Brown Thomas A, Rajappannair Lakshmi, Dalton Arthur B, Bandi Ram, Myers Joseph P, Kefalas Costas H
Department of Medicine, Summa Health System, Akron, Ohio 44221, USA.
Clin Gastroenterol Hepatol. 2007 Aug;5(8):969-71. doi: 10.1016/j.cgh.2007.04.016. Epub 2007 Jul 10.
A 72-year-old man was hospitalized for exacerbation of chronic obstructive pulmonary disease and was treated with oral prednisone and 7 days of moxifloxacin. Five days after completing the antibiotic course, he developed watery diarrhea and diffuse, crampy abdominal pain. On presentation he was afebrile, and abdominal examination revealed diffuse tenderness without peritoneal signs. Stool tested positive for Clostridium difficile toxin A by enzyme-linked immunosorbent assay. Despite starting oral metronidazole, the patient developed a fever of 101.2 degrees F 36 hours after his initial episode of diarrhea, 12 hours after admission. His abdominal pain intensified and became localized to the right and left lower quadrants. Computed tomography scan revealed both a thickened cecal wall and an edematous appendix with ileocecal stranding consistent with appendicitis. Appendectomy was performed, and the appendix was found to be suppurative in appearance and nonperforated. The cecum had mild edema and erythema, whereas the colon and rectum were grossly unaffected. Pathology examination revealed exudative material in the appendiceal lumen and a diffuse transmural inflammatory cell infiltrate. The patient had an uneventful recovery and continued to improve on oral metronidazole. Although Clostridium difficile colitis and appendicitis are each very common independently, C. difficile as an etiology of appendicitis is exceedingly rare. A review of the literature revealed 2 prior cases. We speculate that this association is underdiagnosed, because milder cases might respond to antibiotic therapy alone, and severe cases might involve the entire colon and require total colectomy. In each scenario, the involvement of the appendix might be overlooked.
一名72岁男性因慢性阻塞性肺疾病急性加重入院，接受口服泼尼松及7天莫西沙星治疗。抗生素疗程结束5天后，他出现水样腹泻及弥漫性绞痛性腹痛。就诊时体温正常，腹部检查显示弥漫性压痛但无腹膜刺激征。酶联免疫吸附试验检测粪便艰难梭菌毒素A呈阳性。尽管开始口服甲硝唑治疗，但患者在首次腹泻发作36小时后（入院12小时后）体温升至101.2华氏度（38.4摄氏度）。他的腹痛加剧并局限于右下腹和左下腹。计算机断层扫描显示盲肠壁增厚、阑尾水肿，回盲部有条索状改变，符合阑尾炎表现。遂行阑尾切除术，术中发现阑尾外观化脓但未穿孔。盲肠有轻度水肿和红斑，而结肠和直肠大体未见异常。病理检查显示阑尾腔内有渗出物，并有弥漫性透壁炎性细胞浸润。患者恢复顺利，继续口服甲硝唑后病情持续改善。尽管艰难梭菌结肠炎和阑尾炎各自都很常见，但艰难梭菌作为阑尾炎的病因极为罕见。文献回顾显示此前有2例相关病例。我们推测这种关联可能未被充分诊断，因为轻症病例可能仅对抗生素治疗有反应，而重症病例可能累及整个结肠并需要行全结肠切除术。在每种情况下，阑尾的受累情况可能被忽视。
