The first case of antibiotic-associated colitis by Clostridium difficile PCR ribotype 027 in Korea

Abstract

Clostridium difficile (C. difficile) is a common causative agent of pseudomembranous colitis (PMC). C. difficile-associated diarrhea (CDAD) ranges from mild diarrhea to life threatening PMC. Recently, a highly virulent strain of C. difficile polymerase chain reaction ribotype 027 was found in North America, Europe, and Japan. A 52-yr-old woman with anti-tuberculosis medication and neurogenic bladder due to traffic accident experienced five episodes of C. difficile PMC after taking antibiotics for pneumonia along with septic shock and acute renal failure. She was readmitted to the intensive care unit and treated with oral vancomycin with refractory of oral metronidazole, inotropics and probiotics for over 60 days. C. difficile isolated both at the first and the last admission was identified as C. difficile ribotype 027 by ribotyping, toxinotyping, and tcdC gene sequencing, which turned out the same pathogen as the epidemic hypervirulent B1/NAP1 strain. This is the first case of C. difficile PCR ribotype 027 in Korea. After discharge, she was maintained on probiotics and rifaximin for 3 weeks. She had no relapse for 6 months.

Keywords: Clostridium difficile; Enterocolitis, Pseudomembranous; Ribotype 027.

Fig. 1

Clinical course of the patient. Changes in serum CRP (gray line), diarrhea number (black bars), and medication per day are shown. HERZ, isoniazid 300 mg, ethambutol 800 mg, rifampin 600 mg, pyrazinamide 1,500 mg; Levo/Pip+TZ/AMK, levofloxacin, piperacillin, tazobatam, amikacin; IVIG, intravenous immunoglobulin; MDZ, metronidazole; Vanco, vancomycin; Adm, admission.

Fig. 2

Sigmoidoscopic examination revealed scattered whitish to yellowish pseudomembrane with edematous hyperemic mucosa from rectum to descending colon. (A) the first, (B) the second, (C) the third, and (D) the fourth admissions.

Fig. 3

A representative mucosal lesion with accompanying acute and chronic inflammation. Classic pseudomembranes were not present, but necroinflammatory exudates covered the mucosal ulcerations (H&E stain, ×200).

Fig. 4

PCR products and restriction patterns of C. difficile ribotype 027 isolates from the patient. (A) Identical PCR ribotype profiles obtained from both the first and the last isolates. Lanes: M, 100 bp DNA ladder; 1, the last isolate; 2, the first isolate. (B) Types of restriction patterns by B1 and A3 PCR showing toxinotype III. Lanes: M, DNA size marker; 1, 4, Acc I restriction patterns of B1 fragment; 2, 5, HincII restriction patterns of B1 fragment; 3, 6, EcoRI restriction patterns of A3 fragment.

Fig. 5

Sequence of tcdC containing both 18-bp deletions (white arrows) and a single nucleotide deletion at position 117 (black arrows).