Gastric Perforation Secondary to Invasive Gastric Mucormycosis: A Case Report

Author(s):
Oscar A. Olavarria; Karla Bernardi; Hanadi S. El-Achi; Darryl Duncan; Joshua Person; Stefanos Millas; Tien Ko; Lillian Kao; Mike Liang

Background:

Mucormycosis is a rare opportunistic fungal infection associated with high mortality in immunocompromised patients. Rhinocerebral and pulmonary infections are the most common, while primary gastrointestinal (GI) mucormycosis is unusual and rarely presents as gastric perforation.

Hypothesis:

We report a rare case of gastric perforation secondary to invasive gastric mucormycosis.

Methods:

N/A

Results:

A 54 year-old female with diabetes mellitus (glycosylated hemoglobin of 6.9%), hypoalbuminemia (albumin of 0.8mg/dL), and chronic kidney disease, presented with 4 days of headaches, photophobia and phonophobia. The patient was diagnosed with miliary tuberculosis (TB) and TB meningitis through a positive quantiferon gold test, diffuse micronodular pulmonary lesions on computed tomography (CT), and multiple ring-shaped lesions on magnetic resonance imaging of her brain. She was started on a combination of anti-TB drugs and dexamethasone. Following 30 days of admission, the patient developed acute abdominal pain which progressed to peritonitis. CT abdomen/pelvis demonstrated a large fluid collection posterior to the stomach and free intraperitoneal air. On emergent exploratory laparotomy the stomach was found to be necrotic with a perforation along the greater curvature. Upper endoscopy confirmed full-thickness necrosis of the stomach but normal esophagus and duodenum. A total gastrectomy was performed but due to hypotension and coagulopathy, the GI tract was left in discontinuity and the patient was transferred to the ICU with a temporary abdominal closure. Broad spectrum antibiotics and antifungal were added. In 48 hours a diverting loop cervical esophagostomy, jejunostomy tube placement, and abdominal wall closure were performed. Surgical pathology was consistent with angioinvasive mucormycosis, therefore, patient was switched to amphotericin B. However, despite aggressive efforts, the fungus continued to disseminate, and the patient ultimately expired of sepsis and multiorgan failure.

Conclusions:

Despite aggressive surgical intervention, antimicrobial therapy and critical care, GI mucormycosis has a rapid progression and is associated with high mortality.