The role of surgery in a case of diffuse mucormycosis with haematemesis and gastric necrosis

Abstract

Mucormycosis is a life threatening condition caused by invasion of fungi of the order Mucorales. Gastrointestinal invasion is very rare and often lethal, particularly in disseminated mucormycosis. We present the case of a 26-year-old woman from North Africa with type 2 diabetes who, after a cholecystectomy, developed unexplained septic shock and haematemesis due to gastric necrosis. Computed tomography (CT) revealed a disseminated fungal invasion of the lungs, kidney and paranasal sinuses. A gastrectomy and subsequent amphotericin B treatment resolved her condition. The number of patients with mucormycosis is increasing. Early diagnosis of high risk patients with CT and biopsies from which fungi are directly isolated must be followed by surgery and systemic amphotericin B infusion. Mucormycosis is a life threatening infection caused by fungi of the subphylum Mucoromycotina, order Mucorales. Mucoromycotina are characterised by large, ribbon-like hyphae with only occasional septa (aseptate fungi). These fungi cause mucormycosis, which leads to severe and potentially life threatening infections. Patients at risk of invasive mucormycosis include those with type 2 diabetes or autoimmune disorders, solid organ and hematopoietic stem cell transplant recipients, neonates, users of illicit intravenous drugs and patients with burns, trauma or surgical wounds.1 The symptoms of mucormycosis are varied and depend on the site affected; however, no specific blood test is available. Case HistoryIn the summer of 2010, a 26-year-old woman of North African ethnicity was admitted to our emergency department for abdominal pain, which had developed three days previously, and fever. She complained of upper right quadrant pain with a positive Murphy's sign, tachypnoea and tachycardia. Her blood tests showed increased leucocytes, C-reactive protein and transaminases. Her past medical history revealed type 2 diabetes mellitus. Abdominal ultrasonography identified distended, abnormal gallbladder with lithiasis. She underwent a laparoscopic cholecystectomy for suspected acute cholecystitis.In the early postoperative period, she developed rapid and progressive respiratory failure, and was admitted to the intensive care unit with a diagnosis of severe sepsis. She deteriorated rapidly, developing multiple organ failure with kidney, lung and cardiovascular involvement despite treatment. She required vasoactive support with norepinephrine and dopamine. Blood samples from central and peripheral lines were obtained for culture, and urine was collected for analysis. She was treated with broad spectrum antibiotics and antifungal therapy.On the third postoperative day, her blood results were: white blood cells 33,000/mm 3 , haemoglobin 8g/dl, haematocrit 27.1%, platelets 95,000/mm 3 , creatinine 9.6mg/dl, glucose 151mg/dl, pH 7.22, C-reactive protein 34mg/l and procalcitonin 15ng/ml. She underwent continuous venovenous haemofiltration. On the same day, she had an episode of haematemesis and an oesophagogastroduodenoscopy revealed gastric nec...

Gastrointestinal mucormycosis in apparently immunocompetent hosts—A review

“…A total of 200 cases of GI mucormycosis in non‐classical immunosuppressed or apparently immunocompetent hosts reported during 1948 through 2017 in English literature . The case details could be retrieved for 176 cases.…”

A Case of Invasive Gastrointestinal Mycotypha Infection in a Patient with Neutropenia

“…Management of the catastrophic gastrointestinal bleed with a gastrectomy resulted in the eradication of the mucormycosis and was ultimately curative for our patient. Surgical resection is critical for the definitive treatment of gastrointestinal infection, as mortality is much higher without it [ 20 ]. The treatment of his invasive aspergillosis was limited by the need to preserve his renal function, and combination therapy ultimately proved to be a valuable option in his case as demonstrated by improvement in imaging findings and downtrending serum markers.…”

Gastrointestinal mucormycosis after abdominal aortic aneurysm repair and prolonged hospitalization: A case report and review of the literature

“…Mucorales are vasotropic in nature and cause thrombosis and necrosis of the involved tissue [5] , [6] . The most recognized clinical syndromes of mucormycosis (in decreasing order of occurence) are rhinocerebral, pulmonary, cutaneous, gastrointestinal, disseminated and other uncommon presentations [1] .…”

“…If a prompt diagnosis is made, treatment generally consists of source control by debriding all infected and necrotic tissue followed by systemic antifungal therapy with liposomal amphotericin B. Extensive bowel resection is often required as was the case with the aforementioned patient [5] , [7] .…”