Neonatal gastrointestinal mucormycosis mimicking necrotizing enterocolitis

Nissen, MD; Jana, A K; Cole, Michelle; Jm, Grierson; Gilbert, G. L.

doi:10.1080/080352599750030464

Cited by 8 publications

(14 citation statements)

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“…It has mostly occurred in premature neonates and is often associated with disseminated diseases (8,18,35,41). Necrotizing enterocolitis was found in premature neonates (29,43,63) and less frequently in neutropenic adults (47,48). All of our five cases of invasive intestinal zygomycosis had severe necrotizing ileocecitis leading to intestinal perforation with or without retroperitoneal necrosis, which was in contrast to the classical reports of the stomach being the most frequently involved site in adults with gastrointestinal zygomycosis (32).…”

Section: Discussionmentioning

confidence: 99%

Outbreak of Intestinal Infection Due to Rhizopus microsporus

Cheng

Chan²,

Ngan³

et al. 2009

J Clin Microbiol

117

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Sinopulmonary and rhinocerebral zygomycosis has been increasingly found in patients with hematological malignancies and bone marrow transplantation, but intestinal zygomycosis remains very rare in the literature. We investigated an outbreak of intestinal infection due to Rhizopus microsporus in 12 patients on treatment for hematological malignancies over a period of 6 months in a teaching hospital. The intake of allopurinol during hospitalization (P < 0.001) and that of commercially packaged ready-to-eat food items in the preceding 2 weeks (P < 0.001) were found to be independently significant risk factors for the development of intestinal zygomycosis. A total of 709 specimens, including 378 environmental and air samples, 181 food samples, and 150 drug samples, were taken for fungal culture. Among them, 16 samples of allopurinol tablets, 3 prepackaged ready-to-eat food items, and 1 pair of wooden chopsticks were positive for Rhizopus microsporus, which was confirmed by ITS1-5.8S-ITS2 rRNA gene cluster (internal transcribed spacer [ITS]) sequencing. The mean viable fungal counts of allopurinol obtained from wards and pharmacy were 4.22 ؋ 10 3 CFU/g of tablet (range, 3.07 ؋ 10 3 to 5.48 ؋ 10 3 ) and 3.24 ؋ 10 3 CFU/g of tablet (range, 2.68 ؋ 10 3 to 3.72 ؋ 10 3 ), respectively, which were much higher than the mean count of 2 ؋ 10 2 CFU/g of food. Phylogenetic analysis by ITS sequencing showed multiple clones from isolates of contaminated allopurinol tablets and ready-to-eat food, of which some were identical to patients' isolates, and with one isolate in the cornstarch used as an excipient for manufacture of this drug. We attempted to type the isolates by random amplification of polymorphic DNA analysis, with limited evidence of clonal distribution. The primary source of the contaminating fungus was likely to be the cornstarch used in the manufacturing of allopurinol tablets or ready-to-eat food. Rhizopus microsporus is thermotolerant and can multiply even at 50°C. The long holding time of the intermediates during the manufacturing process of allopurinol amplified the fungal load. Microbiological monitoring of drugs manufactured for highly immunosuppressed patients should be considered.Zygomycosis has become an important emerging infection in patients with hematological malignancy undergoing chemotherapy or bone marrow transplantation (24), especially with the availability of voriconazole as antifungal prophylaxis (25,28,44). Breakthrough zygomycosis in patients on voriconazole prophylactic treatment is usually manifested as sinopulmonary or rhinocerebral disease, since the fungal spores are ubiquitously found in the environment and could therefore be acquired through inhalation or traumatic inoculation through the skin or mucosa. Gastrointestinal zygomycosis has been a rare clinical entity (50, 54), but cases or outbreaks of tongue, gastric, or cutaneous zygomycosis due to Rhizopus microsporus after exposure to contaminated wooden tongue depressors have been reported (23,26,33).The Rhizopus microsporus species gr...

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Section: Discussionmentioning

confidence: 99%

Outbreak of Intestinal Infection Due to Rhizopus microsporus

Cheng

Chan²,

Ngan³

et al. 2009

J Clin Microbiol

117

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“…In particular, gastrointestinal mucormycosis has been seen in premature neonates, often in association with widespread disseminated disease (6,27,71,76,128,137). Necrotizing enterocolitis has been described largely in premature neonates (35,71,106,128,139,157,174,177) and more rarely in neutropenic adults (146,152). Rare cases of gastrointestinal mucormycosis have been described in association with other immune-compromising conditions, including AIDS (19), systemic lupus erythematosus (55), and organ transplantation (77,95,97,138).…”

Section: Epidemiology and Disease Manifestationsmentioning

confidence: 99%

Novel Perspectives on Mucormycosis: Pathophysiology, Presentation, and Management

