Histological and ultrastructural features of gastrointestinal basidiobolomycosis

Gastrointestinal Basidiobolomycosis: A Case Series

Gastrointestinal basidiobolomycosis (GIB) is a rare fungal infection caused by Basidiobolus ranarum, a saprophytic fungus that belongs to the class of Basidiobolomycetes. It mainly infects immunocompetent individuals and is mainly found in arid tropical and subtropical regions, including Southwestern America, Saudi Arabia, Africa, and Asia. Not surprisingly, a great number of human infections have been reported from these warm, humid climate regions that are felicitous for the growth of this fungus, especially from the southern region of Saudi Arabia and Arizona in the United States of America. GIB is easily misdiagnosed as malignancy, inflammatory bowel disease, diverticulitis, lymphoma, and chronic intestinal infections due to its rarity. In this case series, we summarize the clinical features, imaging, histopathological features, and treatment of patients diagnosed with GIB in our institution.

Disseminated Basidiobolomycosis Caused by Basidiobolus omanensis in a Child with Acute Lymphoblastic Leukemia (ALL). Case Report and Literature Review

Basidiobolomycosis is an uncommon fungal infection caused by the genus Basidiobolus. In immunocompetent children, it usually causes cutaneous infection and rarely affects the gastrointestinal tract, and it is extremely rare for the disease to spread. The present study reports the first case of disseminated basidiobolomycosis caused by Basidiobolus omanensis in a child with acute lymphoblastic leukemia who died as a result of uncontrolled infection and multi-organ failure despite surgical and antifungal therapy with L-AMB and voriconazole. A review of the literature yielded 76 cases, including the current case with the majority of which were reported as invasive gastrointestinal infection. The median age was 4 years (61 male and 15 female) and the majority of these children were from the Middle East (80%), specifically Saudi Arabia (45%). Most patients were treated with systemic antifungal agents (mostly itraconazole and amphotericin B). Surgical intervention was done in 25% of these patients and the death rate was 12%.

Gastrointestinal basidiobolomycosis - A rare fungal infection: Challenging to diagnose yet treatable - Case report and literature review

Gastrointestinal Basidiobolomycosis is a rare manifestation of Basidiobolus ranarum infection. In this report, we present two cases of gastrointestinal Basidiobolomycosis. The first patient presented with obstructive symptoms, fever, and weight loss. The diagnosis of Basidiobolomycosis was not made until after surgery, when Liposomal amphotericin-B combined with itraconazole were administered, leading to the resolution of laboratory markers of inflammation and patient's symptoms. The second case involves a young woman who presented with hematochezia, perianal induration, and abdominal pain. The patient had previously been diagnosed with Crohn's disease and treated accordingly, but her symptoms did not improve. Due to the endemicity of tuberculosis in Iran, the patient was treated for TB but still showed no improvement. However, a perianal biopsy sample revealed the Splendore Hoeppli phenomenon and fungal elements in GMS staining, leading to the diagnosis of gastrointestinal Basidiobolomycosis. Treatment with itraconazole and co-trimoxazole led to a significant improvement in symptoms and laboratory indices after one week, including the resolution of perianal induration. The key takeaway from this report is the importance of considering rare infections in the differential diagnosis of gastrointestinal conditions such as IBD and GI obstruction.

Pediatric intussusception due to basidiobolomycosis: a case report and literature review

Background

Pediatric gastrointestinal basidiobolomycosis is an unusual fungal infection caused by Basidiobolus ranarum, an environmental saprophyte found worldwide. Typically, basidiobolomycosis presents as a subcutaneous infection or soft tissue tumor-like lesion, and rarely involves the gastrointestinal tract. Gastrointestinal basidiobolomycosis is most common in young infants. It has no definitive clinical presentation, and almost all cases are misdiagnosed during the initial presentation.

Case presentation

We report the case of a 4-year-old Saudi boy who presented to the emergency department with abdominal pain, nausea, vomiting, and weight loss. Ultrasonography revealed a target sign. Based on the ultrasonography findings, surgery was performed, which revealed the presence of intussusception. Eventually, the patient was diagnosed with intussusception secondary to intra-abdominal basidiobolomycosis based on the histological findings. The patient was readmitted and intravenous voriconazole therapy was initiated. One week after the second admission, the patient developed abdominal pain, nausea, vomiting, inability to hold down food, and constipation. Computed tomography of the abdomen was suggestive of small bowel obstruction, which was managed conservatively. The patient responded well and was subsequently discharged with a prescription of oral voriconazole.

Conclusions

This case reveals that gastrointestinal basidiobolomycosis can cause intussusception. This report will inform clinicians of the importance of considering gastrointestinal basidiobolomycosis in the differential diagnosis of chronic abdominal pain in children, even in the absence of fever or a clinically obvious abdominal mass, especially in countries such as Saudi Arabia, where cases have been reported.

