Case 15

Case Submitted by Najwa El-Nachef, MD

A 29-year-old woman with a 10-year history of ulcerative colitis (UC) presents with acute onset of diarrhea associated with urgency that started three days ago. She has 5-6 watery BMs during the day and 1-2 nocturnal BMs. She developed moderate to severe pan-ulcerative colitis two years ago and her disease has been well controlled on infliximab 5 mg/kg every 8 weeks. She underwent proactive therapeutic drug monitoring recently and her infliximab serum trough level was 10 ug/ml without neutralizing antibodies. Her last colonoscopy two months ago was endoscopically normal without inflammation or dysplasia. She notes that she took azithromycin three weeks ago for treatment of sinusitis.

Notable physical exam findings:

VitalsTemp 100.5°C, HR 90 BPM, RR 12 RPM, BP 110/63
General

Uncomfortable appearing

AbdomenTender to palpation in the left lower quadrant, no guarding or rebound
What tests would you order on this patient? Select all that apply.
Fecal Calprotectin
350 mcg/g (high)
CBC with differential
WBC 16 with neutrophilic predominance
Viral Panel PCR
GI Viral Panel PCR Adenovirus: not detected Norovirus: not detected Rotavirus: not detected
Bacterial Panel PCR
Campylobacter: not detected E. coli O157: not detected Salmonella: not detected Shigella: not detected STEC: not detected Vibrio cholera: not detected
C. Difficile Test
Great! A C. difficile test is indicated for this patient presenting with symptoms which could be due to either IBD flare or C. difficile infection. After you’ve selected any other tests you think are indicated, click the link below to move on to the next part of the case and learn more about testing for C. difficile.

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