"We are what we eat!" Invasive intestinal mucormycosis: A case report and review of the literature

Intestinal mucormycosis as a differential diagnosis of small bowel ischemia

Intestinal mucormycosis is a rare manifestation of the Mucor fungus, associated with high mortality and typically found in immunocompromised patients, though it has also been described in immunocompetent individuals. The mode of acquisition is digestive. It usually presents as abdominal pain, with ischemia and intestinal perforation, and the diagnosis is often histopathological after surgical resection. We present the case of a 54-year-old female patient with recurrent acute myeloid leukemia undergoing treatment with daunorubicin-cytarabine and experiencing febrile neutropenia. She developed patchy and progressive intestinal ischemia that evolved into intestinal necrosis, which was treated with antifungal medications and surgery. Examination of the surgical specimen revealed aseptate wide hyphae with branching at right angles, suggestive of Mucor fungus. This is a rare but highly mortal pathology in which clinical, radiological, and surgical suspicion is essential for early diagnosis and treatment, thus improving the patient's prognosis.

Small bowel mucormycosis: An unexpected case in a penetrating trauma survivor

INTRODUCTION

Small bowel mucormycosis is a rare entity with few reports in the literature. Mortality rates secondary to necrosis and perforation remain above 85 %, with an increase in populations at risk noted.

PRESENTATION OF CASE

This is a case report of a survivor of penetrating trauma who sustained small bowel injuries and was managed with damage control surgery. He required relook laparotomies due to extensive contamination and subsequently developed progressive ischaemia and necrosis of areas of his small bowel - histology confirming mucormycosis. There were no apparent risk factors noted in this case. Early addition of Amphotericin B and prompt surgical management resulted in a positive outcome. The patient was discharged from the hospital successfully. No further complications were noted post-discharge.

DISCUSSION

Small bowel mucormycosis can be a challenging diagnosis and requires a high index of suspicion. The lack of traditional risk factors should not deter a surgeon from considering this diagnosis in trauma patients as the micro-invasive properties of this organism can result in unexpected gastrointestinal ischaemia. Favourable outcomes are associated with prompt surgical debridement, histopathological diagnosis, and appropriate antifungal therapy.

CONCLUSION

Gastrointestinal Mucormycosis is a diagnosis that should be considered in trauma patients with unusual patterns of ischaemia. Prompt therapy can result in positive outcomes.

A rare case of pediatric gastrointestinal mucormycosis with a review of the literature

This manuscript discusses a rare case of pediatric gastrointestinal mucormycosis in a hospitalized patient who presented in diabetic ketoacidosis. A review of the literature is summarized to provide an overview of mucormycosis with a discussion of the mechanisms underlying the susceptibility of diabetic patients for this condition.

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

Introduction

Mucormycosis is a rare systemic fungal infection, mainly observed in immunocompromised patients. It is responsible for surface and deep tissue destruction leading to perforations and hemorrhage. Its pathogenesis represented by an angio-invasion is at the origin of a local infarction and a vascular thrombosis. We report a case of gastrointestinal (GI) mucormycosis-induced multiple gastric ulcers, GI bleeding and rectal perforation.

Case Presentation

A 75-year-old man, with type II diabetes mellitus, was admitted to the intensive care unit for an acute abdominal pain associated with massive hematochezia. Clinical examination was that of an acute peritonitis and a hemorrhagic shock state. Abdominal and pelvic CT scan with intravenous contrast concluded to a perforation of the anterior wall of the rectum. He underwent immediate laparotomy with temporary colostomy. Several upper GI endoscopies had shown multiple gastric ulcer lesions. Lower GI endoscopy showed a fistulous orifice of the rectum on its anterior surface. Histopathology of the gastric biopsy showed acute and subacute inflammatory changes with filamentous elements suggesting mucormycosis. Histopathology of the rectal biopsy showed a subacute non-specific inflammation. Culture of the secretions from the rectal fistula orifice showed the strain Rhizopus sp. Antifungal susceptibility testing reported sensitivity to liposomal amphotericin B. The diagnosis of GI mucormycosis-induced multiple gastric ulcers, rectal perforation and pulmonary embolism in the patient with type II diabetes mellitus was retained. The outcomes were favorable after 6 weeks of treatment with liposomal amphotericin B associated with temporary colostomy and appropriate diabetes management.

Conclusion

GI mucormycosis remains a multidisciplinary diagnostic challenge, less frequent in clinical practice, with a long diagnostic pathway. This opportunistic systemic mycosis can lead to numerous GI complications including perforation, massive GI bleeding and even multiple extra-GI complications. GI mucormycosis has a good prognosis if it is treated early with medical and surgical treatment.