A Pediatric Case of Basidiobolomycosis Presenting With an Abdominal Mass

Basidiobolomycosis is a rare fungal infection caused by Basidiobolus ranarum. The condition has been reported in children and adults presenting with abdominal pain, weight loss, abdominal distension, vomiting, diarrhea, fever, and an abdominal mass. We report a case of a previously healthy 2.5 years old male who presented to the ER complaining of abdominal pain and distension for two weeks together with significant weight loss. He looked ill and cachectic. He had tachycardia but was afebrile. His abdominal examination showed a right-sided abdominal mass. His initial abdominal ultrasound (US) suggested an abdominal tumor. The patient was referred to a tertiary center where he had an ultrasound-guided biopsy that showed fungal hyphae consistent with basidiobolomycosis.

An Infant with Acute Bloody Diarrhea and Gastrointestinal Basidiobolomycosis: An Unusual Presentation of a Rare Disease

Basidiobolomycosis is a fungal infection caused mainly by Basidiobolus ranarum, a filamentous fungus of the order Entomophthorales and the family Basidiobolaceae. This infection typically involves the skin and soft tissue; however, visceral organ involvement has also been reported. Here, we report a case of gastrointestinal basidiobolomycosis in a young child who presented with acute bloody diarrhea which was initially misdiagnosed as intussusception.

Basidiobolomycosis of Right Colon Mimicking as Carcinoma of Colon

Gastrointestinal basidiobolomycosis (GIB) is a rare fungal infection with limited geographic distribution. However, the incidence of GIB has shown an increasing trend because of globalization and frequent traveling. GIB is commonly seen to mimic gastrointestinal malignancy and other diseases such as intestinal tuberculosis and inflammatory bowel disease. Tissue diagnosis is considered to be the gold standard for differentiating these mycotic lesions from tuberculosis and malignancy with confirmation of species performed by culture or polymerase chain reaction. The diagnosis of GIB should be conjectured in patients with suspicion of malignancy, with an inconclusive biopsy. It seems prudent to proceed with radical excision of mass early because both colonic malignancy and GIB have high mortality if untreated.

Primary Basidiobolomycosis of the Cecum in Immunocompetent Patients: Two Case Reports

Colonic basidiobolomycosis is a rare fungal infection caused by Basidiobolus ranarum. Primary cecal basidiobolomycosis is an exceptionally rare condition. The study describes two cases of primary basidiobolomycosis of the cecum in immunocompetent male and female patients (one each). The patients presented with fever, abdominal pain, weight loss, eosinophilia, and high erythrocyte sedimentation rates. Computed tomography revealed wall thickening and mass lesions involving the cecum, suggesting malignancy. Right hemicolectomies were performed to relieve the intestinal obstruction. On microscopy, there were destructive, transmural eosinophil-rich pyogranulomatous reactions with thin-walled, pauci-septated fungal elements surrounded by Splendore-Hoeppli bodies. The patients received antifungal drugs, with no evidence of dissemination or recurrence on follow-up. Primary cecal basidiobolomycosis in immunocompetent hosts is a rare occurrence. It oftentimes clinically masquerades malignant neoplasms and therefore its identification mandates its inclusion in the differential diagnosis of a colonic mass, equally both on the part of the clinicians and pathologists.

Gastrointestinal basidiobolomycosis: Beware of the great masquerade a case report

Basidiobolomycosis is rare infection caused by the saprophytic fungus Basidiobolus ranarum. Gastrointestinal basidiobolomycosis is an infrequent, albeit, increasingly reported, emerging form of the disease and typically affects immunocompetent individuals with potentially grave sequelae if unrecognized. Acquaintance with this exceptionally rare fungus and its potential for presenting as gastrointestinal mass masquerading as colonic malignancy is critical for timely diagnosis, appropriate treatment and successful clinical outcome. We report a case of gastrointestinal basidiobolomycosis masquerading as colonic malignancy in a 29-year-old Omani patient successfully treated with combination of surgery and prolonged azole antifungal therapy.

Gastrointestinal pythiosis with concurrent presumptive gastrointestinal basidiobolomycosis in a Boxer dog

A 2-year-old female spayed Boxer dog was presented for a 1-month history of progressive hemorrhagic diarrhea with tenesmus and weight loss despite trial courses of antibiotics and diet change. Abdominal ultrasound revealed severe, focal thickening, and loss of normal architecture of the colonic wall with abdominal lymphadenomegaly. Dry-mount fecal cytology, performed on several consecutive days, consistently revealed numerous, round, 16-20 μm structures with basophilic, granular content, and a thin cell wall. Transmission electron microscopy identified these structures as fungi. Culture, polymerase chain reaction (PCR), and sequencing of the internal transcribed spacer, D1/D2 regions, and DNA-directed RNA polymerase II core subunit (RPB2) confirmed the presence of Basidiobolus microsporus in the feces. Biopsies collected via ileocolonoscopy revealed marked, multifocal, chronic, neutrophilic, and eosinophilic ileitis and colitis with ulceration, granulation tissue, and intralesional hyphae (identified with Gomori methenamine silver stain). A Pythium enzyme-linked immunosorbent assay and Pythium-specific PCR performed on the formalin-fixed paraffin-embedded biopsy specimens were positive while Basidiobolus-specific PCR was negative, thus confirming a diagnosis of pythiosis. This report describes a fatal case of colonic and intestinal pythiosis with the presence of fecal Basidiobolus sp. spores, suggestive of concurrent gastrointestinal basidiobolomycosis.

