CASE 4
Patient 4 was a 33 year old male with history of diffuse large B-cell
lymphoma (DLBCL) who developed leptomeningeal relapse approximately a
year after his initial therapy. He obtained a second complete remission
(CR2) with a high dose chemotherapy regimen containing cytarabine,
methotrexate, ifosfamide and thiotepa. He received a conditioning
regimen of BCNU, thiotepa and etoposide with autologous peripheral blood
stem cell transplant. He developed regimen related toxicity with
subsequent neutropenic fever and empirically treated with cefepime. The
patient noted ongoing diarrhea and right lower quadrant pain on day + 9.
A CT showed findings consistent with appendicitis and reactive terminal
ileitis (Figure 4). A Clostridium difficile PCR was obtained as
part of a routine institutional diarrhea evaluation and was positive. He
was transitioned to piperacillin-tazobactam and metronidazole. He was
determined not to be a surgical candidate due to pancytopenia and
eventually transitioned to a 2 week course of ciprofloxacin and
metronidazole. His symptoms resolved and subsequent C. difficilePCR was negative.