Abstract
To the Editor:
A 71-year-old male without a history of immunosuppression or proton pump inhibitor use presented elsewhere with right-sided lower abdominal pain. A computed tomography (CT) scan revealed a pelvic abscess in close proximity to the sigmoid colon, which contained multiple diverticula but no evidence of diverticulitis coli. The abscess was not amenable to percutaneous drainage and, after “failing” nonoperative treatment with intravenous antibiotics, the patient underwent diagnostic laparoscopy, which did not identify the abscess or any additional abnormalities. The appendix was removed; the histologic picture was normal. Postoperatively, the patient had persistent right lower-quadrant abdominal pain and signs of partial small bowel obstruction. Regardless, he was discharged home after 21 days of hospitalization on oral ciprofloxacin and metronidazole.
The patient presented to our emergency department two days after discharge with new-onset upper abdominal pain and inability to pass flatus. His abdomen was distended with mild tenderness in both upper quadrants. His white blood cell count was 16,400/mm3, and the serum albumin concentration was 3.5 g/dL. A CT scan showed pneumoperitoneum, as well as a loculated abscess in the right lower quadrant with adherent small bowel, but no evidence of diverticulitis (Fig. 1).
The patient underwent exploratory laparotomy, which recovered murky peritoneal fluid but no purulent material outside the abscess cavity. The dilated proximal small intestine was tethered to the abscess at a transition point in the distal ileum, where a perforation was identified and resected, along with creation of an end-ileostomy and a mucous fistula. The abscess was drained and cultured separately from the peritoneal fluid. The sigmoid colon was unremarkable except for un-inflamed diverticuli. Pathological examination revealed viable small intestine with a 1-cm smooth-walled, full-thickness perforation. An adjacent area of thickened mucosa and serosa was associated with a 1-cm radial mucosal tear. The etiology of the perforation remains unclear despite histopathologic analysis.
Cultures from the abscess yielded Candida albicans, whereas cultures of the peritoneal fluid were positive only for C. difficile. Additional cultures (not assays for the presence of toxin) of the patient's stool and ileostomy output taken postoperatively were negative for C. difficile. The patient was treated with a 7-d course of intravenous metronidazole and fluconazole. He was discharged home tolerating a regular diet, without any further evidence of infection.
Monobacterial isolation of C. difficile from peritoneal fluid, emanating from an extra-colonic infection, has been reported only once previously [5]. Putative sources of the C. difficile in this case, absent any involvement of colon, could be the ileum, the previous appendectomy, or a prior operative misadventure involving the small intestine. The patient had neither signs nor symptoms of C. difficile colitis, and cultures of the patient's pelvic abscess, stool, and ileostomy fluid were negative for C. difficile. Because of the complicated clinical picture of this patient, it is unclear to what degree the C. difficile in the peritoneal fluid contributed to the signs/symptoms of his disease process, or whether the isolate of C. difficile was incidental or consequential to the patient's outcome.