P0299 - Uncanny Association between Clostridium difficile and microscopic colitis

Bipneet Singh, MD¹, Jahnavi Ethakota, MD¹, Sakshi Bai, MD¹, Niroshan Ranjan, MD¹, Ahmad Quereshi, MD¹, Sruthi Ramanan, MD¹, Nidhishri Sridhar, MD², Thai Hau Koo, MD³, Gurleen Kaur, MD⁴, Diva Maraj, MD¹, Hassan Zreik, MD¹, Richard Santos, MD¹, Merritt Bern, MD^1
1Henry Ford Jackson Hospital, Jackson, MI; ²Heart and Vascular Institution, Bangalore, Karnataka, India; ³Hospital University of Science, Kubang Kerian, Kelantan, Malaysia; ⁴Government Medical College and Hospital, Khanna, Punjab, India

Introduction: Chronic diarrhea is often misdiagnosed as IBS-D, especially in women with anxiety, depression, or fibromyalgia. This case highlights the need for thorough evaluation of chronic diarrhea. Causes like bile salt diarrhea post-cholecystectomy, SIBO in diabetics or post-anastomotic surgery, chronic pancreatitis in type 1 diabetics, and giardiasis near water bodies should be considered. Celiac disease and inflammatory bowel disease should be explored especially with family history. After years of empiric treatment, a colonoscopy during an acute exacerbation of chronic diarrhea led to a diagnosis of microscopic colitis (MC), prompting the discontinuation of SSRIs, which are a known risk factor. Concurrently, C. difficile diarrhea, initially missed due to a negative antigen test, was correctly identified via PCR. MC and C. difficile have a reciprocal relationship, where one can predispose to the other.

Case Description/Methods: A 47-year-old female with anxiety, migraines, and chronic diarrhea post-cholecystectomy presented with worsening symptoms. She developed diarrhea after two courses of Augmentin for sinusitis, with a subsequent CT revealing pancolitis. Initial stool cultures were negative. Despite a course of ciprofloxacin and Flagyl, her symptoms worsened post-treatment. Family history included Crohn’s disease. Daily medications included Escitalopram and cholestyramine. She had leukocytosis, and stool studies including C. difficile toxin were negative. Due to high suspicion, a PCR for C. difficile was ordered and returned positive. Treatment with oral vancomycin improved her symptoms significantly. A follow-up colonoscopy with biopsies diagnosed lymphocytic colitis. SSRI discontinuation was advised, and a tapering course of Budesonide was initiated.

Discussion: Microscopic colitis (MC), including collagenous colitis and lymphocytic colitis, presents with chronic watery diarrhea. MC is associated with medications like PPIs, SSRIs, and NSAIDs. Diagnosis requires colonoscopy and biopsies, as the colon appears normal macroscopically. Treatment typically involves a budesonide taper. Persistent diarrhea or recurrent C. difficile infections warrant colonoscopy with random biopsies to check for MC. This case suggests a possible link between C. difficile infection and lymphocytic colitis, supported by recent studies. MC risk factors include older age, female sex, and smoking. Prior gastrointestinal infections, including C. difficile, are more common in MC patients.


Disclosures:


Bipneet Singh, MD¹, Jahnavi Ethakota, MD¹, Sakshi Bai, MD¹, Niroshan Ranjan, MD¹, Ahmad Quereshi, MD¹, Sruthi Ramanan, MD¹, Nidhishri Sridhar, MD², Thai Hau Koo, MD³, Gurleen Kaur, MD⁴, Diva Maraj, MD¹, Hassan Zreik, MD¹, Richard Santos, MD¹, Merritt Bern, MD¹. P0299 - Uncanny Association between Clostridium difficile and microscopic colitis, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.