombocytopenia were attributed to lacosamide, which gradually was substituted with sodium valproate. The hypokalemia was caused by diarrhea. A CT scan of the abdomen demonstrated colitis and pneumobilia (Figure 1A–1C).

The patient was first treated as having neutropenic fever with IV piperacillin/tazobactam and vancomycin. Multiple blood cultures were sterile, and a urine culture was negative. Clostridioides difficile toxins A+ and B+ were detected in stool culture. As soon as Clostridioides difficile infection was confirmed, the intravenous antibiotics and esomeprazole were stopped and treatment with oral vancomycin 125 mg 4 times every day was started. Watery stools gradually reduced and inflammatory markers subsided. The patient remained afebrile, with normal blood pressure. A week later he underwent a second CT scan of the abdomen, which showed normal liver without pneumobilia (Figure 2A, 2B).

Discussion

This is a medical case that combines diarrhea with pancytopenia in a patient with epilepsy, long-term bed rest, and recent antibiotic intake. Computed tomography results directed the attending physicians to investigate the presence of air in the biliary system. The rapid detection of Clostridioides difficile in stool and the immediate initiation of treatment with oral vancomycin resulted in reduction of diarrhea. The absence of other predisposing factors that potentially could induce pneumobilia and the disappearance of the air in the biliary tree on the second CT scan, after the successful treatment of the Clostridioides difficile infection, suggested that the latter was the cause of the pneumobilia.

Clostridioides difficile is a gram-positive, anaerobic, spore-forming, toxin-producing bacterium. It grows best at 37°C and is transmitted via the fecal-oral route. There are 2 forms of the organism: a dormant spore form that is resistant to medication, and a vegetative form that can produce toxins and is susceptible to activity of some medications [3]. Diagnosis is based on a positive GDH antigen test and detection of toxin A and/or toxin B. In indeterminant cases, NAAT can be also performed. C difficile infections are one of the most common nosocomial (hospital-acquired) infections. There are around 450 000 people infected by C. difficile annually in the United States, with 14 000 associated deaths due to CDI. They are easily transmitted between patients from healthcare and community reservoirs, causing a considerable increase in morbidity and mortality in adult hospital patients. Clinical symptoms vary from asymptomatic carriage or mild diarrhea to severe conditions such as pseudomembranous colitis and toxic megacolon with septic shock [4,5].

Conclusions

Pneumobilia caused by Clostridioides difficile infection was treated with orally administered vancomycin, which cured the patient’s diarrhea and pneumobilia. This clinical case details a rare complication of a common infection. More cases and studies are needed for a better understanding of the possible association between Clostridioides difficile infection and pneumobilia.