Pediatric gastrointestinal basidiobolomycosis

Disseminated Gastrointestinal Basidiobolomycosis: A Case Report with Review of Diagnostic Clues

Introduction

Basidiobolomycosis is a rare fungal infection caused by an environmental saprophyte, Basidiobolus ranarum. It usually presents as a chronic subcutaneous infection; however, few cases of gastrointestinal involvement have been reported. The exact transmission route of gastrointestinal cases is not clear, and diagnosis always requires a high index of suspicion because it tends to mimic other inflammatory and neoplastic conditions. Case Report. A 31-year-old immunocompetent woman presented with abdominal pain and an advanced colon mass. She was completely well until about 1.5 years ago, when she underwent bariatric surgery. One year after surgery, chronic abdominal pain developed. A colonoscopy showed an ulcerative lesion in the descending colon, and the biopsy was in favor of ulcerative colitis. Despite immunosuppressive treatment, there was no improvement, and with worsening symptoms, more investigations revealed advanced colon mass with entrapment of the stomach and pancreas. Colonic mucosa biopsy and trucut biopsy of the mass showed just necrosis and acute inflammation; thus, she underwent exploratory laparotomy with colectomy, partial gastrectomy, distal pancreatectomy, and left nephrectomy. On pathologic examination, there was granulomatous inflammation plus the Splendore-Hoeppli phenomenon around fungal hyphae, which was diagnostic for gastrointestinal basidiobolomycosis. Previous pathology slides were reviewed and revealed a tiny focus of basidiobolomycosis. After 6 months of treatment with itraconazole, she is relatively well without any clinical or radiologic abnormalities.

Conclusion

Our case highlights the significance of suspicion for basidiobolomycosis in ulcerative and necrotic lesions with increased eosinophils, especially in the presence of abdominal mass and systemic eosinophilia.

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.

Colonic basidiobolomycosis presenting with intestinal obstruction and a normal eosinophil count

Gastrointestinal basidiobolomycosis (GIB), caused by Basidiobolus ranrum, is a rare fungal infection with a limited geographic distribution. The majority of the cases are reported from the warm areas of Arizona in USA, Saudi Arabia and Iran. We report a middle aged patient who was admitted to hospital with suspected metastatic colonic carcinoma. He presented with constipation, anorexia and weight loss. Computed tomography scan disclosed a mass involving the mid and distal sigmoid colon and hypodense lesion in hepatic segment IV. Excised tissue during a Hartmann's surgery showed an extensive eosinophil-rich transmural inflammation with mural necrotizing granulomas and several broad septated fungal hyphae. He was commenced on voriconazole following surgery. The diagnosis of basidiobolomycosis was established by histopathological examination. Since the diagnosis was not suspected preoperatively tissue culture for fungi was not collected. However molecular testing confirmed the diagnosis of GIB. Therapy involved a combination of surgical resection of the mass and prolonged voriconazole treatment. Increased awareness among physicians is needed for early diagnosis and treatment of GIB.

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.

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.

Visceral basidiobolomycosis: An overlooked infection in immunocompetent children

Visceral basidiobolomycosis is an unusual fungal infection of viscera caused by saprophyte Basidiobolus ranarum. It is very rare in healthy children and poses a diagnostic challenge due to the non-specific clinical presentation and the absence of predisposing factors. We report a case of gastrointestinal basidiobolomycosis in a 4-year-old healthy girl who presented with a short history of abdominal pain, bleeding per rectum, fever, and weight loss. The diagnosis was based on high eosinophilic count, classical histopathology findings of fungal hyphae (the Splendore-Hoeppli phenomenon), and positive fungal culture from a tissue biopsy. Fungal infection was successfully eradicated with a combined approach of surgical resection of the infected tissue and a well-monitored course of antifungal therapy. The atypical clinical presentation, diagnostic techniques, and the role of surgery in the management of a rare and lethal fungal disease in an immunocompetent child are discussed.

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.

