A case of community-acquired Clostridioides difficile infection causing intussusception, severe pneumonia, and severe hypokalemia

Abstract

Background: Clostridioides difficile infection is associated with antibiotic use and manifests as diarrhea; however, emerging cases of fulminant diarrhea caused by binary toxin-producing C. difficile unrelated to prior antibiotic exposure have been reported. Although fulminant colitis caused by C. difficile has been documented, instances of intussusception remain scarce. Here, we present a case of adult intussusception with severe hypokalemia and pneumonia resulting from a community-acquired C. difficile infection in Japan.

Case presentation: An 82-year-old male presented with dizziness, progressive weakness, and diarrhea. Initial vital signs indicated severe respiratory and circulatory distress, and laboratory findings revealed hypokalemia, pneumonia, and septic shock. Imaging confirmed intussusception of the ascending colon. Although colonoscopy suggested a potential tumor, no malignancy was found. The C. difficile rapid test result was positive, indicating community-acquired C. difficile infection. Treatment with vancomycin was initiated; however, intussusception relapsed. Surgical intervention was successful and led to clinical improvement. The patient's complex pathophysiology involved community-acquired C. difficile-induced severe diarrhea, hypokalemia, hypermetabolic alkalosis, and subsequent intussusception. Although adult intussusception is uncommon, this case was uniquely linked to binary toxin-producing C. difficile. The identified strain, SUH1, belonged to a novel sequence type (ST1105) and clade 3, suggesting a highly virulent clone. Resistome analysis aligned with phenotypic susceptibility to metronidazole and vancomycin, confirming their treatment efficacy.

Conclusion: This case report highlights a binary toxin-producing C. difficile that caused intussusception. The consideration of community-acquired C. difficile in the differential diagnosis of severe enteritis is necessary, even in Japan.

Keywords: Binary toxin; Clostridioides difficile; Intussusception.

Fig. 1

Chest X-ray. Chest X-ray showed diffuse consolidation in the right lung. Additionally, incidental finding suggests intestinal obstruction in the abdomen

Fig. 2

CT scan of the abdomen. CT image showed a dilatated colon and the intussusception in the ascending colon

Fig. 3

Colonoscopy. A raised lesion was observed in the ascending colon. A biopsy was performed

Fig. 4

Resection specimen. The portion of the ileocecal lesion exhibiting ischemia was excised

Fig. 5

Maximum-likelihood phylogenetic analysis based on C. difficile core-genomes. The tree includes 16 reference genomes reported in previous studies [6, 9], and was constructed using IqTree ver. 2.2.0.3 [10]. Clades are indicated by their designated number