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Vol. 84. Num. 1.
Pages 1-126 (January - March 2019)
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Vol. 84. Num. 1.
Pages 1-126 (January - March 2019)
Scientific letter
DOI: 10.1016/j.rgmxen.2018.03.008
Open Access
Fecal microbiota transplantation for severe complicated C. difficile colitis in a patient with acquired immunodeficiency syndrome
Trasplante de microbiota fecal en el tratamiento de colitis grave complicada por C. difficile en un paciente con síndrome de inmunodeficiencia adquirida
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P. Martínez-Ayalaa,
Corresponding author
pemayala4@gmail.com

Corresponding author. Unidad de VIH, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico. Tel.: +01-33-36-575633.
, L.A. González-Hernándeza, F. Amador-Laraa, J. Andrade-Villanuevaa, M. Ramos-Solanob
a Unidad de VIH, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
b Instituto de Investigación en Inmunodeficiencias y VIH, Departamento de Clínicas Médicas, CUCS - Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
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Clostridium difficile infection (CDI) continues to be the main cause of hospital-acquired diarrhea and one of the main causes of nosocomial infection. For the last two decades, CDI burden has increased in terms of incidence, morbidity, mortality, and costs.1 The wide spectrum of CDI manifestations ranges from asymptomatic patients to fulminant presentations with toxic megacolon.2 Treatment strategies should be based on disease severity, previous history of CDI, and individual patient risk for recurrence.

Vancomycin is the treatment of choice for severe or complicated CDI. Metronidazole is appropriate for mild disease, and fidaxomicin is a therapeutic option for patients with recurrent CDI or with a high risk for recurrence. Fecal microbiota transplantation (FMI) has been associated with recurrent CDI symptom resolution, but its role as primary treatment and in severe CDI has not been established.3 There is a subgroup of CDI patients that develop fulminant presentations that are refractory to conventional treatments.4 We present herein the case of a patient with HIV infection and colitis due to Clostridium difficile that was successfully treated through fecal microbiota transplantation.

A 28-year-old man was diagnosed with stage C3 human immunodeficiency virus/AIDS (CD4+ T-lymphocyte count of 41 cells/μl and viral load of 127,305 copies/ml), treated for central nervous system toxoplasmosis and hospital-acquired pneumonia with pyrimethamine, clindamycin, and piperacillin-tazobactam. At the tenth day of treatment, the patient developed diarrhea, abdominal distension, and hyperleukocytosis with 61,400 cells/μl. PCR for Clostridium difficile toxins was positive for the hypervirulent 027/NAP1/Bl strain (Cepheid Xpert® C. difficile assay, USA). Treatment was begun with 125mg PO of vancomycin every 6h and 500mg IV of metronidazole every 8h. Due to lack of improvement at 48h, we increased the dose of vancomycin to 500mg PO every 6h. After 12 days of treatment, the patient had clinical deterioration manifested as increased abdominal pain and distension (fig. 1). Therefore, we began the protocol for fecal microbiota transplantation. The donor was the patient's mother, who had no history of chronic disease and whose body mass index was 24. She was screened for hepatitis viruses A, B, and C and for HIV. Stool culture, ova and parasite exam, and Clostridium difficile toxin stool test were negative. Fifty grams of stool were collected from the donor and suspended in 100ml of 0.9% saline solution. The sample was homogenized through a filter until a liquid solution was produced. Two days prior to the procedure all antibiotics were suspended, including the metronidazole and vancomycin. After the patient signed a statement of informed consent, he was infused with 100ml of the prepared sample through a nasojejunal catheter, given that no urgent colonoscopies were available at that time. Forty-eight hours after the infusion, the patient showed dramatic clinical improvement, with resolution of pain and abdominal distension and a decrease in leukocytes from 62,000 to 12,000 cells/μl (fig. 2). The patient was released and has not presented with disease recurrence at the one-year follow-up.

Figure 1.

Radiographic progression of the patient, showing a normal radiographic pattern on the 5th day of treatment for C. difficile infection (A). However, on the 12th day of antimicrobial treatment, the patient presented with clinical worsening and important bowel segment dilation can be seen (B).

(0.1MB).
Figure 2.

The leukocyte count decreased to 12,000 cells/ml 48h after fecal microbiota transplantation.

(0.07MB).

In a systematic review that included a total of 536 patients from 36 clinical trials, FMT efficacy was 87% after the first procedure. Resolution of diarrhea varied according to the infusion site: when the FMT was infused in the stomach, efficacy was 81%; in the duodenum/jejunum it was 86%; in the cecum/ascending colon it was 93%; and in the distal colon it was 84%.5 The number of reports that support the use of FMT in the acute phase of severe cases is on the rise.6 However, there is concern with respect to the greater potential risk for sepsis and infections following FMT. A recent retrospective multicenter study on 80 immunosuppressed patients that underwent FMT suggests that it is an effective modality (a 78% cure rate with a single procedure), with few adverse effects and no infectious complications in those high-risk patients.7 In addition, there is concern about potential long-term complications secondary to FMT. A higher risk for developing obesity, diabetes, colon cancer, atherosclerosis, irritable bowel syndrome, fatty liver, asthma, and autism has been reported.8 It is essential that clinical follow-up of the patients that undergo FMT be carried out over the years to determine the strength of association of the respective reports.

Very few cases have been published on patients with HIV that have received FMT as treatment for CDI, and the majority of those reports are in relation to disease recurrence.7,9,10

FMT is a simple, efficacious, and relatively inexpensive option to be considered in severe cases of CDI, especially those in which broad-spectrum antibiotics cannot be suspended. Clinical trials should be conducted to demonstrate the efficacy of FMT as first-line treatment in immunosuppressed patients with severe disease.

Financial disclosure

No financial support was received in relation to this article.

Conflict of interest

The authors declare that there is no conflict of interest.

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Please cite this article as: Martínez-Ayala P, González-Hernández LA, Amador-Lara F, Andrade-Villanueva J, Ramos-Solano M. Trasplante de microbiota fecal en el tratamiento de colitis grave complicada por C. difficile en un paciente con síndrome de inmunodeficiencia adquirida. Revista de Gastroenterología de México. 2019;84:110–112.

Copyright © 2018. Asociación Mexicana de Gastroenterología
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