Gastrointestinal mucormycosis: A periodic systematic review of case reports from 2015 to 2021

BACKGROUND

GI mucormycosis (GI) is a rare but highly lethal infection in patients. There is no single comprehensive review of the literature that demonstrates the various clinical aspects of this infection.

METHODS

A structured search of PubMed/Medline was used to collect case reports of GI mucormycosis in patients of all ages published between 2015 and November 2021.

RESULTS

Eighty-seven cases were identified through PubMed bibliographic database searches, and final analyses were conducted on 70 adults and ten neonatal patients with GI mucormycosis. Asia had the highest number of reported cases, with 46 (57.5%). Neonatal cases had a mortality rate of 70%, while other cases had a mortality rate of 44%. Corticosteroid therapy and diabetes were the most significant risk factors in patients, while 11% were immunocompetent with no apparent underlying condition. COVID-19 positivity was detected in four adult patients. Moreover, neonatal cases included premature and low-weight infants, metabolic acidosis, and malnutrition. Abdominal pain, fever, and GI perforation were the most common signs of infection, while vomiting occurred in 40% of neonatal cases. In 97% of patients, a histopathologic examination was used to detect infection, whereas culture and molecular methods were used in only 28% and 17% of patients, respectively. Surgery plus anti-infection therapy, anti-infection therapy alone, and surgery alone were used in 61%, 28%, and 11% of patients, respectively. Nonetheless, all neonatal patients underwent surgery. Although used in a small number of patients, posaconazole (30%) and isavuconazole (11%) demonstrated high efficacy in treating patients.

CONCLUSION

GI mucormycosis is a rare but highly lethal disease. Treatment of underlying conditions, the use of multiple diagnostic techniques, and appropriate antifungals in conjunction with surgery can all contribute to infection control.

Unusual manifestation of gastric mucormycosis in a patient with rheumathoid arthritis

Introduction. Mucormycosis is a life-threatening opportunistic infection whose incidence has significantly risen during the last two decades. The gastrointestinal form is very rare, with the stomach as the most common site of infection, followed by the colon and ileum. Risk factors include uncontrolled diabetes mellitus, corticosteroid use, and organ transplantation. We report a patient with a history of rheumatoid arthritis who has developed gastrointestinal mucormycosis. To the best of our knowledge, this is the first such case reported in the literature. Case report. A 53-year-old female patient with a prior medical history of rheumatoid arthritis was admitted to the hospital due to persisting diarrhea. Physical examination revealed diffuse abdominal tenderness to palpation without meteorism and peritoneal signs. Laboratory results demonstrated systemic inflammation, so antibiotic therapy was administered. Abdominal computed tomography findings revealed inflammation of the rectum and the left colon. Colonoscopy findings were indicative of Crohn?s disease. Additionally, the patient had developed profuse rectal bleeding and consequently underwent emergency surgery. Subtotal colectomy with ileostomy and partial gastrectomy was performed. The patient?s condition rapidly worsened after the operation, and she died due to multi-organ failure. Histologic findings of resection specimens discovered chronic active colitis and extensive gastric necrosis associated with dense mixed inflammatory infiltration and numerous non-septate and 90-degree branching hyphae. Diagnosis of invasive gastric mucormycosis was obtained, but unfortunately, several days after the patient?s death. Conclusion. It is very important to obtain high awareness among clinicians of this deadly infection to achieve a prompt diagnosis and effective therapy.

A Rare Case of Gastrointestinal Mucormycosis

Gastrointestinal Mucormycosis (GIM) is a rare life-threatening angio-invasive infection. The classic risk factors include immunosuppression and metabolic derangement. Usually, there are classical risk factors in patients affected by Ileocecal mucormycosis. Few case reports have shown the absence of salient clinical presentation of mucormycosis in prolonged hospitalisation. The presence of association of mucormycosis in patients of typhoid infection is rare. Here, we present a case of invasive ileal mucormycosis occurring as a sequel to typhoid infection which lacked the typical risk factors for mucormycosis.

Coinfection pulmonary mucormycosis and aspergillosis with disseminated mucormycosis involving gastrointestinalin in an acute B-lymphoblastic leukemia patient

Pulmonary mucormycosis and aspergillosis with disseminated mucormycosis involving gastrointestinalin is a very rare but lethal infection leading to extreme mortality. Herein, we present a unique case of pulmonary coinfection with Cunninghamella bertholletiae and Aspergillus flavus, with disseminated mucormycosis involving the jejunum caused by C. bertholletiae in an acute B-lymphocytic leukemia (B-ALL) patient with familial diabetes. Early administration of active antifungal agents at optimal doses and complete resection of all infected tissues led to improved therapeutic outcomes.