Gastrointestinal basidiobolomycosis: An emerging mycosis difficult to diagnose but curable. Case report and review of the literature

BACKGROUND

Gastrointestinal basidiobolomycosis (GIB) is a rare mycosis affecting almost exclusively immunocompetent subjects.

METHODS

We describe a case of GIB caused by Basidiobolus ranarum in a 25-year-old Italian immunocompetent man resident in Ireland who presented a 2-month history of epigastric pain. Suspecting colon cancer he underwent a right hemicolectomy subsequently leading to a diagnosis of GIB by means of molecular biology. After surgery a 9-month therapy with itraconazole was employed with a good outcome. A review of medical literature regarding GIB cases published in the period 1964-2017 is presented.

RESULTS

One-hundred and two cases of GIB were included in this analysis. The disease was observed predominantly in male gender (74.5%) and children (41.2%). Abdominal pain was the single most common complaint (86.3%) followed by fever (40.2%) and evidence of an abdominal mass (30.4%). Peripheral blood eosinophilia was detected in 85.7% of cases. Most of the patients were diagnosed in Saudi Arabia (37.2%) followed by USA (21.6%) and Iran (20.6%). Surgery plus antifungal therapy was employed in the majority of patients (77.5%). An unfavourable outcome was documented globally in 18.6% of patients.

CONCLUSIONS

GIB seems to be an emerging intestinal mycosis among immunocompetent patients living in the Middle East and Arizona.

Paediatric case of gastrointestinal basidiobolomycosis mimicking appendicitis – Case report

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Basidiobolomycosis is a rare fungal infection that leads to subcutaneous infection.

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Gastrointestinal basidiobolomycosis is difficult to diagnose primarily due to its non-specific clinical presentation.

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Gastrointestinal basidiobolomycosis should be a differential especially in paediatric patients present with abdominal mass and eosinophilia.

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Optimal way to manage gastrointestinal basidiobolomycosis is by surgical resection followed by 3 months of antifungal treatment.

Introduction

Basidiobolomycosis is a rare fungal infection caused by Basidiobolus ranarum that normally leads to subcutaneous infection and, rarely, to involvement in the gastrointestinal tract.

Presentation of case

A 6-year-old boy presented to the Emergency department (ED) complaining of abdominal pain of a few weeks’ duration in the right lower quadrant, associated with fever and vomiting. A computed tomography (CT) of the abdomen was done. It showed an enlarged tubular structure in the right iliac fossa, a suspected appendicular lesion, and free fluid collection, as well as multiple enlarged mesenteric and right iliac lymph nodes. Based on these results, the decision was made to do surgical exploration on the patient. After two weeks, the patient developed tachycardia, abdominal distention, constipation, and spikes of fever. Two days later, re-exploration was performed. An ileostomy and colostomy were performed and drains inserted. Post-operative, the patient was pushed to paediatric intensive care unit (PICU), while still intubated and hemodynamically stable. However, he developed cardiac arrest on the same day and cardiopulmonary resuscitation (CPR) was performed, but he couldn't be resuscitated.

Discussion

The patient presented with severe abdominal pain in the right lower quadrant, as well as fever and vomiting. These complaints may have been misdiagnosed as appendicitis. The diagnosis of gastrointestinal basidiobolomycosis was confirmed by histopathology, based on a surgical specimen taken during the primary exploration. The management was a combination between surgical intervention and medical treatment.

An unusual case of gastrointestinal basidiobolomycosis mimicking colon cancer; literature and review

Gastrointestinal basidiobolomycosis (GIB), a rare fungal infection associated with high mortality, has been reported worldwide mainly from tropical and subtropical regions of Asia, USA, and Latin America. The clinical manifestations are highly diverse and non-specific depending on the underlying disease, but fever, abdominal pain, weight loss, diarrhea, constipation and chills have been observed. There are no prominent risk factors for GIB but climatic conditions and life style are related to this infection in arid and semi-arid regions. Therefore timely diagnosis and early treatment is a challenge. Herein, we present an unusual case of gastrointestinal basidiobolomycosis in a 54-year-old male, initially misdiagnosed as colon cancer. After follow-up, no evidence of relapse and the patient was successfully cured by liposomal amphotericin B. In addition, the differential diagnosis and histopathological findings are discussed with a review of the literature.

