Survival with early diagnosis of invasive gastric mucormycosis in a heart transplant patient

Gastric mucormycosis complicated by a gastropleural fistula: A case report and review of the literature

RATIONALE

Mucormycosis is a rare opportunistic fungal infection with poor prognosis. The incidence of mucormycosis has been increasing, and it is a threat to immunocompromised hosts. We present a case of gastric mucormycosis complicated by a gastropleural fistula during immunosuppressive treatment for adult-onset Still disease (AOSD).

PATIENT CONCERNS

An 82-year-old woman diagnosed with AOSD who developed gastric ulcers during the administration of an immunosuppressive therapy with corticosteroids, cyclosporine, and tocilizumab complained of melena and epigastralgia. Esophagogastroduodenoscopy showed multiple ulcers covered with grayish or greenish exudates.

DIAGNOSES

The patient diagnosed with mucormycosis based on culture and biopsy of the ulcers, which showed nonseptate hyphae branching at wide angles. Mucor indicus was identified using polymerase chain reaction.

INTERVENTIONS AND OUTCOMES

Although liposomal amphotericin B was administered, gastric mucormycosis was found to be complicated by a gastropleural fistula. The patient died because of pneumonia due to cytomegalovirus infection, and autopsy revealed the presence of Mucorales around the fistula connecting the stomach and diaphragm.

LESSONS

Gastric mucormycosis is refractory to treatment and fatal. Surgical resection, if possible, along with antifungal drugs can result in better outcomes.

Gastrointestinal mucormycosis in immunocompromised hosts

Invasive mucormycosis is a rare fungal infection in immunocompromised hosts, but it carries a high mortality rate. Primary gastrointestinal disease is the least frequent form of presentation. Early diagnosis and treatment are critical in the management; however, symptoms are typically non-specific in gastrointestinal disease, leading to delayed therapy. To describe the clinical presentation, diagnosis, treatment and outcomes of gastrointestinal mucormycosis in immunocompromised hosts, we reviewed all cases of primary gastrointestinal mucormycosis in immunocompromised hosts reported in English literature as well as in our Institution from January 1st 1991 to December 31st 2013 for a total of 31 patients. About 52% of patients underwent solid organ transplant (SOT), while the rest had an underlying haematologic malignancy. Abdominal pain was the most common presenting symptom, followed by gastrointestinal bleeding and fever. Gastric disease was more common in SOT, whereas those with haematologic malignancy presented with intestinal disease (P = 0.002). Although gastrointestinal mucormycosis remains an uncommon condition in immunocompromised hosts, it carries significant morbidity and mortality, particularly in cases with intestinal involvement. A high index of suspicion is of utmost importance to institute early and appropriate therapy and improve outcomes.

Zygomycosis in solid organ transplant recipients in a tertiary transplant center and review of the literature

Zygomycetes are ubiquitous fungi that can cause invasive disease associated with high mortality. We report 10 solid organ transplant recipients with zygomycosis (incidence 2 per 1000) and reviewed 106 cases in the English-language literature. These included renal (n = 73), heart (n = 16), lung (n = 4), heart/lung (n = 2), liver (n = 19) and kidney/pancreas (n = 2) transplant recipients. All patients were receiving immunosuppression and the vast majority steroids. The clinical presentation included rhino-sino-orbital (n = 20), rhinocerebral (n = 16), pulmonary (n = 28), gastrointestinal (n = 13), cutaneous (n = 18), renal (n = 6) and disseminated disease (n = 15). Most frequently isolated genera were Rhizopus (73%) followed by Mucor (13%). The overall mortality was 49%. While rhino-sino-orbital disease had the best prognosis, rhinocerebral disease had high mortality (93%) comparable to disseminated disease. A favorable outcome was associated with limited, surgically accessible disease and early surgical intervention along with amphotericin B administration.

Outbreak of gastric mucormycosis associated with the use of wooden tongue depressors in critically ill patients

OBJECTIVE

To describe a nosocomial outbreak of gastric mucormycosis caused by Rhizopus microsporus var. rhizopodiformis in five adult patients admitted to an intensive care unit (ICU).

DESIGN

Epidemiological surveillance study.

SETTING

A 12-bed polyvalent ICU of an acute care teaching hospital in Pamplona, Spain.

PATIENTS

Five patients admitted to the ICU requiring artificial ventilation, diagnosis on admission severe pneumonia in four patients and one polytrauma patient, within a 14-week period, were diagnosed with gastric mucormycosis based on microbiological and/or histopathological characteristics. Upper gastrointestinal bleeding was the presenting manifestation in 80% of patients.

INTERVENTIONS

Filamentous fungi isolated at the microbiology laboratory of the hospital were examined at the national Mycology Reference Laboratory in Madrid.

MEASUREMENTS AND RESULTS

Rhizopus microsporus var. rhizopodiformis growth was detected in gastric aspiration samples, environmental samples, wooden tongue depressors used to prepare oral medications (and given to patients through a nasogastric catheter), and in some tongue depressors stored in unopened boxes unexposed to the ICU environment. All depressors were purchased from the same supplier. R. microsporus was not isolated from batches purchased at different times from the same supplier and from another supplier. The outbreak terminated when contaminated tongue depressors were withdrawn from use.

CONCLUSIONS

Wooden tongue depressors contaminated by R. microsporus var. rhizopodiformis used to prepare oral medications caused an outbreak of fungal gastritis with an attributable mortality of 40%. Wooden material should not be used in the hospital setting.

Mucormycosis and entomophthoramycosis: a review of the clinical manifestations, diagnosis and treatment

The class Zygomycetes is divided into two orders, Mucorales and Entomophthorales. These two orders produce dramatically different infections. Genera from the order Mucorales (Rhizopus, Mucor, Rhizomucor, Absidia, Apophysomyces, Cunninghamella and Saksenaea) cause an angioinvasive infection called mucormycosis. Mucormycosis presents with rhino-orbito-cerebral, pulmonary, disseminated, cutaneous, or gastrointestinal involvement. Immunocompromising states such as haematological malignancy, bone marrow or peripheral blood stem cell transplantation, neutropenia, solid organ transplantation, diabetes mellitus with or without ketoacidosis, corticosteroids, and deferoxamine therapy for iron overload predispose patients to infection. Mucormycosis in immunocompetent hosts is rare, and is often related to trauma. Mortality rates can approach 100% depending on the patient's underlying disease and form of mucormycosis. Early diagnosis, along with treatment of the underlying medical condition, surgery, and an amphotericin B product are needed for a successful outcome. Genera from the order Entomophthorales produce a chronic subcutaneous infection called entomophthoramycosis in immunocompetent patients. This infection occurs in tropical and subtropical climates. The genus Basidiobolus typically produces a chronic subcutaneous infection of the thigh, buttock, and/or trunk. Rarely, it has been reported to involve the gastrointestinal tract. The genus Conidiobolus causes a chronic infection of the nasal submucosa and subcutaneous tissue of the nose and face. This paper will review the clinical manifestations, diagnosis and treatment of mucormycosis and entomophthoramycosis.