S2177 Clostridium difficile-Like Diarrhea

Introduction: Clostridium difficile is an important cause of diarrhea in immunosuppressed patients, recent use of antibiotics and in patients presenting from nursing facility. We present a patient with HIV, recently treated with Augmentin and started on a new medication (Juluca) for HIV presenting with watery diarrhea and abdominal pain. Case Description/Methods: 62-year-old woman with HIV infection presented with abdominal pain and watery diarrhea for 2 days. She recently had ureteroscopy and was prescribed Augmentin which she completed about a week ago. She denied any GU complaints. She was started on Juluca (Dolutegravir/ Rilpivirine) for treatment of HIV one day before onset of symptoms. She had diffuse tenderness on abdominal exam and had leukocytosis (23.1k/mcl) with an absolute CD4 count of 568/mcl. On CT scan abdomen she had pancolitis with free fluid. She was found to have Clostridium antigen but without any toxin. On flexible sigmoidoscopy she had lesions shown in the Figure. Erythematous, edematous mucosa and inflamed plaques were seen on ulcerated mucosa with narrowing of sigmoid colon. No pseudomembranes or cytological atypia was seen on histopathology. Specimen culture did not show C. difficile. Discussion: There are multiple causes of inflammatory diarrhea in an immunocompromised host with HIV. Previous infection with C. difficile and recent use of antibiotics increase the risk of C. difficile diarrhea. As per the center of disease control, about a half a million people are infected with C. difficile annually and one in 6 patients will get recurrent infection in 2 to 8 weeks. Our patient presented with multiple risk factors including history of C. difficile, HIV and recent use of antibiotics. The images of sigmoidoscopy were suggestive of pseudomembranous colitis though the tissues without any pathological or microbiological evidence. It highlights the importance of considering other non infectious causes of inflammatory diarrhea like medications. Dolutegravir/ rilpivirine are new class of medications (Integrase inhibitors). In a study by Curtis et al less than 2% of cases had diarrhea but none were severe enough o warrant discontinuation of therapy. Our patient had severe symptoms and required discontinuation of Juluca with regression of his symptoms.Figure 1.: A and B- Images of recto-sigmoid showing pseudomembranes in an edematous, erythematous colon. C,D - Marked narrowing of the sigmoid colon.