Contents lists available at ScienceDirect Visual Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/visj Visual Case Discussion Toxic megacolon due to severe Clostridium difficile colitis Adam W. Breslin ⁎ , Kevin M. Gurysh, Joshua S. Broder Division of Emergency Medicine, Duke University Hospital, Durham, NC, USA ARTICLEINFO Keywords: Clostridium difficile Colitis Toxic megacolon A 73-year-old male nursing facility resident with a history of lym- phoma and recent antibiotic use for possible Clostridium (C.) difficile infection presented with altered mental status, hypotension, and su- praventricular tachycardia. Following volume resuscitation and cardi- oversion, he remained hypotensive and was noted to have significant abdominal distension. Chest radiograph (Fig. 1) was obtained, followed by non-contrast computed tomography (CT). CT revealed a severely dilated colon with diffuse wall thickening (Figs. 2, 3). The patient was diagnosed with toxic megacolon due to severe C. difficile colitis. The patient underwent immediate colectomy but expired in the intensive care unit (ICU) within 24 h. Clostridium difficile is a gram-positive, spore-forming bacterium typically spread by the fecal-oral route. It is a non-invasive pathogen; toxins A and B cause disease, with presentations ranging from asymp- tomatic carrier state to mild diarrhea, pseudomembranous colitis, or the most severe form, acute toxic megacolon, which follows disruption of epithelial integrity and release of inflammatory mediators. 1,2 C. difficile infection accounts for approximately 10% of cases of diarrhea with no vomiting in adults presenting to United States emergency departments, with only 1–2% of the 10% requiring surgical management. 3 Greater than one-third of C. difficile infections lack any traditional risk factors, which include immune compromise and prior exposure to antibiotics, the pathogen, and healthcare. 1,3 Antibiotics including intravenous metronidazole and oral vanco- mycin are the mainstays for severe acute C. difficile infection, with fi- daxomicin reserved for recurrent infections. When clinical condition worsens despite antibiotics, total or sub-total colectomy, diverting ileostomy, or colonic lavage with vancomycin may be considered. More recently, fecal microbial transplantation has shown results in patients with progressive or recurrent infections. 3 Fig. 1. Chest radiograph shows dilated large bowel, without subdiaphragmatic free air. https://doi.org/10.1016/j.visj.2018.07.016 Received 4 April 2018; Accepted 11 July 2018 ⁎ Corresponding author. E-mail address: adam.breslin@duke.edu (A.W. Breslin). Visual Journal of Emergency Medicine 13 (2018) 15–17 2405-4690/ © 2018 Elsevier Inc. All rights reserved. T