Successful treatment of gastrointestinal basidiobolomycosis with voriconazole without surgical intervention

Basidiobolomycosis is a rare disease due to fungus Basidiobolus ranarum, an environmental saprophyte that is found worldwide, though mainly reported in the tropical and subtropical regions. Basidiobolomycosis is an unusual fungal skin infection, rarely involves the gastrointestinal (GI) tract. Most of the cases of paediatric GI basidiobolomycosis (GIB) were reported from the southern region of Saudi Arabia. We report an 11-year-old Saudi boy. He presented with a huge right lower quadrant abdominal mass and marked eosinophilia. Abdominal computed tomography scan revealed a large caecal mass. A biopsy was taken and it showed transmural granulomatous inflammation. A diagnosis of GIB was confirmed by specific features in histopathology. Most of the reported paediatric cases with GIB required adjuvant therapy of antifungal and surgical resection. In our case, treatment with voriconazole alone for 1 year was successful with complete recovery and with no recurrence after a year of discontinuing the treatment.

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.

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.

Fungal infections of the gastrointestinal tract in the immunocompromised host: an update

Fungal infections are one of the most significant causes of morbidity and mortality in immunocompromised patients. The incidence of invasive fungal infections, including those of the gastrointestinal tract, has increased significantly as numbers of immunocompromised patients have increased. The diagnosis of fungal infections in immunocompromised patients may be particularly problematic as these patients may present with atypical clinical features. Although Candida and Aspergillus species represent the majority of fungi diagnosed in the immunocompromised patient population, other fungi are emerging as increasingly common pathogens, and this review will focus on several important emerging fungal infections in immunocompromised patients.

Perforated appendicitis with gastrointestinal basidiobolomycosis: a rare finding

Background: Basidiobolomycosis is a rare fungal infection caused by the fungus Basidiobolus ranarum. Gastrointestinal basidiobolomycosis (GIB) is an unusual presentation of the fungal infection that is reported sparsely in the literature, but is an emerging infection in the southwestern United States. Lack of awareness of GIB has resulted in its delayed diagnosis and in extensive morbidity and mortality in patients with GIB.

METHODS

Case report and literature review.

CASE REPORT

We report the rare case of a young female with GIB that presented as perforated appendicitis with abscess formation.

CONCLUSION

Although GIB is rare, immediate and aggressive therapy should be initiated when it is diagnosed. Both long-term medical and surgical treatment is required for its definitive management.

Gastrointestinal basidiobolomycosis: mimicking Crohns disease case report and review of the literature

Gastrointestinal basidiobolomycosis (GIB) is an unusual fungal infection that manifests in the skin and rarely involves other systems. All of the few cases of GIB reported so far were diagnosed with difficulty, necessitating laparotomy and resection of the inflamed part of the bowel. We report a child with GIB who was successfully diagnosed endoscopically without surgical intervention.

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.

Eosinophilic granulomatous gastrointestinal and hepatic abscesses attributable to basidiobolomycosis and fasciolias: a simultaneous emergence in Iraqi Kurdistan

Background

Deep eosinophilic granulomatous abscesses, as distinguished from eosinophilic subcutaneous abscesses, are rare. Most reports are from the Far-East and India where the most commonly attributed cause is Toxocara. Sulaimaniyah in Northeastern Iraq has experienced an outbreak of eosinophilic granulomatous liver and gastrointestinal (GI) abscesses beginning in 2009. The purpose of this study was to determine the etiology and guide treatment.

Methods

The study was an ongoing investigation of patients having a histopathologic diagnosis of eosinophilic granulomatous abdominal abscesses in Sulaimaniyah hospitals from May 2009 to August 2012. Tissues were examined for organisms, and Enzyme Linked Immunoabsorbent Assays (ELISA) were performed for serum antibodies to Fasciola hepatica, Toxocara, and Echinococcus granulosus.

Results

Fourteen patients had granulomatous inflammation surrounding a central necrotizing eosinophilic exudate identified in surgical pathology specimens from abdominal surgeries. Two children and four adults had abscesses that formed GI masses. These patients included a 39 year old male with oropharyngeal and transverse colon disease, and a 48 year old male with liver and GI abscesses. All sites demonstrated a Zygomycete fungus surrounded by eosinophilic Splendori-Hoeppli material consistent with basidiobolomycosis. Five of the six patients with fungal disease were treated by surgery and 4 to 7 months of itraconozol. One child died of intestinal perforation while receiving IV amphotericin B; two adults required additional surgery for recurrent GI obstruction. Eight patients had isolated liver abscesses with no organisms identified by histopathology: ELISA results for F. hepatica were positive for five, borderline for one, and negative for two patients. These eight patients were treated for fascioliasis by surgical resection of localized abscesses and albendazol. One patient serologically positive for F. Hepatica was found to have a common duct fluke two years after initial diagnosis. Serological testing for Toxocara and Echinococcus granulosus was negative in all 14 patients.

