Case Report
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World J Gastroenterol. May 7, 2014; 20(17): 5135-5140
Published online May 7, 2014. doi: 10.3748/wjg.v20.i17.5135
Ulcerative colitis worsened after Clostridium difficile infection: Efficacy of infliximab
Andrada Seicean, Anca Moldovan-Pop, Radu Seicean
Andrada Seicean, Anca Moldovan-Pop, Radu Seicean, Regional Institute of Gastroenterology and Hepatology, First Surgical Clinic, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca 400162, Romania
Author contributions: Seicean A, Moldovan-Pop A and Seicean R contributed equally to the patient treatment, literature review, and writing of this manuscript.
Correspondence to: Andrada Seicean, MD, PhD, Regional Institute of Gastroenterology and Hepatology, Iuliu Hatieganu University of Medicine and Pharmacy, Strada Croitorilor 19-21, Cluj-Napoca 400162, Romania. andradaseicean@gmail.com
Telephone: +40-74-4332107 Fax: +40-26-4431758
Received: November 21, 2013
Revised: January 25, 2014
Accepted: February 17, 2014
Published online: May 7, 2014
Processing time: 166 Days and 12.7 Hours
Abstract

The incidence of Clostridium difficile (C. difficile) infection (CDI) is 1.8%-5.7% in admitted patients with ulcerative colitis (UC). CDI can worsen UC and increase the risk for colectomy or even death, thus necessitating therapy escalation, such as increasing the corticoid therapy or starting a biologic treatment. Several reported cases with infliximab therapy have provided favorable outcomes in UC patients with CDI, suggesting that infliximab treatment may be protective; however, the optimal infliximab treatment regimen for UC patients with CDI remains to be established. Here, we report a case of worsening UC in the presence of recurrent CDI. The patient had received prior ciprofloxacin and immunosuppressive therapy during a prolonged hospital stay. The deterioration in the patient’s condition likely resulted from the ability of C. difficile to promote relapsing of UC by activating the immune response. Ultimately, the patient was treated with a high dose of infliximab after a low trough level of infliximab at week 8 was identified, yielding better clinical results. Infliximab was found to be safe after repetitive episodes of CDI. The trough level of infliximab was therefore a useful indicator to guide therapy and correlated well with the patient’s outcome.

Keywords: Clostridium difficile; Ulcerative colitis; Inflammatory bowel disease; Trough level; Infliximab

Core tip:Clostridium difficile infection (CDI) in patients with ulcerative colitis (UC) can worsen the disease and increase the risk of colectomy and death, thus requiring an escalation of treatment. This report reveals a case of UC worsened by recurrent CDI, which likely activated the patient’s immune response and stimulated the relapse of UC. Lack of response to infliximab therapy was indicated by low trough levels, and a high-dose infliximab regimen yielded better clinical results. Infliximab trough levels were found to correspond with patient outcome, and thus may serve to guide treatment in similar cases of UC with CDI.