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.