Conclusions

Basidiobolomycosis and F. hepatica are implicated as the cause of abdominal eosinophilic granulomatous abscesses in 12 of 14 patients identified over a period of 40 months in northern Iraq. Treatment was complicated by chronic biliary tract disease in fascioliasis and perforation and recurrent intestinal obstruction with basidiobolomycosis.

Surgical management of gastrointestinal basidiobolomycosis in pediatric patients

INTRODUCTION

Gastrointestinal basidiobolomycosis (GIB) is a rare fungal disease. We reviewed our experience with this disease over the last 10 years, with special emphasis on the surgical aspects.

METHODS

A retrospective chart review was conducted for pediatric patients with GIB who were managed at our institution over the last 10 years. Demographic, clinical, and follow-up data were collected, and descriptive data were generated.

RESULTS

Nine patients with a median age of 7 years were managed for GIB over the study period. Six patients were managed surgically. Four had colonic and liver involvement, 1 had a left hepatic lesion, and 1 had a porta hepatic mass. One patient had multiple liver lesions and was managed medically, and 2 patients had disseminated disease and died shortly after presentation. Tissue biopsies confirmed the diagnosis, and all received antifungal treatment. Patients were followed up for a median of 6 years. All live patients are free of disease, and 4 are still on antifungal medications.

CONCLUSIONS

Gastrointestinal basidiobolomycosis is an aggressive disease that requires early surgical intervention to avoid complications and hasten disease eradication. Long-term follow-up is warranted, given the significant potential for complications.

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.

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.

Histological and ultrastructural features of gastrointestinal basidiobolomycosis

Basidiobolus ranarum is a fungus found in the dung of amphibians, reptiles, and insectivorous bats. Its structural elements include both hyphae and zygospores. Patients with B. ranarum infection may present with subcutaneous, gastrointestinal, or systemic lesions. Here we report a case of gastrointesinal badidiomycosis in a 13-year-old male child who presented with acute abdomen. Exploration revealed a mass in the ascending colon. On histology, transmural granulomatous inflammation composed of abundant eosinophils, lymphocytes, histiocytes and giant cells was seen. Histochemical stains revealed broad, non-septate, hyphae-like structures surrounded by an eosinophilic sheath. On an ultrastructural level, fungal hyphae, spores, and macrophage-laden crystalloids were observed. The diagnosis of gastrointestinal basidiobolomycosis was established and the patient received antifungal treatment. This paper reviews the relevant literature regarding basidiomycosis, and discusses its diverse clinicopathological features, as well as distinguishing it from other diseases.

Gastrointestinal zygomycosis: a report of three cases

Three cases of gastrointestinal zygomycosis, probably caused by Basidiobolus ranarum, are described. The diagnosis was based on morphology of the fungal elements in infected tissues and histopathologic findings. All the three patients responded favorably to management strategy that included surgical resection of the infected portion of the bowel and institution of specific antifungal therapy.

[Zygomycetes in biopsies of the gastrointestinal tract]

Zygomycosis (Mucor- and Entomophtoramycosis) of the gastrointestinal tract is rare compared to other mycoses in the gastrointestinal area. The infection occurs mainly in immunosuppressed patients but rare cases concerning immunocompetent persons are also documented. Zygomycosis occurs in the gastrointestine primarily or due to disseminated disease. We report on a 48-year-old female alcohol-addicted patient who underwent gastric biopsies. The biopsy results showed invasive zygomycosis. Shortly thereafter, the patient died of sepsis. The second case presented here is a 15-year-old female patient with recurrent vomiting. Histological and immunohistochemical analysis of duodenal biopsy specimens revealed fungi of the class Zygomycetes. In addition, histological and/or microbiological examination demonstrated the presence of Candida in both cases.Zygomycosis of the gastrointestinal tract can have an aggressive course, making it important to know the morphological characteristics of the disease to facilitate early diagnosis and therapy. This is all the more important because the cultivation of fungi, as in our cases, is not always successful.

