Bloody diarrhea, jaundice, and sepsis in a septuagenarian

A.J., a 76-year-old healthy woman, developed nausea, vomiting and diarrhea, 1 day after eating a chicken dinner at a local restaurant. Her sister-in-law, with whom she had eaten, developed similar symptoms, which resolved quickly. After 2 days of continued symptoms, the patient was admitted to a local hospital. Physical examination was remarkable only for occult blood in the stool; laboratory data revealed a white blood cell count of 21,000/ mm3, hematocrit of 38.5%, normal serum electrolytes, blood urea nitrogen of 88 mg/dL, and a creatinine of 3.2 mg/dL. Plain film of the abdomen was normal. One day after admission, the patient developed anuria, bloody diarrhea, and jaundice. Renal ultrasound study was normal and laboratory data revealed the following: alkaline phosphatase, 166 IU/L; total bilirubin, 4.6 mg/dL; alanine transferase, 352 IU/L; lactic dehydrogenase, 1011 IU/L; and albumin, 2.9 gm/dL. Stool cultures for enteric pathogens and examination for ova and parasites were negative. Serotyping of fecal Escherichia coli species revealed no 0157:H7. The patient’s renal function gradually worsened, and hemodialysis was started 48 hours after admission. During the initial dialysis, a wide complex tachycardia developed, which normalized after digitalis and procainamide. Echocardiography revealed moderately decreased left ventricular function, calcification of the mitral ring, and right ventricular enlargement. By the 6th day of hospitalization, the alkaline phosphatase was 468 IU/L, total bilirubin was 13.1 mg/dL, and aspartate transaminase was 246 IU/L. Abdominal ultrasonography showed a thick-walled gallbladder. Results of computerized axial tomography of the abdomen and pelvis on the 21st day of hospitalization was normal. The bilirubin peaked at 26.9 mg/dL on the 13th day of hospitalization and decreased to 6.6 mg/dL by the 38th day, whereas the alkaline phosphatase continued to climb, reaching 1555 IU/L by the 38th day. Within the 1st week of the patient’s hospitalization, the serum alanine transferase peaked at 250 IU/L and the aspartate transferase reached 378 IU/L; both of these enzymes returned to near normal values by the end of the 5th week of hospitalization. Sigmoidoscopy to 30 cm on the 10th day of hospitalization revealed normal mucosa with blood coming from above. A barium enema on the same day just revealed several diverticula and a short segment of narrowing, both in the sigmoid. Another sigmoidoscopy on the 22nd day of hospitalization revealed normal mucosa to 25 cm, where a stricture prevented further passage of the instrument. A rheumatologic work-up was negative, including antibodies to nuclear antigens, extractable nuclear antigens, double-stranded DNA, and ribonucleoprotein. Serologic tests for hepatitis A and B, Salmonella and Brucella were negative. Two assays for Clostridium diffcile toxin in the stool were negative. On the 25th day of hospitalization, the patient deveioped a fever of 101“F; the subclavian catheter tip and blood grew Staphylococcus aureus. She received 4 weeks of intravenous vancomycin. During the first 6 weeks of hospitalization, the patient had several loose bloody bowel movements daily and required periodic transfusion. A persistent leukocytosis in the 15-20,000/mm3 range was documented. Leukocytes were noted in the stool on the 14th and 21st days of hospitalization. The patient was transferred to Montefiore Medical Center on the 46th day of hospitalization. At the time of transfer, she was lethargic, with a blood pressure of 150,’ 90 mm Hg, pulse of 90/min, and temperature of 100.6”F. She was jaundiced and had spider angiomata on her chest in addition to clubbed fingers and toes. Her abdomen was slightly distended, without organomegaly or masses; bowel sounds were normal. Rectal examination revealed bloody stool. Laboratory data included the following: white blood cell count, 13,000/mm3; hematocrit, 25%; mean corpuscular volume, 80 fL; platelets, 206,000/mm3;