2005

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Mucormycosis is a life-threatening fungal infection that occurs in immunocompromised patients. These infections are becoming increasingly common, yet survival remains very poor. A greater understanding of the pathogenesis of the disease may lead to future therapies. For example, it is now clear that iron metabolism plays a central role in regulating mucormycosis infections and that deferoxamine predisposes patients to mucormycosis by inappropriately supplying the fungus with iron. These findings raise the possibility that iron chelator therapy may be useful to treat the infection as long as the chelator does not inappropriately supply the fungus with iron. Recent data support the concept that high-dose liposomal amphotericin is the preferred monotherapy for mucormycosis. However, several novel therapeutic strategies are available. These options include combination therapy using lipid-based amphotericin with an echinocandin or with an azole (largely itraconazole or posaconazole) or with all three. The underlying principles of therapy for this disease remain rapid diagnosis, reversal of underlying predisposition, and urgent surgical debridement

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“…In childhood gastrointestinal mucormycosis, stomach is the most commonly involved organ [5], whereas in neonates, the colon is predominantly involved. Alexander P et al have reported 3 babies with colonic necrosis with multiple perforations [2].…”

Section: Discussionmentioning

confidence: 99%

“…To conclude, colonic mucormycosis should be suspected in any preterm neonate with clinico-radiological features of NEC and non-response to conservative line of management involving antibacterial therapy [5]. As the diagnosis is based on histological examination, in most of the cases, maintaining strict aseptic precautions in neonatal nurseries, a high index of suspicion for mucormycosis, early laparotomy, aggressive surgical debridement, early processing of the specimen for histopathological evaluation and early institution of antifungal drugs would go a long way in treating these neonates.…”

Section: Discussionmentioning

confidence: 99%

“…Also, they receive broad-spectrum intravenous antibiotics, which affect healthy gastrointestinal flora; and they are often given steroids to assist weaning off from the ventilator [3]. Interventions such as oro-gastric tube placement [4], endotracheal intubation, and Indomethacin therapy are speculated to increase risk of contracting gastrointestinal mucormycosis by causing mucosal injury [5].…”

Section: Discussionmentioning

confidence: 99%

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A Rare Case of Neonatal Colonic Mucormycosis

Bhosale¹

2017

JPNC

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Mucormycosis of the neonatal gut is a rare disease, with uniformly fatal prognosis. It has occasionally been reported involving the stomach and ileum in immunocompromised hosts. However, mucormycosis of the colon is very rare. We report case of a preterm, low birth weight (LBW) neonate with clinical features of Necrotising enterocolitis found to have characteristic black-velvety colonic gangrene on exploratory laparotomy. The baby initially improved but succumbed to sepsis eventually. Tissue histology diagnosed mucormycosis of the colon. The diagnosis of colonic mucormycosis was unsuspected. This report is presented to create awareness about this rare entity so that it is suspected and diagnosed early.Keywords: Colon; Mucormycosis; Neonate; Low Birth Weight; Necrotising EnterocolitisNeonatal gastrointestinal mucormycosis is a rare, opportunistic fungal infection, with dismal prognosis. Since, the diagnosis is based on histopathological examination of the resected segment (specimen) of stomach and/or bowel, it cannot be diagnosed preoperatively [1,2]. These cases are initially diagnosed as Necrotising enterocolitis (NEC), but later on are confirmed as gastrointestinal (colonic) mucormycosis. Hence, there is delay in specific treatment. Case ReportEight-day-old male neonate was admitted in neonatal intensive care unit (NICU) for preterm care. He was born vaginally to an adolescent primigravida mother at 32 weeks gestational age. His birth weight was 1.2 Kg. The mother had received regular antenatal care and had no identifiable risk factors. Baby had not cried immediately following spontaneous vaginal delivery and had required bag and mask ventilation. There were no obvious congenital anomalies. He was on oral Sildenafil for management for pulmonary hypertension.On tenth day of life, he developed feeding intolerance and per rectal bleeding. A soft to firm lump of about 2×3 cm size was palpable in the right hypochondriac region. Nasogastric tube aspirate was bilious. Erect X-ray abdomen showed dilated stomach with paucity of gas in lower abdomen and pelvis (Figure 1). Dye study done for confirmation of diagnosis showed the same picture i.e. only gastric shadow could be visualized. Ultrasonography of the abdomen showed dilated, peristaltic bowel loops. Haematologic investigations showed raised WBC counts of 16,000/cmm and low Platelet count of 100,000/cmm. The differential diagnosis was malrotation with volvulus or Necrotising enterocolitis. In view of poor general condition, the child was explored under local anaesthesia. He had characteristic black-velvety gangrene confined to middle 8-10 cm of the mid-transverse colon without any frank / impending perforation. Initial 5-7 cm of midtransverse colon from the hepatic flexure was normal. Rest of the colon and small bowel was healthy looking. The non-viable colon was excised. After resection, the free ends were brought out as colostomy and mucus fistula through either end of the incision. Blood loss of about 20 cc was replaced on table. Postoperatively the acti...

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Neonatal gastrointestinal mucormycosis mimicking necrotizing enterocolitis

Cited by 8 publications

References 0 publications

Outbreak of Intestinal Infection Due to Rhizopus microsporus

Outbreak of Intestinal Infection Due to Rhizopus microsporus

Novel Perspectives on Mucormycosis: Pathophysiology, Presentation, and Management

A Rare Case of Neonatal Colonic Mucormycosis

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