Abe et al. Journal of Medical Case Reports 2012, 6:130 http://www.jmedicalcasereports.com/content/6/1/130 C A S E R E P O R T JOURNAL OF MEDICAL CASE REPORTS Open Access Acute fulminant pseudomembranous colitis which developed after ileostomy closure and required emergent total colectomy: a case report Iku Abe*, Yutaka J Kawamura, Junichi Sasaki and Fumio Konishi Abstract Introduction: Pseudomembranous colitis is known to be caused by Clostridium difficile; and, in 3% to 8% of patients, it lapses into an aggressive clinical course that is described as fulminant. We present here a case of extremely rapid and fatal fulminant pseudomembranous colitis that developed after ileostomy closure, a minor surgical procedure. To the best of our knowledge, this is the first case report of fatal fulminant pseudomembranous colitis after closure of a diversion ileostomy in an adult. Case presentation: A 69-year-old Japanese man, who had previously undergone low anterior resection and creation of a diverting ileostomy for stage III rectal carcinoma was admitted for ileostomy closure. Preoperatively, he received oral kanamycin and metronidazole along with parenteral cefmetazole. His surgery and postoperative course were uneventful until the third postoperative day, when fever and watery diarrhea became apparent. The next day he presented with epigastric and left lower abdominal pain. Computed tomography revealed a slightly distended colon. Later that night, his blood pressure fell and intravenous infusion was started. In the early morning of the fifth postoperative day, his blood pressure could be maintained only with a vasopressor. Follow-up computed tomography demonstrated severe colonic dilation. A colonoscopy confirmed the presence of pseudomembranous colitis, and so oral vancomycin was administered immediately. However, within three hours of the administration, his condition rapidly deteriorated into shock. Although an emergent total colectomy with creation of an end ileostomy was performed, our patient died 26 hours after the surgery. The histopathological examination was consistent with pseudomembranous colitis. Conclusion: It is important to recognize that, although rare, there is a type of extremely aggressive pseudomembranous colitis in which the usual waiting period for medical treatment might be lethal. We consider that colonoscopy and computed tomography are helpful to decide the necessity of emergent surgical treatment without delay. Introduction Pseudomembranous colitis is caused by an infection with the bacterium Clostridium difficile (CDI) [1]. It is well known that in some patients with CDI, the ailment lapses into a fulminant state. For these patients, the initial treat- ment of choice is nonsurgical; and then, if such treatment proves to be ineffective, a surgical consult is considered [2]. We present a case of fatal fulminant pseudomembran- ous colitis showing extremely rapid progress after a minor surgical procedure. To the best of our knowledge, this case * Correspondence: m03102_iku@yahoo.co.jp Department of Surgery, Jichi Medical University Saitama Medical Center, 1- 847, Amanuma-cho, Saitama-shi, Saitama, Omiya-ku 330-8503, Japan is the first reported case of fulminant pseudomembranous colitis after ileostomy closure in the English literature. We emphasize the importance of more prompt decision mak- ing and intervention than those described in the conven- tional treatment algorithm for CDI. Case presentation A 69-year-old Japanese man was admitted to our hos- pital for elective ileostomy closure. Ten months earlier, after chemoradiation therapy, he had undergone a low an- terior resection and creation of a diverting ileostomy for rectal carcinoma, which was complicated with post- operative leakage. Histopathological study revealed stage © 2012 Abe et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.