Disseminated angioinvasive basidiobolomycosis with a favourable outcome

Basidiobolomycosis, a rare fungal infection, is of worldwide distribution but areas commonly involved include the tropical areas of Africa, USA and South East Asia. 88% of the cases are reported among patients younger than 20 years. Many of the case reports in Saudi Arabia are from Tohama area where our patient lives. The diagnosis tends to be overlooked as the presentation may mimic colonic carcinoma in adults or inflammatory bowel diseases and tuberculosis in both children and adults. Angioinvasion seen in our patient is extremely rare suggesting the diagnosis of mucormycosis and resulting in a delay in choosing the most appropriate treatment. We report this case to remind physicians and surgeons to consider this diagnosis in patients from endemic area presenting with such conditions.

Human Pathogenic Entomophthorales

The pathogenic entomophthoralean fungi cause infection in insects and mammalian hosts. Basidiobolus and Conidiobolus species can be found in soil and insect, reptile, and amphibian droppings in tropical and subtropical areas. The life cycles of these fungi occur in these environments where infecting sticky conidia are developed. The infection is acquired by insect bite or contact with contaminated environments through open skin. Conidiobolus coronatus typically causes chronic rhinofacial disease in immunocompetent hosts, whereas some Conidiobolus species can be found in immunocompromised patients. Basidiobolus ranarum infection is restricted to subcutaneous tissues but may be involved in intestinal and disseminated infections. Its early diagnosis remains challenging due to clinical similarities to other intestinal diseases. Infected tissues characteristically display eosinophilic granulomas with the Splendore-Höeppli phenomenon. However, in immunocompromised patients, the above-mentioned inflammatory reaction is absent. Laboratory diagnosis includes wet mount, culture serological assays, and molecular methodologies. The management of entomophthoralean fungi relies on traditional antifungal therapies, such as potassium iodide (KI), amphotericin B, itraconazole, and ketoconazole, and surgery. These species are intrinsically resistant to some antifungals, prompting physicians to experiment with combinations of therapies. Research is needed to investigate the immunology of entomophthoralean fungi in infected hosts. The absence of an animal model and lack of funding severely limit research on these fungi.

Pathologic Features of Infectious Gastritis

This manuscript presents a review of infectious causes of gastritis aimed at the practicing anatomic pathologist. We shall highlight unique histologic findings and clinical attributes that will assist those analyzing endoscopically obtained mucosal biopsies of the stomach or resection specimens.

Gastro-intestinal basidiobolomycosis in a 2-year-old boy: dramatic response to potassium iodide

Gastro-intestinal basidiobolomycosis (GIB) is a rare fungal infection caused by Basidiobolus ranarum. Treatment includes surgical resection and long-term antifungal therapy. A 2.5-year-old boy presented with a 10-day history of abdominal pain, fever and diarrhoea, and a palpable abdominal mass was detected. Resection was undertaken and histology confirmed basidiobolomycosis. Treatment with amphotericin B and itraconazole was commenced, but the infection progressed and spread to involve the intestines, liver, ribs and lung, and also the abdominal wall after 6 months, requiring four operative procedures. Because of unresponsiveness to amphotericin and itraconazole, oral potassium iodide was added which resulted in complete resolution of the infection. Potassium iodide is an essential component of the treatment of systemic B. ranarum.

Surgical management of colonic basidiobolomycosis among adolescent and adult patients: presentation and outcome

AIM

The aim of this study was to review retrospectively the clinical presentations, indications for surgery and surgical outcomes of adolescent and adult patients who were diagnosed with colonic basidiobolomycosis in the last 10 years.

METHOD

The study was carried out in Aseer Central Hospital, Abha, Saudi Arabia by reviewing the medical files of all patients in the last 10 years who were diagnosed with colonic basidiobolomycosis and required surgical intervention.

RESULTS

There were 22 patients. Common findings in all patients were weight loss, abdominal pain and an abdominal mass. The right colon was affected in 21 patients. The initial diagnosis was correct in seven patients while nine were thought to be malignant. All patients underwent colonic resection followed by at least 1 year of antifungal medical treatment. Intra-operatively, all patients had moderate or dense adhesions, an abdominal mass and lymphadenopathy. Most surgeons had the impression intra-operatively that the diagnosis was inflammatory rather than malignant. Postoperatively, three patients died within 6 months of the operation due to progression of the disease. Four patients developed severe wound infections, three of whom had abdominal dehiscence and required re-closure.

CONCLUSION

Colonic basidiobolomycosis is a life-threatening fungal infection that should be considered a surgical condition. A high index of suspicion including basidiobolomycosis in the differential diagnosis for the acute abdomen with a colonic mass is required for a proper diagnosis. Early aggressive surgical management followed by a prolonged course of itraconazole postoperatively could improve the outcome of the condition.

