Clostridium Difficile Treatment

Case Presentation
A 4 year old boy presents to the Pediatrician’s office with pain and swelling of multiple large joints. He first developed pain over his right elbow, then right knee and both shoulders. The pain progressed, became associated with low grade fever and his mother also noticed swelling of the affected joints. By the end of day 2, the boy refused to bear weight and had to be carried to the clinic.
The patient has also been having multiple episodes of watery, non-bloody diarrhea for the past 3 weeks. He has been previously healthy except for a recent acute otitis media two months ago which was treated with oral Amoxicillin- Clavulonate for 10 days. No recent throat infection or rash. No similar episodes in the past. No recent travel.
Clostridium difficile is treated with oral Metronidazole or Vancomycin for 10-14 days. Metronidazole is preferred over Vancomycin for the treatment of mild C. difficile infection in children due to its lower cost and comparable effectiveness.
Treatment of reactive arthritis depends on disease activity, functional status, and quality of life of the children. The inflammatory manifestations of reactive arthritis requires the administration of nonsteroidal anti-inflammatory drugs (NSAIDs). Rest, ice, hot packs, and ambulation aids may be useful. Children with chronic or recurrent reactive arthritis also benefit from physical therapy and rehabilitation.
Follow up: The boy had a 2nd relapse of C.diff diarrhea and was treated with Metronidazole. 2 days after completion of this treatment, he started having diarrhea again. The third relapse was treated with oral Vancomycin and the boy had complete resolution of
Extra-articular features (conjunctivitis, uveitis, enthesopathy, urethritis, balanitis, and keratoderma blenorrhagicum) may occur.
Acute presentation of multiple joints in previously healthy children at the same time should prompt the clinician to explore for all possible triggers of reactive arthritis.
Common causes of enteric reactive arthritis are preceding infections attributable to Salmonella, Shigella, Campylobacter, and Yersinia.
Clostridium difficile is an uncommon cause of reactive arthritis, but should be considered as part of the differential especially children with recent antibiotic use or colonic symptoms.
Diarrhea caused by C-difficile is not necessary to be bloody, testing the stool for c-difficile toxins is necessary to be able to make the diagnosis.
Children with positive HLA-B27 Reactive arthritis have more severe involvement and negative HLA-B27 does not rule out reactive arthritis.
The number of joints involved at onset, the presence of fever or anemia, and the number and duration of episodes of disease activity influence the