Fulminant Pseudomembranous Colitis

A 45-year-old woman sustained a fracture of her femur that required operative fixation. She was given intravenous clindamycin for prophylaxis. One week later, she reported diarrhea and abdominal cramping. She had a low-grade fever, and her white blood cell (WBC) count was 13,000/µL. Abdominal radiographs showed evidence of paralytic ileus. Stool studies were positive for Clostridium difficile cytotoxin. Intravenous metronidazole and hydration were started.

During the next 48 hours, the patient’s abdomen became progressively more tense and distended, and high fever developed. Oral vancomycin was added to the regimen. Abdominal radiographs showed extensive colonic distension. Her WBC count rose to 31,000/µL, and toxic megacolon developed.

Emergency surgery revealed a massively distended colon with severe inflammation. Total abdominal colectomy with ileostomy was performed. The photograph shows the severely swollen mucosa of the colon and multiple yellowish plaques of pseudomembrane. The patient recovered over the next 10 days.

Pseudomembranous colitis can occur during or after the use of any antibiotic. Most commonly, this disease is relatively mild and is treated effectively with oral metronidazole. In some patients, however, it runs a very aggressive and fulminant course and may require emergent surgery to prevent perforation of the colon and ensuing peritonitis. Serial clinical evaluations and a high suspicion of this disease are warranted.