Entomophthoramycosis: a neglected tropical mycosis

The term 'entomophthoramycosis' classically refers to infections caused by members of the order Entomophthorales. A new subphylum, Entomophthoramycota, has been created to include Basidiobolomycetes, Neozygitomycetes and Entomophthoramycetes. Basidiobolomycetes encompass Basidiobolus spp., while the Entomophthoramycetes include Conidiobolus spp. Conidiobolus spp. characteristically cause rhinofacial entomophthoramycosis in apparently immunocompetent hosts. Conidiobolus spp. may also cause disseminated infection in immunocompromised patients. Basidiobolus spp. more typically cause subcutaneous entomophthoramycosis of the limbs, buttocks, back and thorax in immunocompetent patients. While once considered to be rare, there is an increasing number of reported cases of gastrointestinal infection caused by Basidiobolus spp. worldwide in countries such as United States, Thailand, Australia, Iran, Egypt and Saudi Arabia. These cases have clinical presentations similar to those of inflammatory bowel diseases, particularly Crohn's disease. Retroperitoneal, pulmonary, nasal and disseminated basidiobolomycosis have also been reported. Histology of entomophthoramycosis may reveal the Splendore-Hoeppli phenomenon. Culture of infected tissue remains the definitive method of laboratory diagnosis. However, molecular methods with specific DNA probes and panfungal primers, as well as real time PCR, are increasingly used to detect and identify these organisms in tissue. Treatment largely consists of therapy with antifungal triazoles. Surgery plays a selective role in the management of entomophthoramycosis, depending upon location, organism and extent of the infection.

Gastrointestinal basidiobolomycosis in a dog

An 8-year-old, spayed, female Shiba dog was presented to a referring veterinarian with a complaint of chronic diarrhea and anorexia. Ultrasound and radiographs revealed an irregular mass in the pelvic cavity. The mass and the affected section of colon were surgically removed. Histopathological examination revealed multifocal coalescing granulomas and effaced intestinal structures. Central necrotic debris surrounded by multinucleated giant cells, lymphocytes, plasma cells and neutrophils was observed. Numerous, irregularly branched hyphae with pale basophilic, thin walls and occasional bulbous enlargements at the tips were present. Polymerase chain reaction identified Basidiobolus ranarum, successfully confirming a definitive diagnosis of basidiobolomycosis. To the best of our knowledge, this is the first report of intestinal basidiobolomycosis in a dog.

Fungal inflammatory masses masquerading as colorectal cancer: a case report

Background

Non malignant invasive tumors of the colon and rectum are very rare. Gastrointestinal Basidiobolomycosis can present as a mass lesion mimicking colorectal cancer.

Case presentation

A 56 year old Caucasian male was evaluated for abdominal and pelvic pain for 4 weeks complicated by acute urinary retention. Radiological evaluation showed him to have recto-sigmoid and cecal mass. Endoscopic examination and biopsies did not reveal a definite diagnosis. Computerized tomography guided biopsy of the mass showed fungal elements consistent with gastrointestinal basidiobolomycosis. He was treated with Itraconazole for 12 months with very good clinical and radiological response.

Conclusion

Basidiobolomycosis of the gastrointestinal tract should be considered during evaluation of colorectal masses with atypical presentation. It is a rare entity seen more in endemic regions of the world for basidiobolomycosis including southwestern United States.

Gastrointestinal basidiobolomycosis with hepatic dissemination: a case report

INTRODUCTION

Gastrointestinal basidiobolomycosis (GIB) is an emerging fungal infection with a few cases reported worldwide. It is caused by Basidiobolus ranarum, which does not usually invade blood vessels and rarely disseminates.

CASE PRESENTATION

We present a rare case of GIB with hepatic dissemination in a 12-year-old Yemeni boy living in southwestern Saudi Arabia. The initial provisional diagnosis was intestinal lymphoma, and a right hemicolectomy was carried out, but histopathological assessment ruled out lymphoma and suggested intestinal tuberculosis. Two weeks after starting antituberculous medications, the patient was referred to our hospital because of fever and right upper abdominal discomfort. There was leukocytosis with marked eosinophilia, and a liver biopsy showed evidence of B. ranarum infection. A second opinion by histopathological examination of resected tissues diagnosed colonic basidiobolomycosis. The patient was treated successfully with itraconazole.

CONCLUSION

GIB is an emerging disease in southwestern Saudi Arabia and should be considered in a patient with an abdominal mass and eosinophilia coming from this region. Persistent elevation of leukocytes and eosinophils after surgical resection of the affected tissue could be used as a predictor of fungal dissemination. Further research is needed for a better understanding of GIB.

