Mucormycosis causing massive lower gastrointestinal bleeding: a case report

Abstract

Background Lower gastrointestinal bleeding (LGIB) is very common in the hospital setting. Most bleedings stop spontaneously, but rare infectious causes of LGIB may lead to rapid and serious complications if left untreated and are sometimes very difficult to diagnose preoperatively. Case presentation We described a young man with poorly controlled Type I diabetes mellitus and chronic alcohol abuse who presented with acute altered mental status. During his hospitalization for treatment of diabetic ketoacidosis, acute renal failure, and sepsis, he suddenly developed massive hematochezia of 1500 mL. Colonoscopy was performed and a deep ulcer covered with mucus with peripheral elevation was noted at the transverse colon. Biopsy of the ulcer later revealed nonpigmented, wide (5–20 µm in diameter), thin-walled, ribbon-like hyphae with few septations and right-angle branching suggestive of mucormycosis demonstrated by Periodic acid–Schiff stain. He received 2 months of antifungal treatment. Follow up colonoscopy post-treatment was normal with no ulcer visualized. Conclusions Early diagnosis and treatment of gastrointestinal (GI) mucormycosis infection is critical but can be challenging, especially in the setting of massive hematochezia. Therefore, clinical awareness for immunocompromised patients and prompt antifungal prophylaxis in cases with high suspicion of infection are essential.

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

“…Within the GI tract, the stomach is the most common site of infection (67%), followed by the colon (21%), small intestine (4%) and esophagus (2%). 1,2,6 For our patient, the locations were a gastric and colonic. Given the rapid evolution of GI mucormycosis, the prognosis is poor with a very high mortality rate, approximately 85%.…”

“…Posaconazole has generally been recommended as maintenance and salvage therapy. 6 , 11 , 18 Isavuconazole, a novel triazole with available oral and intravenous formulations, showed at least partial activity against different strains of Mucorales. 19 A recently conducted open-label Phase 3 study evaluated 37 cases of mucormycosis (21 patients receiving primary therapy, 11 for refractory disease and 5 for intolerance); 31% of overall response, 32% in the primary treatment group, and 36% in patient’s refractory to other antifungal treatments.…”

“…7 The genera Rhizopus are by far the most frequently found. [1][2][3][4][5][6][7][8]11 Mucormycosis can present with different clinical manifestations: rhino-cerebral (39%), pulmonary (24%), cutaneous (19%) and the disseminated form (23%). [1][2][3][4][5][6][7][8]11 Among these manifestations, the GI form remains uncommon and rarely diagnosed in living patients.…”

“…This GI form represents only 7% of reported cases. [1][2][3][4][5][6][7][8]11,12 Diseases of the GI tract are usually acquired by ingestion of contaminated food or by infection of an implanted device. Within the GI tract, the stomach is the most common site of infection (67%), followed by the colon (21%), small intestine (4%) and esophagus (2%).…”

“…2,5 The prognosis of GI mucormycosis is often poor due to delayed diagnosis because of its atypical manifestations requiring a long diagnostic process. 2,[4][5][6] Despite the intensive use of antifungal therapy and surgical debridement, the mortality rate of adult patients varies from 20% to 100%. 2,5 We report a case of GI mucormycosis presenting as massive hematochezia, multiple gastric ulcers and rectal perforation in a 75-year-old man with type II diabetes mellitus.…”