C. Difficile Infection May Activate Dormant Crohn Disease

Infection with Clostridioides difficile colitis may cause a flareup of dormant Crohn disease (CD), according to a study published by Cureus. The investigators noted that the conditions often present with symptoms of abdominal pain and diarrhea, which may cause confusion for health care practitioners because of the similarities between Clostridioides difficile infection (CDI) and CD.

“Crohn’s disease (CD) is a type of inflammatory bowel disease (IBD) characterized by chronic transmural inflammation of any portion of the gastrointestinal tract. The etiology of CD remains unknown although genetic, immunological, and acquired factors have been recognized as contributing to its development,” the study authors wrote. “Alterations of intestinal microbiota, including Clostridioides difficile (C. difficile), are theorized to alter humoral immunity and contribute toward CD flare pathogenesis. As such, cases of IBD remission can be undone by alterations in the gut microbiota and subsequently confound the diagnosis of inflammatory or infectious etiologies of diarrhea.”

The investigators noted that the recognition of CD has grown, which mirrors its increasing prevalence in the United States. Although the precise pathophysiology of CD is unknown, there are various genetic, immunological, and acquired factors believed to be vital in the development of CD. The study authors added that alterations of the intestinal microbiota, including CDI, are hypothesized to play a role in the pathogenesis of CD.

“Clayton et al. have demonstrated a significant association between the asymptomatic carriage of C. difficile and IBD when compared to healthy volunteers,” the study authors wrote. “Furthermore, C. difficile colitis has been associated with increased morbidity, length of stay, and incidence of flares in patients suffering from IBD. Distinguishing an acute flare of IBD in the setting of an active C. difficile colitis remains especially challenging.”

The investigators presented a case study involving a 73-year-old female patient with a history of CD that was in remission for 25 years without maintenance therapy. The woman presented to an academic health center for the treatment of symptoms that included progressively worsening nausea, vomiting, and the onset of diarrhea 3 days prior. The patient said her symptoms began gradually and and included severe non-bloody malodorous watery diarrhea.

The patient did not have any recent sick contacts, travel, or restaurant exposure, and did not have any associated fevers, rashes, or antibiotic exposure in the 2 months prior.

After being admitted for further evaluation and management, the patient’s symptoms improved. However, despite the initial improvement, the patient experienced worsening generalized abdominal pain associated with an increase in the frequency of bowel movements 4 days post admission. The patient’s serum leukocyte count acutely increased and she did not show evidence of infectious sequelae besides gastrointestinal symptoms.

The investigators ultimately found her condition was consistent with a new CD flare. The patient was administered intravenous methylprednisolone in addition to maintaining oral vancomycin. Her leukocytosis and abdominal pain both improved with complete resolution by 8 days post admission. The patient was discharged with oral prednisone and a 14-day course of oral vancomycin to maintain remission.

At 24 days post discharge, her symptoms had resolved following the completion of a 14-day course of oral prednisone and oral vancomycin. The patient opted not to pursue further pharmacotherapy for the maintenance of remission.

The investigators noted that it can be difficult to discern between acute CDI or a new onset IBD flare due to overlapping clinical presentation.

“A high index of suspicion for a CD flare during a C. difficile infection is essential to enable expeditious evaluation and reduce the complications of C. difficile colitis associated with CD patients,” the authors wrote. “An endoscopic evaluation may be utilized to differentiate these 2 etiologies or the presence of both simultaneously. Treatment for patients with C. difficile colitis and a CD flare includes the use of systemic corticosteroids and antibiotics with close monitoring of clinical progression.”

Reference

Hernandez O L, Suarez Z K, Nagi T, et al. (April 03, 2023) Dormant Crohn's Disease Reactivated by Clostridioides difficile Infection. Cureus 15(4): e37062. doi:10.7759/cureus.37062.