Entomophthoromycosis: a challenging emerging disease

Entomophthoromycosis is a rare fungal infection that may affect immunocompetent hosts; predominantly in tropical and subtropical regions. Recently, the importance of this emerging mycosis has increased and the scope of its manifestations has been expanded. These manifestations; however, may masquerade as other clinical entities. Prompt diagnosis of this infection requires a high index of suspicion. Although histopathological examination and cultures are the gold standard diagnostic tools; molecular diagnosis is now available and started to play an important role. The cornerstone treatment is prolonged anti-fungal therapy along with surgical debridement. More awareness of this mycosis is warranted for definitive diagnosis and implementation of early proper therapeutic strategies.

Diagnosis of gastrointestinal basidiobolomycosis: a mini-review

Basidiobolus ranarum (Entomophthoromycotina) very rarely affects the gastrointestinal (GI) tract. To date, reported paediatric GI basidiobolomycosis cases are 27 worldwide; 19 from Saudi Arabia and 8 from other parts of the world. Often these cases present a diagnostic dilemma, are prone to misdiagnosis and lack of disease confirmation by proper molecular methodologies. The fungal mass removed by surgery is usually sent for conciliar histopathology, isolation by fungal cultures and final molecular testing for basidiobolomycosis. The incidence of basidiobolomycoses, their predisposing factors and the molecular diagnosis of the fungus causing the disease in combination with a phylogenetic framework are reviewed.

Gastrointestinal Basidiobolomycosis: First case report from Oman and literature review

Gastrointestinal basidiobolomycosis (GIB) is a rare fungal infection with few reported cases worldwide. We report here the first case diagnosed in Oman in a previously healthy 5-year-old Omani female child who had been thought initially to have an abdominal malignancy. The case was referred to the Royal Hospital, Muscat, Oman, in July 2012. She was treated successfully with surgical resection and prolonged antifungal therapy (voriconazole). Physicians, including clinicians, radiologists and pathologists, should have a high index of suspicion for GIB when a patient presents with an abdominal mass and fever.

Basidiobolomycosis a mysterious fungal infection mimic small intestinal and colonic tumour with renal insufficiency and ominous outcome

Basidiobolomycosis is a rare fungal infection caused by Basidiobolus ranarum a worldwide environmental saprophyte fungus that is potentially a pathogen. B ranarum mainly affects the subcutaneous tissues but gastrointestinal and disseminated infections rarely have been reported previously. We report a case of B ranarum infection in a 12-year-old immunocompetent boy presented with abdominal pain from 2 months earlier before admission in the hospital. Abdominal CT scan revealed a lobulated mass-like lesion in the vicinity of right lower quadrant enveloping ascending colon and terminal ileum with involvement of mesentery. Histopathological examination showed severe full-thickness infiltration of inflammatory cells mainly eosinophils admixed with multinucleated giant cells and large areas of necrosis with granulomatous feature. Periodic acid Schiff staining demonstrated thin-walled septate fungal hyphae's surrounded by eosinophilic material (Splendore-Hoppeli phenomenon) identified as a basidiobolomycosis.

Gastrointestinal basidiobolomycosis in a child; an unusual fungal infection mimicking fistulising Crohn's disease

BACKGROUND

Gastrointestinal basidiobolomycosis is a rare disease caused by the fungus Basidiobolus ranarum. It has been reported in both children and adults. The disease mainly affects the colon and the small bowel; however, cases of the stomach, liver, pancreas, and renal system being affected have been reported.

CASE REPORT

A 2 year old boy presented with the following symptoms; abdominal pain, vomiting, diarrhea, fever and palpable right iliac fossa mass. Laboratory investigations revealed elevated inflammatory markers and peripheral eosinophilia. Colonoscopy showed severely inflamed mucosa of the terminal ileum, cecum and ascending colon. CT scan of the abdomen demonstrated an inflammatory mass with wall thickening of the terminal ileum and the colon. Surgical exploration demonstrated retroperitoneal mass and inflamed terminal ileum, cecum and ascending colon. Upon laparotomy, multiple internal fistulas involving the bowel loops, the urinary bladder, the right ureter and the gallbladder were observed. Further investigations using histopathology of the resected diseased bowel showed extensive necrosis, multinucleated giant cells and numerous eosinophils and large fungal hyphae surrounded by strongly eosinophilic material were seen in the tissue suggestive of B. ranarum infection. The patient responded well to treatment with voriconazole.

CONCLUSION

Gastrointestinal basidiobolomycosis should be considered in the differential diagnosis of every child presenting with abdominal pain, fever and palpable abdominal mass with peripheral eosinophilia. The presence of bowel inflammation and fistulas should not preclude such diagnosis.

Emergence of gastrointestinal basidiobolomycosis in the United States, with a review of worldwide cases

BACKGROUND

We examined the epidemiology, clinical manifestations, histopathology, management, and outcomes of gastrointestinal basidiobolomycosis, an uncommon manifestation of infection caused by the fungus Basidiobolus ranarum.

