A Systematic Review of the Efficacy and Safety of Fecal Microbiota Transplant for Clostridium Difficile Infection in Immunocompromised Patients

Background: Fecal microbiota transplantation (FMT) has been shown to be effective in recurrent Methods: We searched MEDLINE and EMBASE for English language articles published on FMT for treatment of CD infection in immunocompromised patients (including patients on immunosuppressant medications, patients with human immunodeficiency virus (HIV), inherited or primary immunodeficiency syndromes, cancer undergoing chemotherapy, or organ transplant, including-bone marrow transplant) of all ages. We excluded inflammatory bowel disease patients that were not on immunosuppressant medications. Resolution and adverse event rates (including secondary infection, rehospitalization, and death) were calculated. Results: Forty-four studies were included, none of which were randomized designs. A total of 303 immunocompromised patients were studied. Mean patient age was 57.3 years. Immunosuppressant medication use was the reason for the immunocompromised state in the majority (77.2%), and 19.2% had greater than one immunocompromising condition. Seventy-six percent were given FMT via colonoscopy. Of the 234 patients with reported follow-up outcomes, 207/234 (87%) reported resolution after first treatment, with 93% noting success after multiple treatments. There were 2 reported deaths, 2 colectomies, 5 treatment-related infections, and 10 subsequent hospitalizations. Conclusion: We found evidence that supports the use of FMT for treatment of CD infection in immunocompromised patients, with similar rates of serious adverse events to immunocompetent patients

Shigella sonnei Bacteremia Presenting With Profound Hepatic Dysfunction

Worldwide, Shigellosis is a significant public health issue, associated with nearly one million deaths annually. About half a million cases of Shigella infection are reported annually in the United States. Shigella bacteremia is uncommon and generally seen in children and immunocompromised adults. We present a case of a Shigella sonnei bacteremia with marked hepatic derangement in a 27-yearold previously healthy homosexual male with history of Roux-en-Y gastric bypass, who presented to the emergency room with a 4-day history of loose watery stool, abdominal cramps, nausea and vomiting, and yellow skin of 2-day duration. He reports similar diarrhea illness in two close contacts in preceding days. On examination, he was fully oriented but dehydrated, icteric, and febrile. Laboratory data revealed WBC of 2200/L, elevated AST and ALT (201 IU/L, 73 IU/L resp.), normal alkaline phosphatase, elevated total and direct bilirubin of 8.2 mg/dL and 4.4 mg/dL, albumin of 3.2 g/dL, INR of 2.9, prothrombin time of 31.7, and platelet of 96,000/L. Workup for infectious, autoimmune and medication-induced hepatitis, Wilson’s disease, and hemochromatosis was negative. Abdominal ultrasound and computed tomography of the abdomen showed hepatic steatosis and right-sided colitis. Stool and blood cultures were positive for Shigella sonnei. He was treated with ciprofloxacin with improvement in liver function. Followup blood test 4 months later was within normal limits

A Case of Rituximab-Induced Necrotizing Fasciitis and a Review of the Literature.

Necrotizing fasciitis is a fulminant soft tissue infection characterized by rapid progression and high mortality. Rituximab is a generally well-tolerated immunosuppresive medication used for B-cell malignancies and some rheumatological disorders. We report a case of a 69-year-old male with chronic lymphocytic leukemia who suffered necrotizing fasciitis of his left lower extremity secondary t

Primary Mesenteric Carcinoid Tumor Presenting with Carcinoid Syndrome

Neuroendocrine neoplasms (NENs) are a diverse group of tumors arising throughout the body with a common origin from neuroendocrine cells. Well-differentiated NENs, also known as neuroendocrine tumors (NETs), are generally indolent and are often found incidentally, while poorly differentiated tumors are more aggressive. Carcinoid tumors are NETs arising from the gastrointestinal tract and less commonly from the lungs, thymus, and kidneys. NETs in the mesentery arise from metastasis from primary tumor, and carcinoid syndrome in this setting results from concomitant metastasis to the liver. Primary mesenteric carcinoid tumors are very rare. We present a 64-year-old man with carcinoid syndrome from a mesenteric carcinoid tumor without evidence of liver metastasis or other primary tumor sites

Refractory Abdominal Pain in a Patient with Chronic Lymphocytic Leukemia: Be Wary of Acquired Angioedema due to C1 Esterase Inhibitor Deficiency.

