Pseudomembranous Colitis After Ingesting Citrullus Colocynthis: A Case Report

Yazan Ghanameh ¹, Noor Al-Badaineh1, Lina Hoshan ², Noor Abu- Farsakh ³

1. Department of Haematology and Oncology, Istishari Hospital, Amman, Jordan.

2. King Hussein Medical Centre, Amman, Jordan.

3. Department of Gastroenterology, Jordan University Hospital, Amman, Jordan.

Corresponding Author: Yazan Ghanameh, Department of Haematology and Oncology, Istishari Hospital, Amman, Jordan.

Copy Right: © 2022 Yazan Ghanameh, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received Date: June 23, 2022

Published Date: July 01, 2022

Abstract

Pseudomembranous colitis is an inflammation of the colon most commonly associated with C.difficle infection following antibiotic use. There may be other possible unique causes of the condition, such as the ingestion of medicinal plants. A 52-year-old male patient presented with sudden severe left lower quadrant abdominal pain that started 12 hours prior to admission and was associated with diarrhoea that progressed to rectal bleeding following citrullus colocynthis intake. Severe ulcerations were observed on colonoscopy, which were treated with metronidazole, leading to complete remission. Therefore, it is important that attention is paid to herbal intake history when presented with patients suffering from features of acute colitis.

Keywords: Pseudomembranous colitis, citrullus colocynthis, hematochezia

Introduction

Pseudomembranous colitis (PMC) is an inflammation of the colon wherein elevated yellow- white plaques form pseudomembranes on the colonic mucosal surfaces (1). It is most commonly associated with Clostridium difficile infection following antibiotic use, namely penicillin, cephalosporins, clindamycin and fluoroquinolones (1), causing changes to the intestinal bacterial flora. Clinical presentation of PMC may include watery or bloody diarrhoea, abdominal pain, fever, and leukocytosis (2)(3). PMC is primarily managed through cessation of the causative antibiotic followed by the administration of vancomycin, metronidazole or fidaxomicin for up to 14 days. Fecal transplant could also be done in recurrent and resistant cases (1). In the event PMC progresses to a more severe form of fulminant colitis or toxic megacolon, surgical intervention is indicated (3). This is a case report looking closely at other possible causes of PMC, particularly Citrullus colocynthis (L) Schrad., commonly called Colocynth, a medical plant used for its anti-inflammatory (4), antihyperlipidemic (4), antidiabetic (4)(5) and various other activities. In spite of its benefits, diarrhoea, hematochezia and vomiting are some of its complications (6).

Case Presentation

The patient is a 52-year-old male who presented to the ED complaining of sudden severe abdominal pain localised to the left lower quadrant 12 hours prior to admission. Pain was colicky in nature, non-radiating, and associated with bloody diarrhoea. There was no halitosis, dysphagia, hematemisis, vomiting or other gastrointestinal symptoms noted. History of perianal causes of hematochezia (haemorrhoids, fissures) was negative, though patient reported a history of arthralgia that started a few days ago, for which he took the colocynth medicinal plant.

He is medically free and had no similar episodes in the past. Patient was not on any other medications. On physical examination, the patient was fully conscious. He was dehydrated, in pain, with tenderness on the left side of the abdomen. His blood chemistry showed normal white blood count. His ESR was 8 mm/hour. His liver and renal function tests were normal. Fresh blood was noted on per rectum exam.

Colonoscopy was performed within 12 hours of presentation and revealed severe ulcerations on the mucosal surfaces of the colon. Biopsy was obtained and showed exudative material forming a pseudomembrane on surface mucosa with sloughed glands.

Treatment commenced with metronidazole. On third day post-endoscopy, faecal stool test for C. difficle was ordered, and the result came back as negative. There was a significant improvement in symptoms 36 hours post-admission, with a drastic response to medical treatment.

Discussion

Citrullus colocynthis is cucurbit plant that is widely spread across the desert areas worldwide (4). It has medicinal properties, some of which are antidiabetic, anti-inflammatory, antilipidemic, and various others (4). It was found to be toxic, causing gastrointestinal tract irritation, leading to symptoms varying from a simple upset to bloody diarrhoea and severe colitis.

Our study shows the correlation between the ingestion of colocynth and the incidence of hematochezia. Similarly, a study executed in Iran presented 4 cases of patients who had taken the herb for hypoglycaemic control, and consequently developed an episode of bloody diarrhoea (6).

Conclusion

Pseudomembranous colitis is an inflammation of the colon, commonly caused by antibiotic intake. Herbs, such as Citrullus Colocynth, could also be a possible cause. Therefore, patients presenting with features of acute colitis and hematochezia should raise suspicions of herb ingestion.

References

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3. James P. Celebrezze, David S. Medich (2005). Current Therapy in Colon and Rectal Surgery (Second Edition), 267-270

4. Hussain, A. I., Rathore, H. A., Sattar, M. Z., Chatha, S. A., Sarker, S. D., & Gilani, A. H. (2014). Citrullus colocynthis (L.) Schrad (bitter apple fruit): A review of its phytochemistry, pharmacology, traditional uses and nutritional potential. Journal of ethnopharmacology, 155(1), 54-66.

5. Abdel-Hassan, I. A., Abdel-Barry, J. A., & Mohammeda, S. T. (2000). The hypoglycaemic and antihyperglycaemic effect of Citrullus colocynthis fruit aqueous extract in normal and alloxan diabetic rabbits. Journal of ethnopharmacology, 71(1- 2), 325-330.

6. Javadzadeh, H. R., Davoudi, A., Davoudi, F., Valizadegan, G., Goodarzi, H., Mahmoodi, S., ... & Faraji, M. (2013). Citrullus colocynthis as the Cause of Acute Rectorrhagia. Case reports in emergency medicine, 2013.