A bleeding colonic ulcer from invasive Aspergillus infection in an immunocompromised patient: a case report

Abstract

IntroductionInvasive Aspergillus commonly involves the lungs, but can also affect other organs such as the skin, adrenal glands, central nervous system, liver, spleen and the gastrointestinal tract. Gastrointestinal aspergillosis is rare and is most often discovered in immunocompromised patients. There is only one other case report to our knowledge that describes the diagnosis being discovered on histopathological analysis of endoscopic biopsies of necrotic ulcers.Case presentationA 36-year-old Hispanic woman presented with septic shock secondary to extensive Fournier gangrene that required multiple surgical debridement of the perineal and retroperitoneal area. Her vital signs on admission were a temperature of 39.4°C and blood pressure of 85/56mmHg, pulse rate of 108/min and respiratory rate of 25. An examination of the perineum/genital area revealed bilateral gluteal and perilabial edema, erythema and focal areas of necrotic tissue with purulent discharge. Other surgeries included small bowel resections with ileoileal anastomosis that later developed an anastomotic leak that required and diverting end ileostomy. Eleven weeks after admission, our patient developed hematochezia from the colostomy associated with a decrease in hemoglobin and hematocrit to 6.4g/dL and 20.2% respectively. Colonoscopy through the ostomy revealed blood throughout the colon and a 3cm necrotic ulcer with an adherent clot in the transverse colon. Biopsies were taken from the edge of the ulcer. Histopathological analysis of the specimen with Grocott’s methenamine silver stain revealed septated hyphae with the 45-degree-angle branching that is morphologically consistent with Aspergillus species. Our patient was treated with intravenous voriconazole for 30 days with a prolonged hospitalization but no recurrent bleeding.ConclusionsGastrointestinal aspergillosis is an unusual presentation of invasive Aspergillus associated with a high mortality rate. Characteristic features of gastrointestinal aspergillosis include invasion of the mesenteric arteries, intravascular thrombosis and subsequent tissue ischemia. Clinical manifestations of invasive Aspergillus of the gastrointestinal tract can include fever, abdominal pain, ileus, peritonitis, bloody diarrhea or hematochezia. In an autopsy series of patients with invasive Aspergillus, 37 of 107 patients had Aspergillus involvement of the gastrointestinal system; the most common pathological findings included ulcers and abscesses. Although rare, invasive aspergillosis may present with gastrointestinal bleeding associated with necrotic ulcers on endoscopic examination.

Antibody-guided in vivo imaging of Aspergillus fumigatus lung infections during antifungal azole treatment

“…In addition, the ex vivo results showed a discrepancy between radiotracer uptake in the spleen of animals infected with A. fumigatus compared to animals with a sham inoculation. This might point toward dissemination of the pathogen to the spleen, which has been reported several times in humans 50 , 51 . However, it might alternatively demonstrate accretion of soluble antigen released into the bloodstream during invasion of the lung.…”

Difficult diagnosis of invasive fungal infection predominantly involving the lower gastrointestinal tract in acute lymphoblastic leukaemia

“…IA most commonly affects the lower respiratory system and nasal sinuses. Other extrapulmonary locations of the infection include the central nervous system, eyes, skin, kidneys, heart, bones, joints and GI tract [6] . Aspergillosis is a highly lethal infection in the GI tract, which is the second most common site of IA.…”

A rare disease mimics postoperative bile leakage: Invasive Aspergillosis

“…As in present case, in individuals with normal immune system, it has also been reported that IAA may develop as result of operating room sterilization problems. [2,3] Gastrointestinal presentation of invasive aspergillosis (IA) is unusual. In a study conducted by Hori et al that examined an autopsy series, it was reported that small intestine-localized gastrointestinal system (GIS) aspergillosis was detected in 37 of 107 cases examined.…”

“…Clinical- ly, it can present with fever, abdominal pain, ileus, peritonitis, bloody diarrhea and hematochezia. [3] In addition, apart from gastrointestinal tract, urinary system may also be affected. [4] Literature survey indicated that the present case is first to develop after LC.…”