Successful Management of a Rare Gastric Mucormycosis Presenting with Massive Melena in a Polytrauma Patient

Mucormycosis is a rare, life-threatening, and opportunistic fungal infection that usually occurs in immunocompromised patients. Rhinocerebral and pulmonary manifestations are the common form. The rare form of gastrointestinal mucormycosis occur in all parts of the alimentary tract, with emphasis on the stomach being the most common site. Primary gastric mucormycosis following traumatic injury is an extremely rare form that is usually lethal; thus, only a few cases of survival have been reported even after early diagnosis and aggressive surgical resection, combined with antifungal treatment. We herein report a case of delayed-onset gastric mucormycosis in a polytrauma patient without predisposing factors, which was successfully treated by antifungal medical therapy alone with no surgical debridement.

Occurrence and species diversity of human-pathogenic Mucorales in commercial food-stuffs purchased in Paris area

Mucormycoses are life-threatening fungal diseases that affect a variety of patients including those with diabetes mellitus or hematological malignancies. The responsible agents, the Mucorales, are opportunistic pathogens originating from the environment such as soil or decaying organic matter. The aim of the present study was to assess the prevalence and diversity of human-pathogenic species of Mucorales in commercially available foodstuffs in France. All food samples were purchased from January 2014 to May 2015 in France. A total of 159 dried food samples including spices and herbs (n = 68), herbal tea (n = 19), cereals (n = 19), vegetables (n = 14), and other foodstuffs (n = 39) were analyzed. Each strain of Mucorales was identified phenotypically, and molecular identification was performed by ITS sequencing. From the 28 (17.6%) samples that were culture-positive for Mucorales, 30 isolates were recovered. Among the isolates, 13 were identified as Rhizopus arrhizus var. arrhizus, 10 R. arrhizus var. delemar, two Rhizopus microsporus, one Lichtheimia corymbifera, three Lichtheimia ramosa, and one Syncephalastrum racemosum. Culture-positive samples originated from different countries (Europe, Asia) and brands. The samples most frequently contaminated by Mucorales were spices and herbs (19/68, 27.9%), followed by herbal tea (2/19, 10.5%), cereals (2/19, 10.5%), other food products (5/39, 12.8%). The present study showed that human-pathogenic Mucorales were frequently recovered from commercially available foodstuffs in France with a large diversity of species. The potential danger represented by Mucorales present in food for immunocompromised patients should be further analyzed.

Invasive intestinal mucormycosis in a 40-year old immunocompetent patient - a rarely reported clinical phenomenon: a case report

BACKGROUND

Mucormycosis is rare, life-threatening fungal infection. Frequently observed in those patients having underlying immunosuppression such as, diabetes, organ transplantation, Human immunodeficiency virus (HIV) infection, and elevated serum iron. However, invasive intestinal mucormycosis occurring in immunocompetent individuals without the traditional risk factors is extremely rare clinical phenomenon.

CASE PRESENTATION

We report a 40-year-old male patient who presented with 1 week history of diffuse abdominal pain and high grade fever, associated with vomiting and frequent loose stools. Has history of chronic alcohol ingestion. Otherwise, no past history of chronic medical illness, nor he had contact with individuals with similar illness. He was in a septic shock with multiple organ failure up on presentation to emergency room. Physical examination revealed icterus sclera with abdominal tenderness. He was immediately resuscitated using crystalloids, supported with inotrope, and antibiotics. Histopathological examination of tissue sample from colonic ulcer biopsy revealed invasive intestinal mucormycosis. Patient showed full clinical and histopathological resolution after course of parenteral Liposomal Amphotercin B.

CONCLUSION

This case highlights the fact that, despite its life-threatening nature, it's possible to treat patients with invasive intestinal mucormycosis with aggressive antifungal and supportive care without surgical intervention, provided that all the necessary supportive care were initiated early and the disease was diagnosed early and appropriate medical management was initiated timely. In addition, it's important to consider intestinal mucormycosis even in patients who are immunocompetent without traditional risk factors.

Gastrointestinal Mucormycosis in a two-year-old child: A clinical and radiological enigma

Mucormycosis is a rare, fatal angioinvasive infection occurring in immunocompromised individuals. Gastrointestinal mucormycosis is rare variety with high mortality rate. We present a case of GI mucormycosis in a 2-year-old male child who presented with abdominal mass with no underlying risk factors. The aim of this case report is to emphasize on its etiopathogenesis and keeping mucormycosis high in the differential diagnosis in a child presenting with abdominal mass.

