Acute Inflammatory Ascites Complicating Clostridium difficile Colitis

Abstract

Clostridium difficile (CD) is a spore-forming, Gram-positive anaerobic bacillus that causes toxin-mediated mucosal injury leading to pseudomembranous colitis, clinically characterized by diarrheal disease. Ascites is an infrequent manifestation in severe or fulminant CD colitis. The pathogenesis of ascites in CD colitis is poorly understood but includes hypoalbuminemia due to protein-losing enteropathy, transmural inflammation, toxin-mediated capillary leak, colonic perforation, and concomitant diseases. We report the case of a middle-aged woman who presented with an opioid overdose and subsequently developed severe CD colitis. The infection was complicated with low serum-ascites albumin gradient (SAAG), high protein, culture-negative, neutrophil-predominant ascites, devoid of visceral perforation, or an alternative etiology for ascites. Treatment with oral vancomycin and intravenous metronidazole led to the complete resolution of symptoms and ascites. This case highlights an uncommon presentation of a common healthcare-associated infection and reinforces the importance of recognizing atypical manifestations of CD. While there are no specific management guidelines for this subset, treating the underlying colitis appears sufficient to resolve the ascites in most cases.

Keywords: ascites; clostridium difficle infection; colitis; diarrhea; serum-ascites albumin gradient.

Figure 1. X-ray chest demonstrating bilateral predominantly lower zone opacities

Figure 2. Contrast-enhanced computed tomography images

(A-D) Axial images demonstrating ascites (red x), pleural effusion (blue x), a normal-appearing pancreas (yellow arrow), and thickened sigmoid and rectum (green arrows); (E) coronal image depicting ascites (red x) and thickened sigmoid (green arrow).

Figure 3. Ultrasound images

Minimal fluid was demonstrated in the right (A) and left (B) upper quadrant sonographic images, with no evidence of cirrhosis (red arrows).