NYU Medical Grand Rounds Clinical Vignette

1. NYU Medical Grand Rounds Clinical Vignette Andy Levy, MD PGY-2 March 26, 2013 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

2. Chief Complaint UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Mrs. C is a 39 year old Hispanic female patient who presents with intermittent watery diarrhea for 1 year.

3. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • The patient originally developed diarrhea and low-grade fever 1 year ago after completing a long course of clindamycin for a dental infection. • She was diagnosed with C. difficile colitis via PCR at an outside hospital and discharged on PO metronidazole • She continued to have watery diarrhea despite multiple courses of PO flagyl and PO vancomycin and was hospitalized at outside hospitals three times over the past year for dehydration.

4. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • On these admissions she was presumed to have recurrent C. difficile infection as stool PCR was positive. • She was most recently discharged 2 weeks prior to this presentation on PO vancomycin, which she took with no improvement in her diarrhea; she was still having 6-10 watery bowel movements daily w/ some diffuse abdominal pain and postprandial nausea • Pt presented to the emergency department with these symptoms

5. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Past Medical History: None • Past Surgical History: Dental surgery, appendectomy • Social History: Denies tobacco, alcohol and other illicit drug use. Originally from Mexico, came to the US 13 years ago • Family History: Denies family history of IBD • No Known Drug Allergies • Medications: Vancomycin PO 250mg four times daily

6. Physical Examination UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • General: Hispanic female, lying in stretcher, no acute distress • Vital Signs: T: 98.6 BP:91/61 HR:86 RR:16 and O2 sat:100% on RA • Patient was orthostatic with dry mucous membranes and diffuse mild abdominal tenderness • Remainder of the physical exam was normal

7. Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • CBC: WBC 5.0, Hgb 10.8, Plt 350 • Basic Metabolic panel: within normal limits • Hepatic panel: within normal limits • INR, PT, PTT within normal limits • C. diff toxin assay negative x 3, PCR negative x 2 • No fecal leukocytes, negative stool culture, stool negative for ova and parasites

8. Other Studies UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Chest X-Ray: no infiltrates, effusions, consolidations

9. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Differential Diagnosis • Recurrent C. difficile colitis

10. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 1: • The patient was started on IV hydration, PO vancomycin and IV metronidazole • Hospital Day 2: • Flexible sigmoidoscopy showed normal-appearing colonic mucosa with no evidence of colitis or pseudomembranes • Hospital Day 3: • Antibiotics were discontinued after C. diff toxin assays and PCR were negative

11. Hospital Course UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Hospital Day 4: • Colonoscopy with small area of colitis in ascending colon and small area of proctitis in rectum, but otherwise colonic mucosa and terminal ileum appeared normal • Biopsies revealed mucosal lymphoid aggregate throughout most of colon and rectum • Hospital Day 5-7: • The patient was started on cholestyramine and probiotics with some improvement in diarrhea • She was discharged on HD 7.

12. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Differential Diagnosis • Post-infectious IBS • Microscopic Colitis