METHODS

In this retrospective observational cohort study, cases of gastrointestinal basidiobolomycosis in the United States were identified by reviewing medical records from Mayo Clinic Hospital (Phoenix, AZ) and contacting local infectious diseases specialists, pathologists, gastroenterologists, the Arizona Department of Health Services, health departments of adjacent states, the Armed Forces Institute of Pathology, and the US Centers for Disease Control and Prevention. A comprehensive literature review identified additional cases worldwide.

RESULTS

Of 44 patients (mean age, 37 years [range, 2-81 years]) with gastrointestinal basidiobolomycosis, most were from the United States (19 patients [43%], of whom 17 [89%] were from Arizona) or Saudi Arabia (11 [25%]). Most (28 [64%]) were previously healthy. Common chronic medical conditions among 15 patients (34%) were diabetes mellitus (8 patients [18%]) and gastric disorders (7 [16%]). Common findings were abdominal pain (37 patients [84%]) and a palpable abdominal mass (19 [43%]). Intraabdominal malignancy was the leading provisional diagnosis (19 patients [43%]). The large bowel was involved in 36 (82%), the small intestine in 16 (36%), and the liver or gallbladder in 13 (30%). Characteristic histopathologic findings were observed in 43 (98%). Eight patients (18%) died. Combined surgical intervention and antifungal therapy was the preferred treatment.

CONCLUSIONS

Gastrointestinal basidiobolomycosis is an emerging invasive fungal infection in desert regions of the US Southwest. Clinical findings mimic malignancy and inflammatory bowel disease. Surgical excision and prolonged antifungal therapy are associated with favorable outcomes.

Development of a specific polymerase chain reaction assay for the detection of Basidiobolus

The etiology of chronic diarrhea is complex in humans and animals. It is always necessary to evaluate a list of differential diagnosis, including bacteria, protozoa and fungi. Basidiobolomycosis is a fungal disease reported sporadically worldwide, mainly caused by B. ranarum, a frequent organism found in soil or in the intestine and skin of lizards and frogs. It is an opportunistic pathogen that causes infections characterized by granulomatous lesions in the subcutaneous tissues as well as in the intestinal wall in humans and animals. In this work we have developed a PCR technique to differentiate Basidiobolus from other causes of intestinal disease in dogs and humans. To test the specificity of the PCR assay we included closely related organisms, common intestinal microbiota and pathogenic organisms, such as Aspergillus, Candida, Cryptosporidium, Escherichia, Giardia, Mucor, Proteus, Rhizopus and Salmonella. Pythium insidiosum, which cause clinically similar disease in dogs but require a different treatment. Only Basidiobolus was positive to the PCR assay.

Basidiobolomycosis of the colon masquerading as stenotic colon cancer

Basidiobolus ranarum is a widespread saprophyte fungus with pathogenic potential. It affects mainly the subcutaneous tissues of the trunk and limbs. Relatively recently, occasional reports of gastrointestinal basidiobolomycosis appeared in the literature. Due to the rarity of the condition and the nonspecific presenting features, the correct diagnosis is usually hard to reach. In this paper, we describe the clinical course of an otherwise healthy female, who presented with a colonic mass. She received subtotal colectomy followed by oral itraconazole, with successful outcome.

Sensory innervation of the female human umbilical skin: morphological studies

BACKGROUND

Sensory stimuli are conducted by several cutaneous sensory nerves and tactile corpuscles. The latter are specialized sensory organs that represent the starting point of many afferent sensory pathways. To date, our knowledge about the distribution of the sensory innervation in the umbilical skin of females is incomplete.

AIM OF THE STUDY

To elucidate the morphology of the cutaneous innervation of the normal female umbilical skin.

MATERIALS AND METHODS

Biopsies of normal umbilical skin were obtained from female patients undergoing umbilical hernial repair. The specimens were processed for both immunohistological (antibodies against PGP9.5, pan-neuronal marker, and S-100 protein, marker of Schwann cells) and ultrastructural (transmission electron microscopy) examinations.

RESULTS

The authors found abundant genital end-bulb-like structures, numerous epidermal and dermal Merkel cells, Meissner and Ruffini corpuscles, intraepidermal nerve terminals, and multiple free nerve endings surrounding the ducts and acini of the sweat glands.

CONCLUSIONS

The umbilical skin of females has abundant sensory innervation similar to that of the glans penis.

Basidiobolomycosis: Case series

BACKGROUND

Basidiobolus ranarum is a fungus found in the dung of amphibians, reptiles and insectivorous bats. Basidiobolomycosis is a chronic subcutaneous infection of the trunk and limbs caused by B. ranarum. The disease is a well-known infection in the tropical areas. It usually presents with subcutaneous or gastrointestinal lesions and rarely with systemic affection. Recently, the etiologic role of B. ranarum in the gastrointestinal infections has been increasingly recognized.

PATIENTS AND METHODS

Here, we retrospectively reviewed the records of five patients with basidiobolomycosis, all from the same geographic region (Tohama area, Aseer province, southern region of the Kingdom of Saudi Arabia).