Acquired angioedema due to C1 inhibitor deficiency (C1INH-AAE) is a rare and potentially fatal syndrome of bradykinin-mediated angioedema characterized by episodes of angioedema without urticaria. It typically manifests with nonpitting edema of the skin and edema in the gastrointestinal (GI) tract mucosa or upper airway. Edema of the upper airway and tongue may lead to life-threatening asphyxiation. C1INH-AAE is typically under-diagnosed because of its rarity and its propensity to mimic more common abdominal conditions and allergic reactions. In this article, we present the case of a 62-year-old male with a history of recently diagnosed chronic lymphocytic leukemia (CLL) who presented to our hospital with recurrent abdominal pain, initially suspected to hav

An Unholy Alliance: “Spotless” Rocky Mountain Spotted Fever and Shigella sonnei Bacteremia

Bacteremia complicating Shigella infection is uncommon as is Rocky Mountain spotted fever (RMSF) without a rash. A 27-year-old previously healthy MSM presented with a 4-day history of watery stool, abdominal cramps, nausea and vomiting, and yellow skin and finger tips of 2 days duration. He reported a self-limited diarrhea illness in two close contacts in preceding days. No tick exposure. On examination, he was dehydrated, icteric, febrile and had no rash. Relevant laboratory data included WBC of 2200/µl, elevated AST, ALT (201 IU/L, 73 IU/L respectively), normal alkaline phosphatase, elevated total and direct bilirubin of 8.2 mg/dl and 4.4 mg/dl, albumin of 3.2 g/dl, INR of 2.9, prothrombin time of 31.7 and platelet of 96,000/µl. Work up for infectious, autoimmune and medication-induced hepatitis, Wilson’s disease and hemochromatosis was negative. He tested negative for HIV. CT abdomen and magnetic resonance cholangiopancreatography showed hepatic steatosis, right sided colitis and normal biliary ducts. Rickettsia ricketsii IgM was positive. Stool and blood cultures were positive for Shigella sonnei. He was treated with Doxycycline and Ciprofloxacin with clinical improvement. Follow up blood test 4 months later was within normal limits. Our patient had Shigella bacteremia and positive Rickettsia ricketsii IgM without a typical rash. Absence of a rash occurs in 10% of cases, delays diagnosis of RMSF and is associated with increased mortality. Rash typically appears in the first five days of illness. Marked hepatic derangement with coagulopathy occurs in advanced RMSF or may have been a sequelae of Shigella bacteremia

Fecal Microbiota Transplantation for Clostridium difficile Infections in Immunocompromised Patients: A Systematic Review

Introduction: Fecal microbiota transplant (FMT) is proven to be eff ective in recurrent Clostridium diffi cile infection (CDI), with resolution in 80% to 90% of patients. However, since immunosuppressed patients were oft en excluded from FMT trials, guidelines recommend FMT with caution in this subgroup due to concerns of potential adverse eff ects. We conducted a systematic review of the literature of FMT for CDI in immunocompromised patients, to quantify the effi cacy and safety in this population. Methods: We searched MEDLINE, EMBASE, and Google scholar for English-language articles published on FMT for treatment of CDI from inception through May 2016. We defi ned ‘immunocompromised’ as patients receiving immunosuppressive agents, HIV/AIDS, inherited or primary immunodefi ciency syndromes, malignancies, or recipients of solid organ transplants (SOT) or hematopoietic stem cell transplants (HSCT). Infl ammatory bowel disease patients not on immunosuppressants were excluded. We included patients of all ages. Two reviewers independently assessed eligibility and conducted subsequent data extraction. Resolution and adverse events rate were calculated. Results: 50 studies were included, none of which were randomized designs. A total of 381 immunocompromised patients were included. Mean age was 58.2 years (range: 6.5 to 88 years). Reason for immune compromise included immunosuppressant use (74.2%); SOT (22.9%); malignancy (13.0%); HSCT (2.8%); and HIV/AIDS (2.3%). Mean number of recurrences prior to FMT was 2.6. Antibiotics were tried in most (316, 82.9%) prior to FMT, of which 22% received 3 or more CDI treatments. Seventynine percent received FMT via colonoscopy. Of the 330 (86%) who reported outcomes, 227/261 (87%) reported resolution aft er fi rst treatment, with 90% noting success aft er multiple treatments. Of the 211 reporting adverse events, there were 2 deaths (0.9%), 2 colectomies (0.9%), 5 episodes of bacteremia or infection (2.4%) and 14 new hospitalizations (6.6%). Conclusion: FMT for treatment CDI in immunocompromised patients is eff ective with few serious adverse events and should be considered in patients with recurrence despite standard treatment

Angiosarcoma of the Colon Presenting with Chronic Diarrhea, Rectal Bleeding, and Pelvic Discomfort.

Colonic angiosarcoma is a rare malignancy representing only 0.0012% of all colorectal malignancies. Due to its non-specific symptoms, diagnosis is often delayed. However, because of the aggressive nature of this malignancy, it is important to keep it in the differential diagnosis of rectal bleeding, pelvic discomfort, chronic diarrhea, and weight loss in patients with risk factors. We present a case of angiosarcoma of the colon in a 74-year-old female with a remote history of chemo-radiation for anal squamous cell carcinoma (ASCC)