A 34-year-old Spanish man with no previous medical history presented with diarrhoea during a tourist trip to Cuba, where he stayed for 15 days. Five days after arriving to Cuba, he started with watery diarrhoea – up to 14 stools per day without pathological products –, abdominal pain and temperature up to 37.3°C. For this reason, he received antibiotic treatment twice: firstly, in Cuba for 3 days (unknown active principle), and secondly after returning from the trip, with ciprofloxacin 500mg/12h for 7 days. Given the lack of improvement, he decided to consult to our International Health Department. During the trip, he had eaten street-food, uncooked vegetables, peeled fruit and ice with drinks. The patient denied having had unprotected sex and he had not visited any healthcare facility. At our visit, the physical exam revealed abdominal pain at palpation of left lower quarter but peritonism and blood test only showed elevated acute-phase reactants.
From a microbiological point of view, no trophozoites or ova were observed in two microscopic coproparasitological exams and no enteropathogenic microorganisms were isolated in a bacterial culture. The patient was then tested for Clostridioides difficile infection (CDI). Glutamate dehydrogenase (GDH) was detected by immunochromatography (Health & Research C. difficile GDH, Vegal Farmaceutica, Spain). Detection of three targets: Toxin B, Binary Toxin (cdtA), and tcdC deletion, for presumptive identification of the 027/NAP/BI epidemic strains of C. difficile, were determined by real time polymerase-chain reaction (Xpert®C. difficile, Cepheid, CA, USA), with Ct values of 23.3; 23.2; 23.1, respectively. Faecal specimen was sent to a reference laboratory, where ribotype 027 was confirmed by ribotyping and sequencing of gene tcdC, that showed 18pb delection in position 117.
Given the potential virulence of the strain, treatment with Fidaxomicin 200mg/12h for 10 days, was prescribed. The patient presented an excellent clinical evolution with resolution of gastrointestinal symptoms 48h after treatment initiation and with no further relapses.
C. difficile is a sporulated anaerobic gram-positive bacilli. Although it is the main etiological agent of health-care associated diarrhoea in high income countries, it is increasingly being reported as a cause of community acquired diarrhoea (representing up to 25% of cases of CDI).1 In the last decade, the rise of a new C. difficile strain, known as B1/NAP1/027 brought important changes on the CDI epidemiology, spreading throughout United States of America, Canada and Europe after its first description in Quebec in 2001.2 Furthermore, its higher virulence – caused by a mutation on the tcdC repressor gene – and the high resistance to fluoroquinolones, have entailed a change on the clinical spectrum of the CDI. As a consequence, infection by C. difficile ribotype 027 has been associated with more severe cases, poor response to common antibiotic treatment and higher relapse rates.1
Despite ribotype 027 is an uncommon cause of CDI in Spain,3 some health-care related outbreaks have been reported.4 Index cases coming from high prevalence countries have usually been identified, but indigenous community-acquired cases have also been identified.4 Regarding the spread of this strain along Latin America, outbreaks in Costa Rica,5 Panama6 and Chile7 have been reported. However, it is probably a very undiagnosed entity due to the scarce access to diagnostic test for anaerobic bacteria by routine.8
Interestingly, it is estimated that about 1–3% of general population can be asymptomatic carriers of C. difficile toxigenic strains,9 being at risk of developing invasive infection due to colon microbiome changes. In fact, not only the overuse of antibiotics in traveller's diarrhoea but also the impact of travelling itself can prompt these microbiome changes, favouring infections by enteropathogens such as C. difficile in travellers.10
Although acquisition of the CD 027 strain before arriving to Cuba cannot be completely ruled out as initial symptoms started only five days after settling the country, from the best of our knowledge, it is the first reported case of CDI 027 after travelling to Cuba. We consider this case relevant, not only for the possible country of acquisition, but also for its clinical presentation as a traveller's diarrhoea in a healthy patient with no contact with health-care facilities. C. difficile 027 has been usually associated with nosocomial outbreaks and it is rarely suspected in healthy patients with no classical risk factors. Although our patient took antibiotic treatment, the beginning of symptoms was previous to the first antimicrobial treatment and he had no contact with any health-care facility. As a consequence, we consider that our case highlights the importance of being aware of CDI in patients with persistent diarrhoea even when they do not fulfilled classical CDI risk factors.
We would like to thank Dr. Mercedes Marín, from Microbiology Department, Hospital Gregorio Marañón, Madrid, for the ribotype confirmation.
