Estifan Elias, Nanavati Sushant M, Kumar Vinod, Vora Aarohi, Alziadat Moayyad, Sharaan Ahmed, Ismail Mourad
Department of Medicine, St. Joseph's University Medical Center, Paterson, NJ, USA.
Division of Pulmonary and Critical Care, St. Joseph's University Medical Center, Paterson, NJ, USA.
J Glob Infect Dis. 2020 Feb 19;12(1):34-36. doi: 10.4103/jgid.jgid_117_19. eCollection 2020 Jan-Mar.
Clostridium difficile colitis has been the most recognized bacterial enterocolitis for years and other bacteria such as Staphylococcus colitis has been relegated. Staphylococcus enterocolitis following antibiotics had been one of the most frequent complications in surgical patients in the 1950s and 1960s and now reappear with more resistance such as methicillin-resistant(MRSA) colitis which brings a new challenge. A 32-year-old Hispanic female with a history of type I diabetes mellitus presenting with altered sensorium and a 2-day history of watery, nonbloody diarrhea, intractable emesis, and diffuse crampy abdominal pain. About a month before the presentation, the patient had a soft-tissue laceration on the left foot requiring a 7-day course of cephalexin and clindamycin that healed appropriately. On physical examination, she was tachycardic with heart rate of 110 bpm and tachypneic with respiratory rate of 28, somnolent but arousable with the Glasgow Coma Scale >12. The abdomen was soft, tender diffusely to palpation without rebound or guarding. On the biochemical analysis, her blood glucose was 968 mg/dL with anion gap metabolic acidosis (AG 46). In the intensive care unit, she initiated on intravenous (IV) fluids, insulin, and IV antibiotics for suspicion of colitis. Clostridium difficile testing was negative, but stool cultures grew MRSA for which she was started on vancomycin and TMP-SMX. Due to continued abdominal pain on antibiotics, computed tomography of the abdomen with contrast showed acute appendicitis with inflammatory debris and without perforation or abscess requiring laparoscopic appendectomy. Our case presented with diabetic ketoacidosis (DKA), which complicates the etiology of abdominal pain on admission for the clinician masking-MRSA colitis associated with a rare complication of appendicitis double challenge and difficult to diagnose as most DKA patients present with abdominal pain. This is the first case report describing MRSA enterocolitis in patient with DKA complicated by acute appendicitis.
艰难梭菌结肠炎多年来一直是最广为人知的细菌性小肠结肠炎，而其他细菌如葡萄球菌性结肠炎则已较少被提及。抗生素相关性葡萄球菌小肠结肠炎在20世纪50年代和60年代曾是外科手术患者中最常见的并发症之一，现在又以耐甲氧西林金黄色葡萄球菌（MRSA）结肠炎等更具耐药性的形式再度出现，这带来了新的挑战。一名32岁的西班牙裔女性，有I型糖尿病病史，出现意识改变，伴有2天的水样、无血腹泻、顽固性呕吐和弥漫性痉挛性腹痛。在发病前约一个月，患者左脚有软组织裂伤，接受了为期7天的头孢氨苄和克林霉素治疗，伤口愈合良好。体格检查时，她心动过速，心率为110次/分，呼吸急促，呼吸频率为28次/分，嗜睡但格拉斯哥昏迷量表评分>12时可唤醒。腹部柔软，触诊时有弥漫性压痛，无反跳痛或肌紧张。生化分析显示，她的血糖为968mg/dL，伴有阴离子间隙代谢性酸中毒（AG 46）。在重症监护病房，因怀疑结肠炎，她开始接受静脉输液、胰岛素和静脉抗生素治疗。艰难梭菌检测为阴性，但粪便培养长出MRSA，为此她开始使用万古霉素和复方磺胺甲恶唑。由于使用抗生素后腹痛持续，腹部增强CT显示急性阑尾炎伴炎性渗出物，无穿孔或脓肿，需要行腹腔镜阑尾切除术。我们的病例表现为糖尿病酮症酸中毒（DKA），这使临床医生在入院时对腹痛病因的判断变得复杂，掩盖了与罕见并发症阑尾炎相关的MRSA结肠炎这一双重挑战，且由于大多数DKA患者都有腹痛，因此难以诊断。这是第一例描述DKA患者并发急性阑尾炎合并MRSA小肠结肠炎的病例报告。