RESULTS

All the cases presented with prolonged fever and other manifestations suggestive of either chronic infection (such as tuberculosis) or malignancies (such as lymphoma). The diagnosis of gastrointestinal basidiobolomycosis was established on histolological ground (granulomatous reaction, dense infiltrate of eosinophils and fungal structures). One case was diagnosed based on the histological features combined with positive tissue culture for B. ranarum. One case was treated by surgical resection of fungal masses (Case I), followed by itraconazole and amphoterecin-B therapy. The other four cases had non-resectable fungal masses and they responded very well for antifungal therapy (cases II, III, and IV received amphotericin-B and itraconazole and case V received amphotericin-B and voriconazole).

CONCLUSIONS

Our study raises several notions. Gastrointestinal basidiobolomycosis is often misdiagnosed as cancer (lymphoma or carcinoma), tuberculosis or inflammatory bowel disease. Its recognition needs high index of suspicion and increased awareness especially in patients with chest, abdominal or neck masses and eosinophilia. The diagnosis of basidiobolomycosis can be established on histological basis in most cases. The fungal morphology and the Splendore-Hoeppli phenomenon are characteristic histological features of this condition. There are no prominent risk factors. Usually, surgery and prolonged antifungal therapy are required.

Gastrointestinal basidiobolomycosis: an unusual fungal infection mimicking colon cancer

CONTEXT

-Basidiobolomycosis is a rare disease caused by the fungus Basidiobolus ranarum, an environmental saprophyte found worldwide. Patients with B ranarum infection may present with subcutaneous, gastrointestinal, or systemic lesions. Gastrointestinal basidiobolomycosis poses diagnostic difficulties, as its clinical presentation is nonspecific, with no identifiable risk factors.

OBJECTIVE

-To discuss and compare the clinical features and histopathologic findings and other ancillary techniques that could be helpful in identifying gastrointestinal basidiobolomycosis.

DESIGN

-We report 3 cases of gastrointestinal basidiobolomycosis and describe the clinical and morphologic findings while emphasizing the importance of identifying this unusual entity on endoscopic biopsies, thus avoiding unnecessary major surgeries. Fungal cultures were also performed, which are of diagnostic significance. Our first patient was lost to follow-up; however, patients 2 and 3 were followed up for 4 and 2 years, respectively.

RESULTS

-In all 3 cases, patients presented with a clinical profile suggestive of malignancy. None of the patients gave any specific history. There was widespread abdominal disease with peritoneal involvement and colonic masses. Colonoscopic biopsy specimens showed nonspecific inflammation in 1 case; however, they showed only granulomatous inflammation in a second case and granulomas associated with fungal hyphae in a third. Typical morphology included hyphae, irregularly branched, thin-walled, occasionally septated and surrounded by a thick eosinophilic cuff (Splendore-Hoeppli phenomenon).

CONCLUSION

-Gastrointestinal basidiobolomycosis can be detected on small endoscopic biopsy. The unequivocal diagnosis requires microbiologic cultivation of the fungus obtained from tissues. The prognosis for this disease is usually favorable as seen in 3 of our cases; however, cases with fatal outcome are on record.

Mucocutaneous Splendore-Hoeppli phenomenon

Splendore-Hoeppli phenomenon (asteroid bodies) is the in vivo formation of intensely eosinophilic material (radiate, star-like, asteroid or club-shaped configurations) around microorganisms (fungi, bacteria and parasites) or biologically inert substances. This study presents a literature review concerning Splendore-Hoeppli reaction in the mucocutaneous diseases. It examines the histopathological features, nature and differential diagnosis of this reaction. It also discusses the mucocutaneous infections and the non-infective diseases associated with it. Available studies indicate that several mucocutaneous infections can generate Splendore-Hoeppli reaction. The fungal infections include sporotrichosis, pityrosporum folliculitis, zygomycosis, candidiasis, aspergillosis and blastomycosis. The bacterial infections include botryomycosis, nocardiosis and actinomycosis. The parasitic conditions include orbital pythiosis, strongyloidiasis, schistosomiasis and cutaneous larva migrans. In addition, Splendore-Hoeppli reaction may be seen with non-infective pathology such as hypereosinophilic syndrome and allergic conjunctival granulomas. The Splendore-Hoeppli reaction material comprises antigen-antibody complex, tissue debris and fibrin. Although the exact nature of this reaction is unknown, it is thought to be a localized immunological response to an antigen-antibody precipitate related to fungi, parasites, bacteria or inert materials. The characteristic formation of the peribacterial or perifungal Splendore-Hoeppli reaction probably prevents phagocytosis and intracellular killing of the insulting agent leading to chronicity of infection. To conclude, Splendore-Hoeppli reaction is a tell tale of a spectrum of infections and reactive conditions. The molecular pathways involved in the development of this reaction are open for future investigations.