A fatal pseudo-tumour: disseminated basidiobolomycosis

BACKGROUND

Basidiobolomycosis is a rare disease caused by the fungus Basidiobolus ranarum, member of the class Zygomycetes, order Entomophthorales, found worldwide. Usually basidiobolomycosis is a subcutaneous infection but rarely gastrointestinal manifestations have been described; 13 adults and 10 children and a few retroperitoneal or pulmonary cases. In gastrointestinal basidiobolomycosis the colon is most frequently involved, usually presenting with subacute mild abdominal pain. In contrast to children only very few described adult patients had hepatic masses. Definitive diagnosis requires culture, serological testing can be helpful. The fungal morphology and the Splendore-Hoeppli phenomenon are characteristic histological features. There are no prominent risk factors. Usually surgery and prolonged antifungal therapy are required.

CASE PRESENTATION

A 61 year old man presented with progressive left abdominal pain and constipation since a few months. Colonoscopy showed an obstructing tumour in the descending colon, and a hemicolectomy was performed. Histology showed inflammation, possibly caused by a fungal or parasitic infection, without definite identification of an organism. A few weeks postoperatively a CT scan made because of abdominal discomfort, revealed a livermass (6 cm). Treatment with metronidazole, directed against an amoebic liver abscess, was unsuccessful. He developed a marked eosinophilia (27.7%). A liver biopsy was performed and the patient was referred to a university hospital.A repeated CT scan showed a livermass of 9 cm diameter. Review of colon and liver biopsy samples showed extensive necrosis and histiocytes, multinucleated giant cells and numerous eosinophils. Grocott stained sections contained unusually large hyphae surrounded by strongly eosinophilic material in haematoxylin and eosin stained sections (Splendore-Hoeppli phenomenon). A presumptive diagnosis of Basidiobolus spp. infection was made and treated with amphotericin B (Itraconazol contra-indicated because of renal insufficiency). A few days later the patient died of a septic shock. After autopsy Basidiobolus ranarum was cultured from liver, gallbladder and colon.

CONCLUSION

Our patient died of gastrointestinal basidiobolomycosis with an obstructing colon tumour and a large hepatic mass. This was a rare presentation of basidiobolomycosis and the second fatal case described worldwide.

Eosinophilia: Causes and pathobiology in persons with prior exposures in tropical areas with an emphasis on parasitic infections

Eosinophilia in patients exposed to tropical or subtropical environments is caused most commonly by helminth (worm) infections. Besides a detailed exposure history, the diagnostic approach must consider other infections and noninfectious causes of eosinophilia, as treatments for many of these disorders differ.

Management of rare fungal infections

PURPOSE OF REVIEW

Fungal infections caused by rare fungi have increased in recent years. This may be due to the increase in the number of immunocompromised patients. Some rare fungi are geographically restricted, but with globalization and travel these infections are seen worldwide. The aim of this review is to address recent advances in the management of some uncommon fungal infections.

RECENT FINDINGS

Dematiaceous fungi (Phaeohyphomycetes) have been reported in both immunocompromised and immunocompetent individuals. Cerebral involvement and disseminated disease are associated with high mortality rates. Surgical excision and broad-spectrum triazole antifungal therapy are associated with better outcomes. Mucormycosis in diabetic and immune-suppressed patients is associated with high mortality. Early radical surgical debridement and amphotericin B-based regimens are a key to success. Basidiobolomycosis has recently been reported to cause chronic granulomatous infection of the gastrointestinal tract. Treatment with itraconazole and surgical resection is associated with favourable outcomes. Invasive fusariosis in cancer patients is typically resistant to most antifungal agents, but recent data have suggested a response to voriconazole. Voriconazole also demonstrated activity against Scedosporium apiospermum, but was less active against Scedosporium prolificans. Amphotericin B and itraconazole are currently the treatments of choice for the southeast Asian fungus, Penicillium marneffie.

SUMMARY

Parallel to the increased number of patients susceptible to invasive infections has been an increase in the number of broad-spectrum antifungal agents allowing for better therapeutic options. High-quality data are lacking because of the rarity of such infections. In future, new triazoles and echinocandins will probably replace amphotericin B as the first therapeutic choice for many uncommon fungal infections.