Unusual Presentation of Necrotizing Enterocolitis Presenting in a Term Infant

Necrotizing enterocolitis (NEC) is a gastrointestinal emergency causing inflammation and necrosis of the intestine, most commonly in premature formula-fed infants. There exists limited conflicting data on the pathophysiology behind NEC development and the underlying intestinal bacteria behind the disease. We report a case of a two-week-old female patient who was born full term. During her birth hospitalization, she was transferred to the neonatal intensive care unit for late-onset tachypnea and apnea, where she received ampicillin and gentamicin intravenously through a peripheral line for a total of 36 hours. The newborn presented to the emergency department (ED) with bloody stool at two weeks of life. Her abdominal X-ray showed possible intramural air with concern for pneumatosis, and the patient was admitted to the pediatric ward with suspected NEC. Stool investigations were positive for occult blood, lactoferrin, and <i>Clostridioides difficile</i> (<i>C. difficile</i>) DNA amplification but negative for <i>C. difficile</i> toxins. The patient was started on intravenous vancomycin, cefepime, and metronidazole as empirical antibiotic coverage. Oral feeds were held for bowel rest. Over the course of the next six days, repeat X-rays were taken daily, and the patient's symptoms resolved with complete resolution of the X-ray's abnormalities. The patient was gradually restarted on oral feeds, which were well tolerated by the time of hospital discharge. Our case demonstrates a unique presentation of late-onset NEC in a term infant. This patient case reflects modified Bell criteria stage IIA, including bloody stool with intestinal dilation, ileus, and pneumatosis intestinalis. The concomitant positive test for <i>C. difficile</i> in this case could be a causative relationship or just incidental, as it could also be bacterial colonization; therefore, further study is recommended to further investigate the relationship between NEC and <i>C. difficile</i> infection (formerly called <i>Clostridium difficile</i>), especially in full-term infants.