Signs of Fulminant Clostridioides difficile Disease
Fulminant C. difficile infection is a life-threatening emergency characterized by hypotension/shock, ileus, toxic megacolon, or end-organ failure requiring immediate recognition and aggressive intervention. 1, 2
Clinical Presentation
Hemodynamic Instability
- Hypotension or septic shock requiring vasopressor support 1, 2
- Signs of distributive (vasodilatory) shock with hemodynamic instability 1
Gastrointestinal Manifestations
- Ileus with vomiting and absent passage of stool (paradoxically, diarrhea may be absent) 1, 3
- Toxic megacolon: radiological distension of the colon combined with severe systemic inflammatory response 1
- Signs of peritonitis including decreased bowel sounds, abdominal tenderness, rebound tenderness, and guarding 1
- Colonic perforation 2
Laboratory Abnormalities
- Marked leukocytosis (>15 × 10⁹/L), often with extreme elevations 1, 3
- Marked left shift with band neutrophils >20% of total leukocytes 1
- Elevated serum lactate indicating tissue hypoperfusion 1, 3
- Rise in serum creatinine >50% above baseline or ≥1.5 mg/dL 1, 2
Systemic Signs
- High fever (core body temperature >38.5°C) 1
- Rigors (uncontrollable shaking with feeling of cold followed by temperature rise) 1
- End-organ failure 2
Radiological Findings
Imaging Characteristics
- Distension of the large intestine 1
- Colonic wall thickening including low-attenuation mural thickening 1
- Pericolonic fat stranding 1
- Ascites not explained by other causes 1
- Radiological signs of bowel distension in the context of ileus 1
Endoscopic Findings
- Pseudomembranous colitis on colonoscopy or sigmoidoscopy 1
Critical Clinical Context
A key pitfall is that patients with fulminant disease may present with ileus and leukocytosis WITHOUT diarrhea, making the diagnosis challenging if clinicians rely solely on stool frequency. 3 The ESCMID guidelines emphasize that ileus represents severely disturbed bowel passage with vomiting and absent stool combined with radiological bowel distension. 1
The presence of both ileus and leukocytosis should immediately prompt consideration of fulminant disease requiring aggressive management including early surgical consultation. 3 Fulminant CDI is associated with the NAP1 hypervirulent strain and carries mortality rates approaching 20-30% even with intervention. 4, 5
Patients meeting fulminant criteria require immediate escalation beyond standard therapy, including consideration of surgical intervention (subtotal colectomy with end ileostomy) when medical therapy fails or when rising white blood cell counts and hemodynamic instability develop. 4, 6