# Unusual Presentation of Necrotizing Enterocolitis Presenting in a Term Infant

## TL;DR

A full-term infant presented with a rare case of necrotizing enterocolitis (NEC), highlighting the potential role of C. difficile and the need for further research.

## Contribution

This paper presents a unique case of late-onset NEC in a term infant and explores the possible link with C. difficile.

## Key findings

- The patient met modified Bell criteria stage IIA for NEC with symptoms including bloody stool and pneumatosis intestinalis.
- C. difficile DNA was detected in stool, though toxins were absent, raising questions about causation versus colonization.
- The infant's symptoms resolved with conservative treatment, including antibiotics and bowel rest.

## Abstract

Necrotizing enterocolitis (NEC) is a gastrointestinal emergency causing inflammation and necrosis of the intestine, most commonly in premature formula-fed infants. There exists limited conflicting data on the pathophysiology behind NEC development and the underlying intestinal bacteria behind the disease. We report a case of a two-week-old female patient who was born full term. During her birth hospitalization, she was transferred to the neonatal intensive care unit for late-onset tachypnea and apnea, where she received ampicillin and gentamicin intravenously through a peripheral line for a total of 36 hours. The newborn presented to the emergency department (ED) with bloody stool at two weeks of life. Her abdominal X-ray showed possible intramural air with concern for pneumatosis, and the patient was admitted to the pediatric ward with suspected NEC. Stool investigations were positive for occult blood, lactoferrin, and Clostridioides difficile (C. difficile) DNA amplification but negative for C. difficile toxins. The patient was started on intravenous vancomycin, cefepime, and metronidazole as empirical antibiotic coverage. Oral feeds were held for bowel rest. Over the course of the next six days, repeat X-rays were taken daily, and the patient’s symptoms resolved with complete resolution of the X-ray’s abnormalities. The patient was gradually restarted on oral feeds, which were well tolerated by the time of hospital discharge. Our case demonstrates a unique presentation of late-onset NEC in a term infant. This patient case reflects modified Bell criteria stage IIA, including bloody stool with intestinal dilation, ileus, and pneumatosis intestinalis. The concomitant positive test for C. difficile in this case could be a causative relationship or just incidental, as it could also be bacterial colonization; therefore, further study is recommended to further investigate the relationship between NEC and C. difficile infection (formerly called Clostridium difficile), especially in full-term infants.