Michael Dong
Charlottesville, Virginia
Michael Q. Dong1, Brian Wentworth, MD2, R. Ann Hays, MD2
1University of Virginia School of Medicine, Charlottesville, VA; 2University of Virginia Health System, Charlottesville, VA
Introduction: Fulminant disease develops in 3-8% of patients with Clostridioides difficile infection (CDI) and may progress to toxic megacolon (TMC), the latter of which is typically managed surgically but has high mortality. Although fecal microbiota transplantation (FMT) is a well-established therapy for recurrent CDI, its utilization in cases of TMC is sparsely documented. Here we describe our experience with a patient who elected FMT over surgery and their clinical response.
Case Description/Methods: A 74-year-old African-American woman with a recent perforated duodenal ulcer with surgical repair was transferred to our medical ICU (MICU) with septic shock from an initial CDI. She was previously treated with PO vancomycin, which was switched to fidaxomicin in the setting of continued diarrhea. On admission, she was afebrile with hypotension, tachycardia, and tachypnea. Labs showed leukocytosis, thrombocytopenia and an AKI. Physical exam revealed an acutely ill appearing woman with a diffusely tender, distended and tympanic abdomen.
Fidaxomicin was stopped and PO/PR vancomycin and IV metronidazole were initiated. On day 3 of admission, the patient clinically deteriorated and abdominal x-ray demonstrated increased bowel distention. TMC was diagnosed and surgery was consulted. Colectomy was offered but she declined the procedure. FMT was discussed as an alternative, off-label therapy and she agreed to proceed with placement via colonoscopy. The elevated risk of perforation was deemed acceptable by the patient. Colonoscopy revealed pseudomembranes, deep ulcers, and friable mucosa. Donor stool was deployed at the hepatic flexure and the scope was carefully withdrawn.
Over the 48 hours post-procedure, the patient had hemodynamic improvement and decreased pressor requirement. Her stool output decreased and abdominal exam improved. By 72 hours, however, the patient’s condition again worsened and she elected palliative care and died shortly thereafter.
Discussion: While colectomy is standard treatment for fulminant CDI with TMC, FMT may represent a non-surgical alternative in selected cases. We describe transient, but profound, clinical improvement in patient parameters for 48 hours following FMT. The mechanism of benefit may be multifactorial, including repopulation of normal colonic flora and mechanical colonic decompression. Although our patient died, her case provides a framework for clinicians to consider this therapy and the expected response.
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Citation: Michael Q. Dong; Brian Wentworth, MD; R. Ann Hays, MD. P1050 - FAILED FECAL MICROBIOTA TRANSPLANTATION FOR FULMINANT C. DIFFICILE COLITIS WITH TOXIC MEGACOLON. Program No. P1050. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.