An unusual cause of bowel obstruction: Rhizopus Arrhizus diverticulitis

Mucormycosis is a fungal infection primarily afflicting immunocompromised or diabetic patients. Its presentation ranges from rhino-orbito-cerebral infections to disseminated mucormycosis with angioinvasion. We present a patient who developed a bowel obstruction one month after bone marrow transplant and was diagnosed with Rhizopus arrhizus diverticulitis despite antifungal therapy since transplantation. She underwent surgical removal with immediate fungal resurgence, declined further invasive intervention and was discharged on palliative isavuconazole. Seven months later she is alive with fungal containment.

Jejunal stricture due to mucormycosis

Mucormycosis is generally considered to be an acute, rapidly progressing, opportunistic fungal infection. Chronic manifestations are extremely rare. Mucormycosis affecting the jejunum is very rare and few cases have been reported. We report a case of mucormycosis causing jejunal stricture in an infant aged six months.

Invasive Gastrointestinal Mucormycosis: A Master Masquerader

We report 3 previously healthy children of postneonatal age who developed fatal form of gastrointestinal mucormycosis after systemic inflammatory response syndrome, shock and metabolic acidosis. Abdominal distension and peritonitis were secondary complications. The study highlights the importance of clinical suspicion of gastrointestinal mucormycosis when the triad of shock requiring vasoactive drugs, metabolic acidosis and abdominal distension is present.

Risk Mitigation for Immunocompromised Consumers of Mucormycete Spoiled and Fermented Foods: Germain Guidance and Remaining Needs

Mucoralean invasive fungal infections, while unusual among the general population, have a high mortality rate among immunocompromised individuals who become infected. They are also common spoilage organisms in cultured dairy products, some fresh produce, and baked goods. Additionally, Mucor and Rhizopus spp. are utilized in the production of traditional fermented foods including mold ripened cheeses and fermented soy products. The risk that consumption of these foods poses to immunocompromised consumers has been previously identified. However, actionable guidance on implementation of appropriate dietary restrictions and microbial specification targets for food manufacturers serving these populations is scarce and is limited by insufficient data regarding traceback analysis in cases of invasive fungal infections where food is the suspected transmission vector. Culture-dependent and molecular subtyping methods, including whole genome sequencing, will improve identification of the point source. In turn, the empirically determined information on root-cause can best direct the development of appropriate food safety policies and programs.

Near-fatal mucormycosis post-double lung transplant presenting as uncontrolled upper gastrointestinal haemorrhage

Invasive fungal infections in immunosuppressed transplant patients are associated with significant morbidity and mortality. We present a case of splenic mucormycosis post-double lung transplant, presenting as uncontrolled near-fatal upper gastrointestinal haemorrhage, to remind clinicians of the need to consider pre-transplant invasive fungal infection risk factors if an unexpected fungal infection arises in the post-transplant period. This case also highlights the valuable contribution of molecular technology for fungal identification but also the need for clinical correlation.

Combination liposomal amphotericin B, posaconazole and oral amphotericin B for treatment of gastrointestinal Mucorales in an immunocompromised patient

Mucormycosis is a life threatening infection caused by fungi in the order Mucorales. Mucormycosis can affect any organ system with rhino-orbital-cerebral and pulmonary infections being the most predominant infection types. Gastrointestinal mucormycosis is rare and accounts for only 4-7% of all cases. Here, we present a case of invasive gastrointestinal mucormycosis in an immunocompromised host treated with systemic and topical anti-mold therapy.

Fatal haemorrhagic duodenal mucormycosis in a non-immunocompromised host: A case report

Mucormycosis is an opportunistic infection caused by the fungi of the Mucorales order of the class Zygomycetes. Gastrointestinal mucormycosis is an uncommon, fatal condition accounting for only 7% of the cases. We present the case of a gastroduodenal mucormycosis presenting as recurrent massive hematemesis. We report this case to alert clinicians of this rare but fatal condition and to encourage further research into its pathogenesis and management.

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Mucormycosis is rare and often fatal.

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Rhino-orbital-cerebral and pulmonary infections dominate literature.

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Gastrointestinal mucormycosis is rare and is fatal in 85% of cases.

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We encourage further research into its pathogenesis.

