Acute appendicitis in the setting of Clostridium difficile colitis:: Case report and review of the literature

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.