A 6-year-old girl with lymphoma presented to our clinic with fever, diarrhea, abdominal distension, and shortness of breath, and was admitted. Before admission, she had received standard chemotherapy for a pediatric diffuse large B-cell lymphoma at a specialist cancer hospital. The chemotherapy process is shown in Figure 1. Following the final chemotherapy session 10 days before admission, she had been in a period of post-chemotherapy myelosuppression, during which she developed a severe infection. After intravenous administration of cephalosporin antibiotics, she developed diarrhea and abdominal distension; however, no pathogen was identified. Her condition did not improve, and thus, the antibiotic therapy was discontinued. When the fever occurred during the period, she was administered intravenous vancomycin, imipenem, and carprofen for 3 days in a regional hospital, but her condition did not improve. Subsequently, she developed diarrhea with jelly-like stools (Figure 2), abdominal distension, nausea, vomiting, and shortness of breath. On Day 4, she was transferred to our clinic for further treatment.
Clinical examination revealed the following findings on admission: temperature, 37.5 C; heart rate, 130 beats/min; respiratory rate, 52 breaths/min; respiratory moaning; neck and rib retraction; decreased bilateral breath sounds; shifting dullness (+); and mild edema of the lower limbs.
Laboratory tests performed on the day of admission revealed a white blood cell count of 1.80 x 109/L (with 30.5% neutrophils); hemoglobin level of 6.9 g/dL; platelet count of 35 x 109/L; elevated C-reactive protein levels of 220 mg/L; decreased albumin levels of 2.8 g/dL; and elevated lactate dehydrogenase levels of 282 U/L. A stool examination was positive for fecal white blood cells but was negative for common bacteria and fungiculture, rotavirus, adenoviridae antigens, and C. difficile culture using ChromID and C. difficile agar (CDIF) (bioMerieux, Marcy L'Etoile, France). Chest and abdominal computed tomography showed lung consolidations, pleural effusion, bilateral atelectasis, and massive ascites (Figure 3).
Based on these findings, she was diagnosed with severe pneumonia and diarrheal disease; however, the cause of the massive hydrothorax and ascites remained unclear. She continued to be treated with vancomycin, imipenem, and carprofen, and she was mechanically ventilated for progressive dyspnea. To relieve her dyspnea, we performed bilateral drainage of the thoracic and abdominal effusions, and drained clear, yellowish fluid. The results of the laboratory tests performed on the pleural and peritoneal effusions are given in Table 1. With continued antibiotics and other therapy, her fever resolved. However, the amount of hydrothorax and ascites did not decrease significantly, and further tests were performed to investigate the cause of the persistent hydrothorax and ascites. A cytology test of the pleural and peritoneal fluid showed negative results. The chyle test, a qualitative test which uses ether to extract lipid and Sudan III to identify the presence of red fat globules microscopically, showed negative results, as did pathogen microbial high-throughput sequencing (PMseq). Bacteria, Mycobacterium tuberculosis, and fungal cultures of the pleural and peritoneal fluid were also negative. Due to the continuing diarrhea, we performed genetic testing using a real-time polymerase chain reaction assay for C. difficile toxin. This was positive for toxin B. To re-confirm the results, we re-cultured C. difficile using CDIF, and the test results were positive. Based on the above findings, we diagnosed CDI and hypothesized that the massive hydrothorax and ascites was a rare manifestation associated with the CDI.
CDI is an antibiotic-related infection; therefore, we discontinued intravenous antibiotic therapy following the diagnosis, and treated the patient with oral vancomycin and Saccharomyces boulardii immediately. Furthermore, her oncologist suggested that chemotherapy for her lymphoma be suspended until she recovered from the CDI.
Her stool frequency returned to normal after 3 days, her fever subsided after 1 week, her intestinal discomfort was relieved with the return to healthy stools, and her massive hydrothorax and ascites resolved completely. She was discharged after a 10-day oral course of vancomycin. She did not relapse during the 1-month follow-up period and resumed chemotherapy at the specialist cancer hospital.
Computed tomography scan of the chest and abdomen showing multiple consolidations in both lung fields:. Pleural effusion, and ,atelectasis bilaterally.