Intestinal Perforation Secondary to Mucormycosis Associated With Puerperal Sepsis

Abstract

Mucormycosis is a rare opportunistic infection, usually seen in diabetics, immunocompromised, or those with coronavirus disease 2019 (COVID-19). Gastrointestinal involvement is uncommon but often deadly. We report a case of gastrointestinal mucormycosis causing intestinal perforation in a non-diabetic, COVID-19 negative, immunocompetent woman, associated with puerperal sepsis. A 22-year-old woman presented to our center on post-natal day five, following delivery with insertion of an intrauterine contraceptive device (IUCD). She had complaints of breathlessness, fatigue, and giddiness. Examination revealed tachycardia, tachypnea, hypotension, and bilateral pedal edema. Following appropriate investigations, she was diagnosed with puerperal sepsis with pre-renal acute kidney injury. Imaging was suggestive of retained products of conception, and she subsequently underwent dilation and evacuation (D&E) on day eight of admission. Following brief symptomatic improvement, on day 10 of admission, she developed vomiting, abdominal distension, and pain, with obstipation. Erect X-ray showed air under the diaphragm, suggestive of perforation. She emergently underwent laparotomy with limited right hemicolectomy, ileostomy with mucous fistula. Intraoperative findings revealed a closed-loop obstruction involving terminal ileum, with two perforations. The biopsy report later revealed colonization of Mucor and hemorrhagic necrosis along the entire length of the resected specimen. She was started on amphotericin B, and after a slow recovery, was discharged. Gastrointestinal mucormycosis is rare and has a mortality rate of 94%. It is usually seen in those with predisposing factors for mucormycosis. This is the first report of mucormycosis associated with puerperal sepsis. It is typically acquired via ingestion and may cause perforation, where mortality is further increased. Diagnosis can only be confirmed by histopathology demonstrating the characteristic morphology of Mucor. Treatment requires resection of necrotic tissues, intensive treatment with amphotericin B, and correction of predisposing factors. Our case highlights the need for a high degree of suspicion for mucormycosis in patients with intestinal perforation, even if immunocompetent, and its potential association with puerperal sepsis.

Gastrointestinal Mucormycosis-Induced Massive Lower Gastrointestinal Bleeding, Rectal Perforation, and Pulmonary Embolism: A Long Diagnostic Pathway in a Case Report

“… 5–7 , 11 , 12 Many patients with mucormycosis had presented with risk factors for immunosuppression, including diabetes (9%), persistent neutropenia, hematologic malignancies (44%), HIV infection, prematurity malnutrition and undernutrition, long-term systemic corticosteroid therapy, immunosuppressive therapy following organ or stem cell transplantation, and increased serum iron levels. 1 , 2 , 4–8 , 11 , 12 Our patient had type II diabetes mellitus. The diagnosis of GI mucormycosis often remains late because of the nonspecific presentation.…”

“…7 The genera Rhizopus are by far the most frequently found. [1][2][3][4][5][6][7][8]11 Mucormycosis can present with different clinical manifestations: rhino-cerebral (39%), pulmonary (24%), cutaneous (19%) and the disseminated form (23%). [1][2][3][4][5][6][7][8]11 Among these manifestations, the GI form remains uncommon and rarely diagnosed in living patients.…”

“…1,2 The entire organ system can be affected, but rhino-orbital, cerebral and pulmonary infections dominate the literature. [1][2][3][4] The GI form of mucormycosis is by far the least frequent. 4 These fungi are responsible for both superficial and deep tissue destruction associated with angioinvasion.…”

“…[1][2][3][4] The GI form of mucormycosis is by far the least frequent. 4 These fungi are responsible for both superficial and deep tissue destruction associated with angioinvasion. This pathogenesis is the cause of massive GI hemorrhage, GI perforation, disseminated systemic infection, local infarction and vascular thrombosis.…”

“…2,5 The prognosis of GI mucormycosis is often poor due to delayed diagnosis because of its atypical manifestations requiring a long diagnostic process. 2,[4][5][6] Despite the intensive use of antifungal therapy and surgical debridement, the mortality rate of adult patients varies from 20% to 100%. 2,5 We report a case of GI mucormycosis presenting as massive hematochezia, multiple gastric ulcers and rectal perforation in a 75-year-old man with type II diabetes mellitus.…”