S5144 Clostridioides difficile-Induced Disseminated Intravascular Coagulation in a Patient With ESRD: A Fatal Case Report

Introduction: Clostridioides difficile infection is a well-established cause of colitis, typically presenting with diarrhea, abdominal pain, and leukocytosis. Rarely, it may lead to severe systemic complications such as disseminated intravascular coagulation (DIC), especially in immunocompromised individuals. We present a fatal case of C. difficile –associated DIC in a patient with end-stage renal disease (ESRD). Case Description/Methods: A 71-year-old woman with type 2 diabetes, ESRD on hemodialysis (M/W/F), and paroxysmal atrial fibrillation was admitted with acute anemia and suspected colitis. Initial imaging showed colitis, and empiric antibiotics (cefepime and vancomycin) were started. Initially, she denied diarrhea on admission. Lab work revealed an INR of 11, raising concern for upper GI bleeding. Nasogastric tube output was bloody, prompting fluid resuscitation and FFP administration. C. difficile testing returned positive. She later developed fever, worsening LLQ pain, and new-onset diarrhea, followed by hemodynamic instability requiring ICU transfer and vasopressors. Despite aggressive management, she declined with persistent tachycardia, transfusion-dependent anemia, and acute respiratory failure requiring intubation. Workup showed anemia of chronic disease, low B12, markedly elevated D-dimer, and no signs of hemolysis. Esophagogastroduodenoscopy showed no active bleeding. Computed tomography (CT) angiography revealed severe colitis with friable mucosa but no clear bleeding source. Antibiotics were escalated to fidaxomicin and eravacycline. Given the coagulopathy, elevated D-dimer, and clinical deterioration, C. difficile –induced DIC was suspected. Due to instability, invasive interventions were deferred. She ultimately succumbed to asystole. Discussion: This case accentuates the rare but lethal complication of C. difficile colitis. Atypical presentations without initial diarrhea and complicating factors such as anticoagulation can obscure diagnosis. Clinicians should maintain vigilance for systemic manifestations like DIC, even in the absence of bowel necrosis, particularly in high-risk populations such as those with ESRD.