Toxic Megacolon – A Three Case Presentation

Open access


Introduction: Toxic megacolon is a life-threatening disease and is one of the most serious complications of Clostridium difficile infection (CDI), usually needing prompt surgical intervention. Early diagnosis and adequate medical treatment are mandatory.

Cases presentation: In the last two years, three Caucasian female patients have been diagnosed with toxic megacolon and treated in the Clinical Infectious Diseases Hospital, Constanta. All patients had been hospitalized for non-related conditions. The first patient was in chemotherapy for non-Hodgkin’s lymphoma, the second patient had undergone surgery for colon cancer, and the third patient had surgery for disc herniation. In all cases the toxin test (A+B) was positive and ribotype 027 was present. Abdominal CT examination, both native and after intravenous contrast, showed significant colon dilation, with marked thickening of the wall. Resolution of the condition did not occur using the standard treatment of metronidazole and oral vancomycin, therefore the therapy was altered in two cases using intracolonic administration of vancomycin and intravenous tigecycline.

Conclusions: In these three cases of CDI, the risk factors for severe evolution were: concurrent malignancy, renal failure, obesity, and immune deficiencies. Ribotype 027, a marker for a virulent strain of CD, was found in all three cases complicated by toxic megacolon. The intracolonic administration of vancomycin, and intravenous tigecycline was successful when prior standard therapy had failed, and surgery was avoided.

If the inline PDF is not rendering correctly, you can download the PDF file here.

  • 1. Cohen SH Gerding DN Johnson S et al. Clinical Practice Guidelines for Clostridium difficile infection in adults: Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infection Control and Hospital Epidemiology. 2010;31:431-455.

  • 2. Sartelli M Malangoni MA Abu-Zidan FM et al. WSES guidelines for management of Clostridium difficile infection in surgical patients. World J Emerg Surg. 2015;10:38.

  • 3. Dallal RM Harbrecht BG Boujoukas AJ et al. Fulminant Clostridium difficile: an underappreciated and increasing cause of death and complications. Ann Surg. 2002;235:363–72

  • 4. Adams SD Mercer DW. Fulminant Clostridium difficile colitis. Curr Opin Crit Care. 2007;13:450–5.

  • 5. Rubin MS Bodenstein LE Kent KC. Severe Clostridium difficile colitis. Dis Colon Rectum. 1995;38(4):350.

  • 6. Koo HL Koo DC Musher DM DuPont HL. Antimotility Agents for the Treatment of Clostridium difficile diarrhea and colitis. Oxford Journals Medicine & Health Clinical Infectious Diseases. 2009; 48(5):598-605.

  • 7. Sayedy L Kothari D Richards RJ. Toxic megacolon associated Clostridium difficile colitis. World J Gastrointest Endoc. 2010;2(8):293-7.

  • 8. Grigorescu BL Fodor RS Cioc AD et al. Factors Favouring the Development of Clostridium Difficile Infection in Critically Ill Patients. The Journal of Critical Care Medicine. 2016;2(1):38-43.

  • 9. Martin JS Monaghan TM Wilcox MH. Clostridium difficile infection: epidemiology diagnosis and understanding transmission. Nat Rev Gastroenterol Hepatol. 2016;13(4):206-16.

  • 10. Sayedy L Kothari D Richards RJ. Toxic megacolon associated Clostridium difficile colitis. World J Gastrointest Endosc. 2010;2(8):293–297.

  • 11. Stallmach A. Clostridium difficile infection: What is currently available for treatment? Internist (Berl). 2016;57(12):1182-1190.

  • 10. Abou Chakra CN McGeer A Labbé AC et al. Factors Associated With Complications of Clostridium difficile Infection in a Multicenter Prospective Cohort. Clin Infect Dis. 2015;61(12):1781-8.

  • 11. Shivashankar R Khanna S Kammer PP et al. Clinical factors associated with development of severe-complicated Clostridium difficile infection. Clin Gastroenterol Hepatol. 2013;11(11):1466-71.

  • 12. Khanafer N Barbut F Eckert C et al. Factors predictive of severe Clostridium difficile infection depend on the definition used. Anaerobe.2016;37:43-8.

  • 13. Mulki R Baumann AJ Alnabelsi T et al. Body mass index greater than 35 is associated with severe Clostridium difficile infection. Aliment Pharmacol Ther. 2016 Oct 28. doi: 10.1111/apt.13832. [Epub ahead of print]

  • 14. Lu H Wu Z Xu W Yang J Chen Y Li L. Intestinal microbiota was assessed in cirrhotic patients with hepatitis B virus infection. Intestinal microbiota of HBV cirrhotic patients. Microb Ecol. 2011;61(3):693-703.

  • 15. Aly AM Adel A El-Gendy AO Essam TM Aziz RK. Gut microbiome alterations in patients with stage 4 hepatitis C.Gut Pathog. 2016;8(1):42.

  • 16. Naimushin A Eliasaf S Livneh A. Clostridium difficile-associated diarrhea: causes and relationship to reactive arthritis. Harefuah. 2011;150(1):64-6.

  • 17. Yu JH Kim NY Lee HM et al. A case of pseudomembranous colitis in a juvenile rheumatoid arthritis patient taking methotrexate. Korean J Gastroenterol. 2010;56(6):387-90.

  • 18. Vaahtovuo J Munukka E Korkeamäki M Luukkainen R Toivanen P. Fecal microbiota in early rheumatoid arthritis. J Rheumatol. 2008;35(8):1500-5.

  • 19. Ofosu A. Clostridium difficile infection: a review of current and emerging therapies. Ann Gastroenterol. 2016;29(2):147-54.

  • 20. Arvand M Hauri AM Zaiss NH Witte W Bettge-Weller G. Clostridium difficile ribotypes 001 017 and 027 are associated with lethal C. difficile infection in Hesse Germany. Euro Surveill. 2009;14(45): pii: 19403.

  • 21. Rao K Micic D Natarajan M et al. Clostridium difficile ribotype 027: relationship to age detectability of toxins A or B in stool with rapid testing severe infection and mortality. Clin Infect Dis. 2015;61(2):233-41.

  • 22. Dubberke ER Sadhu J Gatti R et al. Severity of Clostridium difficile-associated disease (CDAD) in allogeneic stem cell transplant recipients: evaluation of a CDAD severity grading system. Infect Control Hosp Epidemiol. 2007;28:208–11.

  • 23. Henrich TJ Krakower D Bitton A Yokoe DS. Clinical Risk Factors for Severe Clostridium difficile–associated Disease. Emerg Infect Dis. 2009;15(3):415–22.

  • 24. Akamine CM Ing MB Jackson CS Loo LK. The efficacy of intracolonic vancomycin for severe Clostridium difficile colitis: a case series. BMC Infect Dis. 2016;16:316.

  • 25. Britt NS Steed ME Potter EM Clough LA. Tigecycline for the Treatment of Severe and Severe Complicated Clostridium difficile Infection. Infect Dis Ther. 2014;3(2):321–331.

  • 26. Gergely Szabo B Kadar B Szidonia Lenart K et al. Use of intravenous tigecycline in patients with severe Clostridium difficile infection: a retrospective observational cohort study. Clin Microbiol Infect. 2016. doi: 10.1016/j.cmi.2016.08.017. [Epub ahead of print]

  • 27. Larson KC Belliveau PP Spooner LM. Tigecycline for the treatment of severe Clostridium difficile infection. Ann Pharmacother. 2011;45(7-8):1005-10.

Journal information
Cited By
All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 326 176 7
PDF Downloads 157 103 2