University of Wisconsin Hospital and Clinics Madison, WI, United States
Matthew Caldis, MD, MS1, Kerstin Austin, MD2, Igor Slukvin, MD, PhD2 1University of Wisconsin Hospital and Clinics, Madison, WI; 2University of Wisconsin School of Medicine & Public Health, Madison, WI
Introduction: Escherichia coli (E. coli) species are a major inhabitant of the human GI tract. However, diarrheagenic serotypes are among the most common bacterial causes of gastroenteritis worldwide. We present a sporadic case of shiga toxin-producing enterohemorrhagic E. coli (EHEC) O111 infection manifesting as widespread ischemic colitis.
Case Description/Methods: 59 yo female with osteoarthritis on diclofenac and tobacco use presenting with 1 day of crampy abdominal pain, nausea with nonbilious, non-bloody emesis, and dark stool. Notes 12-14 small, loose BMs since symptom onset. No fevers. No personal or family history of IBD or colorectal cancer, no prior colonoscopy, normal recent Cologuard. On admission, afebrile and hemodynamically stable, well-appearing, soft and diffusely tender abdomen without rebound or guarding. Labs showed WBC 14.3, H/H 16.1/48, lactate 1.0, FOBT +. Initially treated with IV PPI and IV fluids, with stable hemoglobin overnight. EGD showed LA Grade A esophagitis, without evidence of bleeding throughout upper GI tract. Colonoscopy showed continuous, nonbleeding ulcerated mucosa with stigmata of recent bleeding in the right colon, and discontinuous areas of similar appearance in the left colon and rectum. Endoscopically most consistent with ischemic colitis, subsequently confirmed on pathology. Ceftriaxone/metronidazole started given severity of findings. CT angiogram abdomen/pelvis showed widespread severe colitis without evidence of large vessel occlusion. Stool culture positive for E. coli serogroup O111, with shiga toxin 1 and 2 gene DNA detected. Clostridium difficile PCR positive as well and patient started on oral vancomycin. Empiric antibiotics were discontinued given increased risk of hemolytic uremic syndrome (HUS) with shiga toxin-producing E. coli infection. Clinically, abdominal discomfort improved, stool became formed and brown, and she did not develop HUS.
Discussion: To our knowledge, this is the first reported culture-proven case of shiga toxin-producing E. coli O111 infection manifesting as ischemic colitis. While there are multiple reported cases of ischemic colitis due to E. coli O157:H7, the most common cause of EHEC infection, these cases occurred during known national outbreaks but were not culture-proven. This case highlights the importance of an infectious stool evaluation in the workup of right-sided colonic ischemia in the absence of significant vascular compromise, and demonstrates one of the numerous pathological manifestations of an EHEC infection.
Figure: A) Endoscopic image of cecum. B) Histologic image of cecum: 1) Loss of surface epithelium and deep crypts. 2) Necroinflammatory membrane debris. C) Endoscopic image of descending colon. D) Histologic image of descending colon: 3) Fragment of normal colon. 4) Intramucosal hemorrhage without significant necrosis. E) Endoscopic image of rectum. F) Histologic image of rectum: 5) Lamina propria hyalinization and crypt loss.
Disclosures: Matthew Caldis indicated no relevant financial relationships. Kerstin Austin indicated no relevant financial relationships. Igor Slukvin indicated no relevant financial relationships.
Matthew Caldis, MD, MS1, Kerstin Austin, MD2, Igor Slukvin, MD, PhD2. P2276 - A Sporadic Case of Shiga Toxin-Producing Enterohemorrhagic Escherichia Coli O111 Infection Manifesting as Ischemic Colitis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.