An Interesting Case of a 57-Year-Old Male with an Upper Gastrointestinal Bleeding and Obstructive Uropathy with Bilateral Hydronephrosis Diagnosed with Systemic Mucormycosis

Abstract

Mucormycosis is a rare and invasive fungal disease with high mortality rate caused by members of the order Mucorales. Mucorales species are vasotrophic organisms that may cause angioinvasive disease in immunosuppressed hosts. Risk factors include diabetic ketoacidosis, chronic kidney disease, organ or bone marrow transplantation, neutropenia, burns, malignancies, and steroid therapy. There are six different clinical presentations of mucormycosis, which includes rhino-orbital cerebral, pulmonary, gastrointestinal, cutaneous, disseminated, and miscellaneous infection. Here, we report a case of a 57-year-old male with stage-IV sarcoidosis on long-term steroids presenting with upper gastrointestinal bleeding and obstructive uropathy who was diagnosed with systemic mucormycosis. Biopsy obtained by endoscopy revealed necrotic debris with acute leukocytic exudate and numerous variably sized, 90-degree angulated fungal hyphae favoring mucormycosis-causing species. Imaging studies showed hydronephrosis, and cystoscopy findings were consistent with fungal infection of the bladder. Isavuconazonium sulfate was used as systemic salvage therapy along with continuous bladder irrigation with amphotericin-B for localized bladder infection after a trial with first-line systemic treatment with intravenous liposomal amphotericin-B failed. A repeat endoscopy showed inflammatory changes with a pathology report in which mucormycosis was no longer appreciated. The patient was discharged home to complete 6 months of antifungal therapy with monthly follow-ups. The patient has been asymptomatic after 12-month completion of therapy.

Disseminated mucormycosis presenting as a renal mass in an human immunodeficiency virus-infected patient: A case report

“…The best practice guidance for renal mucormycosis is antifungal therapy and surgical debridement. 3,13 In our limited resource setting, One of the advantages of liposomal amphotericin B pertinent to this case would have been its lower nephrotoxicity side effect profile. 3 Reports of patients surviving disseminated renal mucormycosis with antifungal therapy alone (which fails often because it poorly penetrates the tissue), in the absence of surgical debridement are lacking.…”

“…3,13 In our limited resource setting, One of the advantages of liposomal amphotericin B pertinent to this case would have been its lower nephrotoxicity side effect profile. 3 Reports of patients surviving disseminated renal mucormycosis with antifungal therapy alone (which fails often because it poorly penetrates the tissue), in the absence of surgical debridement are lacking. However, Devana et al reported a case that was successfully treated with antifungal therapy alone with additional pus drainage http://www.sajid.co.za Open Access and no surgical intervention (debridement/nephrectomy).…”

“…It is historically accompanied by high mortality rate ranging between 50% and 80% even with appropriate treatment. 1,2,3 The causative agents of mucormycosis vary across different geographic locations. Rhizopus arrhizus is the most common agent isolated worldwide.…”

“…Other agents include those of the genera Lichtheimia, Mucor, Rhizomucor, Apophysomyces and Cunninghamella. 1,3,4,5,6,7 Less common species are Cokeromyces, Syncephalastrum and Saksenaea. Mucormycosis is the third most frequent invasive fungal infection of high significance after candidiasis and aspergillosis.…”

Gastric and small bowel perforations secondary to mucormycosis and graft versus host disease in an allogeneic transplant host

“…Endoscopic examination may show ulceration and necrosis without an obvious site of bleeding. 5 A definitive diagnosis requires positive tissue cultures and histopathologic demonstration of the fungi which appear as thick non-septate hyphae branching at right-angles. 6 Risk factors in our patient included graft versus host disease, prolonged corticosteroid therapy, and ongoing bacterial infections.…”