SHM Converge Scientific Abstract ePoster Gallery-A Difficile Diagnosis: Clostridioides Difficile Infection Without Diarrhea

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This case describes a 59-year-old man with ESRD on hemodialysis, peripheral neuropathy, and peritoneal mesothelioma who presented with tachycardia, hypotension, abdominal pain, nausea/vomiting, and reported diarrhea. He had recent hospitalization and severe illness, but initial evaluation showed diffuse ileus on abdominal CT rather than clear infectious diarrhea. Over several days, he worsened with rising leukocytosis, persistent abdominal distention, shock requiring ICU transfer and vasopressors, and no bowel movement despite ongoing symptoms.<br /><br />The key diagnostic challenge was suspected Clostridioides difficile infection (CDI) despite the absence of diarrhea. The report highlights that fulminant CDI can present with paralytic ileus, which may prevent stool passage and lead to under-testing. It also reviews common C. diff tests: PCR for toxin-producing genes is highly sensitive but may detect colonization; toxin ELISA is highly specific but less sensitive; and GDH ELISA is highly sensitive but not specific, often creating confusing mixed results.<br /><br />Because the patient had multiple CDI risk factors and persistent ileus, clinicians maintained a high suspicion. When he eventually passed a small stool, PCR testing was positive for toxin-producing C. diff. Treatment with oral vancomycin plus IV metronidazole led to rapid improvement in leukocytosis, ileus, and shock within 48 hours.<br /><br />The case emphasizes that CDI can occur without diarrhea, especially in fulminant disease with ileus. In such cases, guidelines support alternative testing such as rectal swabs. Standard treatment is oral vancomycin or fidaxomicin, with IV metronidazole or vancomycin enemas as adjuncts when ileus limits drug delivery.

Asset Subtitle

Jonah Kan

Meta Tag

Author List Diego Suarez, Jonah Kan

Category Clinical Vignettes

Concept Clostridioides difficile

Concept Oral Vancomycin

Concept Fidaxomicin

Concept Polymerase Chain Reaction

Concept Toxin Enzyme-Linked Immunosorbent Assay

Distinguished Non-Finalist

Presenter Organization Mayo Clinic Rochester

Presenting Author Jonah Kan

Track Adult

Keywords

Clostridioides difficile infection

fulminant CDI

paralytic ileus

no diarrhea

PCR testing

toxin ELISA

GDH ELISA

oral vancomycin

IV metronidazole

septic shock

Clostridioides difficile

Oral Vancomycin

Fidaxomicin

Polymerase Chain Reaction

Toxin Enzyme-Linked Immunosorbent Assay