Intussusception associated with pseudomembranous colitis.

In a Clinical Quiz published in the Journal(1), an intussusception associated with Clostridium difficile infection, not pseudomembranous colitis (PMC), was first reported in a 19-month-old infant. We introduce a 12-year-old boy admitted to our clinic with ileocolic intussusception secondary to antibiotic-associated PMC as the first report in a pediatric patient. A 12-year-old boy was admitted with a colicky, left-side abdominal pain for 1 day. No symptom of fever or vomiting was present, but he had passed watery diarrhea without blood. The left lower quadrant of his abdomen was moderately tender on palpation, but no palpable mass was present. His white blood cell count in peripheral blood was 11,540/mm3 with 81% neutrophil count and his C-reactive protein was 0.45 mg/dL. A stool smear test proved positive for mucus and white blood cells, but negative for occult blood. Abdominal CT (Fig. 1) visualized a target lesion consistent with ileocolic intussusception, but no evidence of mass lesion as a lead point. The intussusception was fortunately reduced by barium enema, and CT under scrutiny revealed left-side colonic wall thickening. Colonoscopy was, thus, applied to search for a lead point such as lymphoma. Pseudomembranes were observed in whole left-side colon, but no mass or other pathological lesion was identified. Histologically “volcano” lesions were observed in biopsy specimens. According to his parents, he had taken amoxicillin for 3 days and thereafter had experienced watery diarrhea 2 to 3 times per day for 10 days. In addition, he experienced paroxysmal abdominal pain and 4 incidents of diarrhea on the day before admission. C difficile toxin was negative by stool examination. Based on his clinical data observed, a final empirical diagnosis of PMC was made. His serum immunoglobulin A and immunoglobulin G levels were within the normal range. He was treated with oral metronidazole and Lactobacillus GG and subsequently improved; his PMC did not recur.FIG. 1: Ileocolic intussusception (arrow, right), several mesenteric lymph nodes (arrow head), and diffuse left-side colon wall thickening with “accordion sign” (arrow, left).A review of the literature in English identified only 1 case of intussusception in a 37-year-old woman with Hodgkin lymphoma, the case that is related to PMC (2). The intussusception in this case was supposed to have developed from altered bowel motility caused by extensive bowel edema associated with right-side PMC attributable to C difficile infection, even though the use of antibiotics was not explicitly stated. In the present case, left-side PMC was identified endoscopically and by CT, and the swelling of mesenteric lymph nodes around the ileocolic valve was discerned (Fig. 1), which suggested an inflammatory reaction to PMC. In general, the intussusception observed in 2-years-old and older children is more likely to have a lead point. In the present case, we may conclude that the lead point is the swollen lymph node from the inflammatory reaction to PMC, even if the causal relation between PMC and intussusception could not be sufficiently clarified. The use of broad-spectrum antibiotics is likely to increase the incidence of PMC (2,3). Although it is a rare clinical association, we note the possibility of PMC associated with intussusception in a pediatric patient.