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Week 10

1. A 64-year-old woman presented to the hospital with 3 days of abdominal pain, nausea, vomiting and profuse watery diarrhoea. She was recently discharged from the hospital for a urinary tract infection following a successful renal transplant from her son with excellent function. She is currently on Tacrolimus (trough level 9 ng/ml), Myfortic (720 mg bd) and prednisolone (15 mg od). She had just completed a 14-day course of ciprofloxacin.

On admission to the hospital, the blood pressure was 65/41 mmHg. Hypothermia was present. The temperature was 35.8°C. She was obese and appeared in mild distress. Her abdomen was mildly distended, with silent bowel sounds. There was tenderness in the lower quadrants without rebound tenderness.

The WBC was 53.9 109 /L with 84% neutrophils. The Hct was 36.1%. There was severe metabolic acidosis with an anion gap of 19, bicarbonate level of 12 mmol/ L, and lactic acid level of 3.6 mmol/L. The arterial blood gas demonstrated a pH of 7.11, CO2 of 16, and O2 of 150 on 2 litres of oxygen via nasal cannula. The serum creatinine was 1051 μmol/L. The K+ was 2.5 mmol/L, and Mg++ of 0.24 mmol/L. The INR was 2.1.
The patient was resuscitated with IV fluids and placed on dopamine and later norepinephrine. She was also given intravenous ciprofloxacin 500 mg every 12 h, oral vancomycin 250 mg every 6 h and IV metronidazole 500 mg every 6 h. A CT of the abdomen and pelvis demonstrated circumferential wall thickening of the colon consistent with pan colitis (see below). The transverse colon was dilated to 5.8 cm. The colonoscopy is shown below.

The patient did not improve despite treatment over the next 36 h. The WBC rose to 62.4 109 /L with a more tender abdomen. A repeat CT scan showed transverse colon was dilated to 8.7cm. There was no other source of infection. Blood, urine, and stool cultures were negative.
25
Mar
171

What is the differential diagnosis? How would you confirm the diagnosis? Who would manage this patient? Substantiate your answer!

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