Sir: The occurrence of toxic megacolon, severe sepsis and multiple organ dysfunction syndrome (MODS) secondary to Clostridium difficile infection is rare and associated with high mortality. We report a patient who survived following definitive surgical management. A 69-year-old man with pneumonia was admitted to ICU for ventilation. Cefotaxime and clarithromycin were commenced empirically. Subsequently the patient developed diarrhoea and cefotaxime was discontinued. Stool samples tested positive for C. difficile toxin and enteral metronidazole was commenced. Despite treatment the patient developed pyrexia and leucocytosis (62× 10 9/l), and vasopressor support was required. Abdominal computed tomography (Fig. 1) demonstrated dilatation and oedema of the transverse colon and inflammation of the pericolonic fat. A subsequent laparotomy revealed massive distension of the transverse colon and subtotal colectomy was performed. Postoperatively there was marked clinical improvement but the patient developed renal failure, requiring dialysis.