Fluoroquinolone-Induced Ischemic Colitis: A Case Series

Introduction: Ischemic colitis is a common cause of acute lower gastrointestinal bleeding in the elderly with a reported incidence of 4% in this population (1). Antibiotic-associated ischemic colitis is uncommon, which is typically right-sided and is thought to be due to an altered gut microbiome (2). We present 2 cases of ciprofloxacin-induced ischemic colitis. Case Description/Methods: A 38-year-old woman who presented with acute rectal bleeding, abdominal pain, and mucoid diarrhea after a 7-day course of ciprofloxacin for acute sinusitis. Colonoscopy demonstrated sub-epithelial hemorrhage, erythema, and erosion in the transverse colon (Figure 1A). Subsequent pathology was consistent with ischemic colitis (Figures 1B, C). She recovered after antibiotic cessation and at follow-up was asymptomatic. A 68-year-old woman was admitted to the hospital with a 2-day history of severe right lower quadrant abdominal pain and CT suggestive of a cecal mass. Colonoscopy was performed revealing ulceration and luminal narrowing in the cecum (Figure 1D). Biopsies were consistent with ischemic colitis (Figure 1F). Further history revealed a recent course of ciprofloxacin for a periodontal infection. Symptoms resolved with conservative management and repeat colonoscopy performed 2 months after discharge showed complete healing (Figure 1E). Discussion: Focal ischemic colitis is usually self-limiting, and most patients make a full recovery within a few weeks (3). Both patients we present developed ischemic colitis following a course of ciprofloxacin. Drug-induced ischemic colitis is not common, but a detailed medication history should be obtained, including antibiotic use, in patients who present with symptoms suggestive of ischemic colitis. References 1. Brandt LJ, Boley SJ. AGA technical review on intestinal ischemia. Gastroenterology 2000;118(5):954-68. 2. Brandt LJ, Feuerstadt P, Longstreth GF, Boley SJ. ACG Clinical Guideline: Epidemiology, Risk Factors, Patterns of Presentation, Diagnosis, and Management of Colon Ischemia (CI). Am J Gastroenterol 2015;110(1):18-44. 3. Tadros M, Majumder S, Birk JW. A review of ischemic colitis: is our clinical recognition and management adequate? Expert Rev Gastroenterol Hepatol 2013;7(7):605-613.Figure 1.: Figure A demonstrated inflammation and scattered erosions in the transverse colon. Figure B with microscopic change that are characterized by increased fibrosis shown by dense eosinophilia of the lamina propria with acute inflammatory cells (black arrow), smaller crypts with loss of goblet cells (red arrow), compared to more normal crypt with intact goblet cells (star) (200x magnification). Figure C with microscopic changes showing a higher magnification (400x magnification) of the smaller crypts with goblet cells (red arrow) and increased fibrosis shown by dense eosinophilia of the lamina propria with acute inflammatory cells (black arrow). Figure D: Ulceration in the cecum Figure E: Complete resolution of cecum ulceration Figure F: Cecal biopsy shows ulcerated mucosa with fibrinopurulent exudate and necrosis.