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Ileal Mucormycosis Causing Bleeding in Necrotizing Pancreatitis

McDonald, Nicholas M. MD1; Engler, Conrad F. DO2; Amateau, Stuart K. MD, PhD2

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doi: 10.14309/crj.0000000000000165
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CASE REPORT

A 60-year-old man with a history of type 2 diabetes mellitus and with gallstone pancreatitis was admitted to an outside institution. He underwent endoscopic retrograde cholangiopancreatography with biliary sphincterotomy and placement of a common bile duct stent. The patient was transferred to our institution after he developed necrotizing pancreatitis complicated by anuric renal failure requiring hemodialysis. His pancreatitis was conservatively managed. Eleven days following endoscopic retrograde cholangiopancreatography, the patient developed hematochezia with an associated hemoglobin decrease from 9.4 to 7.1 g/dL. Computed tomography demonstrated subtle ileal wall thickening (Figure 1). Esophagogastroduodenoscopy revealed no post-sphincterotomy bleeding or other etiologies to explain his anemia. Colonoscopy revealed an inflamed terminal ileum with friable mucosa containing stigmata of recent bleeding and was extensively biopsied (Figure 2). Histopathology displayed numerous branching hyphal elements, and fungal polymerase chain reaction testing was positive for Rhizopus (Figure 3). The patient was initiated on posaconazole and may ultimately require surgical resection of the affected bowel.

Figure 1.
Figure 1.:
Abdominal computed tomography showing subtle ileal wall thickening (circle).
Figure 2.
Figure 2.:
Colonoscopy showing an inflamed terminal ileum with friable mucosa containing stigmata of recent bleeding (arrows).
Figure 3.
Figure 3.:
Histopathology of the biopsy showing numerous branching hyphal elements. Fungal polymerase chain reaction testing was positive for Rhizopus.

Rhizopus is a genus within the mucoraceae family of fungi. These organisms are commonly found in soil, decaying vegetable matter, and bread. Rhizopus are generally harmless to an immunocompetent host but cause opportunistic infections in immunocompromised hosts. Classically, they have been associated with pulmonary, nasal, and orbital infections. Those who develop mucormycosis often have risk factors such as chronic steroid use, HIV, diabetes, or solid organ transplantation.1,2 However, there has been a rising incidence of mucormycosis occurring in otherwise immunocompetent adults.3 While the gastrointestinal tract is less commonly affected than the pulmonary system, gastric and colonic involvement has been described. If the gastrointestinal tract is involved, the most common site of involvement is the stomach, followed by the colon and ileum.1 The most common symptoms include nausea, vomiting, fever, and hematochezia, but depend upon the affected site.1 Management involves treating the underlying predisposing condition, minimizing immunosuppressive medications if possible and antifungal agents. Generally, antifungal therapy alone is inadequate to control the infection, and patients often require operative management to debulk the infected tissue.1 Even with maximal medical and surgical therapy, mucormycoses are often very challenging to treat and recalcitrant infections.

DISCLOSURES

Author contributions: NM McDonald and CF Engler wrote the manuscript. All authors edited the manuscript. SK Amateau is the article guarantor.

Financial disclosure: None to report.

Informed consent was obtained for this case report.

REFERENCES

1. Spellberg B. Gastrointestinal mucormycosis: An evolving disease. Gastroenterol Hepatol. 2012;8(2):140–2.
2. Roden MM, Zaoutis TE, Buchanan WL, et al. Epidemiology and outcome of zygomycosis: A review of 929 reported cases. Clin Infect Dis. 2005;41(5):634–53.
3. Kaur H, Ghosh A, Rudramurthy SM, et al. Gastrointestinal mucormycosis in apparently immunocompetent hosts-A review. Mycoses. 2018;61(12):898–908.
© 2019 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.