Gastrointestinal Mucormycosis of the Jejunum in an Immunocompetent Patient: A Case Report

RATIONALE

Gastrointestinal Mucormycosis (GIM) is a kind of opportunistic fungal infection with poor prognosis. It usually occurs in patients with immune deficiency. We reported a case of immunocompetent male patient.

PATIENT CONCERNS

This patient was presented as abdominal distension and gastrointestinal bleeding.

DIAGNOSES

A variety of hemostatic methods was ineffective to stop the bleeding. The patient finally received laparotomy, and the jejunum lesions were found.

INTERVENTIONS

Pathological examination confirmed it to be gastrointestinal mucormycosis in jejunum.

OUTCOMES

However, after systemic anti-fungi therapy, the patient died of septic shock.

LESSONS

The diagnosis mainly relies on pathological examination. Early diagnosis and early application of systemic amphotericin B liposome were fundamental for improving the prognosis.

Nosocomial Jejunal Mucormycosis - an Unusual Cause of Perforation Peritonitis

Mucormycosis is a rare but highly invasive opportunistic fungal infection. Gastrointestinal disease although uncommon is highly fatal. We report a case of jejunal mucormycosis in a 24 year old undernourished female with preceding surgical intervention for acute intestinal obstruction of tubercular etiology. On 8^th post-operative day, she developed oozing from suture line, prompting exploratory laparotomy, bowel resection, jejunostomy and ileal mucus fistula. Resected bowel showed one perforation and several areas of impending perforations. Characteristic broad, pauci-septate hyaline, empty looking hyphae with infrequent branching were found transmurally and showing angio-invasion. Local intestinal tissue trauma coupled with her sub-normal immune status permitted this unusual nosocomial infection. Histopathological demonstration of the fungus in surgical specimens remains cornerstone of diagnosis of mucormycosis in view of its non-specific symptoms, low isolation rates of mycological culture and lack of other rapid tests.

Invasive Fungal Infections Acquired from Contaminated Food or Nutritional Supplements: A Review of the Literature

Fungi are an integral part of the natural environment and, therefore, play many roles in relation to food: some fungi are used in food production, some are food sources themselves, and some are agents of food spoilage. Some fungi that contaminate food can also be harmful to human health. The harmful but noninfectious health consequences of mycotoxins have been well-characterized, but the extent to which fungi in food pose a risk for invasive infections is unknown. We conducted a literature review to identify cases of invasive fungal infections (IFIs) believed to have resulted from ingestion or inhalation of food, beverages, or dietary supplements (excluding Saccharomyces infections). We identified 11 publications describing cases or small outbreaks of IFIs related to foods or beverages and three describing IFIs related to dietary supplements. These food-associated IFIs were predominantly mold infections, and the few yeast infections were associated with dairy products. Suspected foodborne IFIs appear to be rare, but are increasingly described in the electronically searchable literature. They are associated with a variety of foods, are due to a variety of fungal pathogens, and primarily occur in persons with immunosuppressive conditions or other predisposing factors. Various guidelines for high-risk patients recommend avoidance of certain food products that may contain high levels of fungi, but further work is needed to evaluate the effectiveness of these restrictive diets in preventing fungal infections. The relationships between food spoilage, food insecurity, and IFI risk are another area that may warrant further exploration.

Ventriculitis due to infection with Rhizopus arrhizus

A 52-year-old heart–lung transplant patient presented to the emergency department with acute onset of neurologic symptoms. MRI showed ballooning of the left ventricle, midline shift and contrast enhancement in the anterior horn of the left ventricle. Ventricle neuroendoscopy revealed whitish, floccose aerial structures within the left ventricle. Brain biopsy cultures grew Rhizopus arrhizus. Therapy with liposomale amphotericin B and posaconazole was performed. Except for hemianopsia and deficits in minute motor activity, the patient completely recovered.

Spontaneous pneumothorax followed by reversed halo sign in immunocompromised patient with pulmonary mucormycosis

Mucormycosis, an invasive fungus with a variety of clinical presentation, is a devastating infection in immunocompromised host. Here an unusual case of pulmonary mucormycosis is introduced in an immunodeficient patient in which pneumothorax was followed by reversed halo sign (RHS). The clinicians, who visit immunocompromised persons with pneumothorax, should be considerate to take immediate imaging and pathologic measures to confirm or reject mucormycosis.

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Spontaneous pneumothorax; in pulmonary mucormycosis that followed by reversed halo sign.

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Pneumothorax in pulmonary mucormycosis on day 0.

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Reversed halo sign on day +9.

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Histhopathology of mucormycosis(rhinoorbital mucormycosis).

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PNS CT scan that shows soft tissue density with orbital extension.