Clostridioides difficile Enteritis Resulting in Multisystem Organ Failure: A Fatal Case Report

Introduction: Clostridioides difficile (C. diff) enteritis is a rare clinical entity that is associated with significant morbidity and mortality. No guidelines for management of C. diff enteritis currently exist. Here we present a fatal case of fulminant C diff. enteritis in a patient with a history of rectal cancer and diverting loop ileostomy presenting as septic shock and multiorgan system failure. Case Description/Methods: A 64-year-old man with a recent history of diverting loop ileostomy as a result of rectal adenocarcinoma presented with fatigue and increased ileostomy output. He denied abdominal pain or distention. His physical exam revealed an acutely ill appearance. The ileostomy was pink and painless. He had no leukocytosis nor anemia. CT scan showed findings of small bowel obstruction with a transition point at the diverting ileostomy. Additionally, long segmental enteritis was present. The patient was admitted to the ICU with tachycardia and hypotension; his ostomy bag was full of completely liquid stool. Stool resulted positive for C. diff toxins on PCR. The patient was started on oral vancomycin and intravenous metronidazole. Bedside endoscopy via ileostomy displayed circumferential pseudomembranes coating the small bowel mucosa. The patient continued to have profuse liquid stool via ostomy but regained hemodynamic stability. He was transferred to the general floor, but his condition again deteriorated with respiratory distress and bilateral pleural effusions, encephalopathy, and pancytopenia. Antimicrobials were escalated to tigecycline and fidaxomicin in addition to vancomycin and metronidazole. Chest tubes were placed bilaterally, and dialysis was initiated. With no response to antimicrobials, an attempt was made for emergency fecal microbiota transplant. Unfortunately, due to complications of the pandemic this was unable to be arranged. The decision was made to pursue comfort measures with palliative care. The patient expired within days. Discussion: Clostridioides difficile enteritis is rarely encountered and is associated with estimated mortality reaching 25%. Patients with inflammatory bowel disease, abdominal surgery, or altered gastrointestinal anatomy are at increased risk. Because of the high morbidity and mortality, consideration should be taken to involve a multidisciplinary approach including medical, surgical, critical care, and palliative care teams. Our case demonstrates that despite these careful treatment efforts, C. diff enteritis remains a life-threatening diagnosis.