SHM Converge Scientific Abstract ePoster Gallery-Clouded Case of Colitis: Capecitabine and Clostridium Causing Life-Threatening Diarrhea

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This case describes a 77-year-old woman with breast cancer who developed severe diarrhea, mouth pain, oral ulcers, hypotension, tachycardia, and profound neutropenia after starting capecitabine three weeks earlier. Initial workup showed diffuse enteritis/colitis on CT and a positive Clostridium difficile test, so she was treated for suspected neutropenic enterocolitis and C. diff infection with broad-spectrum antibiotics and oral vancomycin. Although her neutropenia improved and imaging later showed partial resolution, her diarrhea persisted and repeat CT continued to show inflammatory changes in the distal ileum, raising concern for capecitabine toxicity.<br /><br />DPD (DPYD) testing revealed an intermediate metabolizer variant, supporting impaired fluoropyrimidine breakdown and likely capecitabine accumulation. Colonoscopy and biopsy were unrevealing, though ileoscopy was limited by stool burden. Her symptoms slowly improved after changing C. diff therapy to fidaxomicin, adding supportive care and antimotility agents, and she was eventually discharged after a prolonged hospital stay.<br /><br />The discussion emphasizes that capecitabine can cause severe gastrointestinal toxicity, mucositis, diarrhea, and neutropenia, especially in patients with DPD deficiency. In this patient, C. diff infection likely complicated or amplified the presentation, but persistent terminal ileitis and delayed recovery suggested a major role for capecitabine-induced injury. The report highlights uridine triacetate, an FDA-approved antidote for early severe fluoropyrimidine toxicity, which is most effective when given within four days of the last dose but may still help later. The authors suggest it was not used here because the positive C. diff result may have led to anchoring bias.<br /><br />Overall, the case argues for early recognition of capecitabine toxicity, prompt use of uridine triacetate when suspected, and broader pre-treatment DPD testing in the United States to prevent life-threatening adverse events.

Asset Subtitle

Rita Auro

Meta Tag

Author List Alexander Garcia, Kevin d'Mello, Rita Auro

Category Clinical Vignettes

Concept Capecitabine

Concept Diarrhea

Concept Dihydropyrimidine Dehydrogenase

Concept Capecitabine Toxicity

Concept Uridine Triacetate

Distinguished Non-Finalist

Presenter Organization Cooper University Health Care

Presenting Author Rita Auro

Track Adult

Keywords

capecitabine toxicity

DPD deficiency

DPYD variant

neutropenia

diarrhea

mucositis

Clostridium difficile

neutropenic enterocolitis

uridine triacetate

fluoropyrimidine toxicity

Capecitabine

Diarrhea

Dihydropyrimidine Dehydrogenase

Capecitabine Toxicity

Uridine Triacetate