Guidelines on treatment of ulcerative colitis (UC) follow a stepwise approach of escalating medical therapy. Similarly, treatment guidelines for Clostridioides difficile infection (CDI) are well-established based on severity. The combination of fulminant UC & CDI especially patients with treatment naïve pancolitis is challenging with concerns for safety & efficacy of various therapies in concurrent conditions.
A 21-year-old male presented with 3 weeks of diarrhea, hematochezia & abdominal pain. Stool cultures & CD were negative & antibiotics were started. Subsequent colonoscopy showed pancolitis & UC on biopsy. IV steroids & probiotics were initiated with modest improvement & he was discharged. However, he was readmitted with worsening symptoms, started on IV steroids. Repeated colonoscopy with biopsies confirmed moderate active chronic colitis with focal ulceration & no granulomas or dysplasia. CD testing was positive. Hence, PO vancomycin was started. He had IBD-related arthritis & was started on sulfasalazine then methotrexate (MTX). Response to IV steroids (10 days) & PO vancomycin (14 days) was limited, therefore with infliximab was started. Vancomycin was switched to fidaxomicin with IVIG (3 doses). Colonoscopy was repeated revealing ongoing severe pancolitis with pseudomembrane, Mayo grade 3. Fecal microbiota transplant (FMT) was done. Biopsies were negative for CMV. Follow up CD testing was negative, yet, he progressed to fulminant UC within 6 weeks of initial diagnosis despite 4 doses of infliximab & steroids. He remained hemodynamically stable with supportive care. He was reluctant to have colectomy & hence tofacitinib was started. Despite IV steroids, infliximab, & tofacitinib; sulfasalazine & MTX; parallel PO vancomycin, fidaxomicin, IVIG & FMT, along with lactobacillus acidophilus, bloody diarrhea continued; patient was dependent on fluid support & blood transfusions. Finally, total colectomy was done as a last resort.
Guidelines are lacking on treatment of concurrent refractory fulminant UC with CDI especially in patients who do not want colectomy. Potential success of biologic therapy & risk of progression to fulminant CDI in this setting is unknown. Safety & efficacy of the various treatments including immunosuppressants & FMT in cases of concurrent UC & CDI is a grey zone. Further case-reports & studies are needed to establish the optimal stepwise approach & guide therapeutic choice & decision making.