POST-OPERATIVE CLOSTRIDIUM DIFFICILE INFECTION IN INFLAMMATORY BOWEL DISEASE PATIENTS WITH ATYPICAL PRESENTATION Stephany T Nugyen MD, Lan Nguyen BS, John Bobo MD, Nisha Loganantharaj MD; Department of Medicine, LSU Health New Orleans, New Orleans, LA.
Introduction: The incidence of enteric infections, especially Clostridium difficile infections (CDI), is increasing among individuals with inflammatory bowel disease (IBD). We aim to highlight the importance of maintaining a high index of suspicion for CDI in individuals with IBD, particularly post-operative patients. Case: A 56-year-old female with ileal Crohn’s disease complicated by an ileal stricture and enteral fistula status post ileocecectomy 3-months prior, presented with an acute change in bowel habits after starting Risankizumab post-operatively. She was biologic naïve prior to starting therapy. She had nausea, bloating and constipation with once weekly bowel movements with overflow diarrhea. She was found to have C. difficile by PCR. Similarly, a 57-year-old female with ileal Crohn’s disease complicated by an ileal stricture status post ileocolic resection 1-year prior, presented to clinic with a change in bowel habits while on Risankizumab post-operatively. She had five to six loose stools daily with occasional rectal bleeding, nausea and early satiety. She was biologic naïve prior to starting therapy. Her stool sample was positive for C. difficile by PCR.
The patients presented were similar in terms of age, sex, and Crohn’s disease complications requiring surgical intervention. Additionally, both patients exhibited atypical presentations of CDI—constipation, nausea and early satiety. These patients were biologic naïve prior to starting Risankizumab post-operatively. Discussion: These cases suggest there is utility in testing for CDI in patients with IBD, especially following surgical intervention. It is unclear why patients with IBD are at a particularly high risk for CDI but it was thought to be due to the immunosuppressive therapy used for management of IBD. When patients with IBD contract C. difficile, they can present with severe symptoms leading to prolonged hospitalization and have a greater mortality rate. In the long term, they have a higher rate of colectomy and require escalated medical care for their IBD management. It is important to consider CDI in all patients with IBD in the post-operative setting, especially because they may present with atypical CDI symptoms that can mimic or trigger an IBD flare. Given the severe impact of CDI in patients with IBD, early diagnosis and treatment are imperative.
A CASE OF NOCARDIA BRASILENSIS CAUSING NECROTIZING FASCIITIS IN AN IMMUNOCOMPETENT PATIENT Blane Edwards MD, Julio Figueroa MD; Department of Medicine, LSU Health New Orleans, New Orleans, LA.
Introduction: Nocardia brasiliensis is a species of bacteria responsible for cutaneous infections, which are usually from inoculation through skin trauma. Case: A 71-year-old female with asthma presented with left-sided medial ankle pain and swelling for 4 days. The patient first noticed a “pimple” that developed redness and swelling. She presented to an urgent care due to severe pain that made ambulation difficult. She was given doxycycline without improvement. The area developed a blister with bloody discharge as well as worsening pain, swelling, and redness, prompting presentation to the hospital the next day. She was found to
have a fever of 101.8oF, a heart rate of 120 bpm, and a leukocytosis to 16 (x109/L). The exam was significant for an exquisitely tender, erythematous lesion to the left medial ankle with purple bullae without crepitus. A Computed Tomography showed soft tissue edema and skin thickening without an abscess or definite evidence of deep compartment involvement. The patient was started on vancomycin, piperacillin-tazobactam, and clindamycin. Podiatry was consulted for emergent surgical intervention. The patient underwent debridement and a
second subsequent debridement with a wound VAC placement the following day, where necrosis down to the fascia overlying muscle was noted. 18
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