Invasive intestinal mucormycosis in a 40-year old immunocompetent patient - a rarely reported clinical phenomenon: a case report

Wotiye et al. BMC Gastroenterology (2020) 20:61 https://doi.org/10.1186/s12876-020-01202-5 CASE REPORT Open Access Invasive intestinal mucormycosis in a 40year old immunocompetent patient - a rarely reported clinical phenomenon: a case report Abdi Bati Wotiye1,2*, Poornachandra KS1 and Biniyam Alemayehu Ayele3 Abstract Background: Mucormycosis is rare, life-threatening fungal infection. Frequently observed in those patients having underlying immunosuppression such as, diabetes, organ transplantation, Human immunodeficiency virus (HIV) infection, and elevated serum iron. However, invasive intestinal mucormycosis occurring in immunocompetent individuals without the traditional risk factors is extremely rare clinical phenomenon. Case presentation: We report a 40-year-old male patient who presented with 1 week history of diffuse abdominal pain and high grade fever, associated with vomiting and frequent loose stools. Has history of chronic alcohol ingestion. Otherwise, no past history of chronic medical illness, nor he had contact with individuals with similar illness. He was in a septic shock with multiple organ failure up on presentation to emergency room. Physical examination revealed icterus sclera with abdominal tenderness. He was immediately resuscitated using crystalloids, supported with inotrope, and antibiotics. Histopathological examination of tissue sample from colonic ulcer biopsy revealed invasive intestinal mucormycosis. Patient showed full clinical and histopathological resolution after course of parenteral Liposomal Amphotercin B. Conclusion: This case highlights the fact that, despite its life-threatening nature, it’s possible to treat patients with invasive intestinal mucormycosis with aggressive antifungal and supportive care without surgical intervention, provided that all the necessary supportive care were initiated early and the disease was diagnosed early and appropriate medical management was initiated timely. In addition, it’s important to consider intestinal mucormycosis even in patients who are immunocompetent without traditional risk factors. Keywords: Mucormycosis, Intestinal invasive, Immunocompetent * Correspondence: ; 1 Department of Gastroenterology and Hepatology, Fortis Hospital, Bannerghata Road, Bangalore, India 2 Department of Internal Medicine, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Wotiye et al. BMC Gastroenterology (2020) 20:61 Background Mucormycosis is an uncommon, life-threatening infection caused by fungi belonging to the subphylum Mucormycotina, order Mucorales. Among organisms responsible for causing mucormycosis, Rhizopus species are the most common cause of infection. The major portals of entry include the sinuses, lungs, gastrointestinal tract and skin [1, 2]. Mucormycosis mostly affects immunocompromised hosts including patients with diabetes, malignancy, HIV, organ transplant recipients and patients on immunosuppressive therapy [3]. While any organ system may be affected, rhino-orbital-cerebral and pulmonary infections dominate the literature [3–5]. Very few cases of gastrointestinal mucormycosis in an immunocompetent host have been reported [5, 6]. The aim of this case report is to highlight the importance of early detection and aggressive medical management of invasive mucormycosis may result in good outcome. Case presentation This is a 40-year old man referred from local health facility to our hospital with diagnosis of acalculous cholecystitis after he presented with a week history of diffuse abdominal pain and high grade fever. Associated with this he had history of vomiting and frequent loose stools. He had history of chronic alcohol abuse. He has no urinary complaints, no past history of hypertension, diabetes mellitus, dyslipidemia or cardiac illness. No history of similar illness in the family and in his neighborhood. No history of contact with individuals suffering from similar illness, or traveling to region where such illness is common. He runs small business in the town. Physical examination showed emaciated but fully conscious. Vital signs were, Blood pressure = 80/50 mmHg, Pulse rate = 115/beat/minute, Temp = 99.6 °F, and RR = 26 breath/minute. Venous blood gas (VBG) analysis was suggestive of metabolic acidosis. He had scleral icterus bilaterally. In addition he had superficial and deep abdominal tenderness in epigastric and right upper quadrant region. Page 2 of 6 Abdominal ultrasound showed mild hepatomegaly with mild course increased echo pattern, gall bladder wall thickening with mild pericholecystic fluid collection and mild ascites. Otherwise, the patient had no overt signs of liver cirrhosis. Computed tomography (CT) showed Gall bladder wall edema with intense pericholecystic fat stranding and free fluid around liver and spleen (Fig. 1a, b). There was mild ascites, nodular liver contours. The colon showed edematous thickening and ulcer at right transverse colon and hepatic flexure (Fig. 2a, b). He was admitted to medical ICU and started on parenteral antibiotics and inotropes and resuscitated with intravenous fluids. Urine and blood culture were negative. He was negative for Dengue IgM. On second day our patient’s condition was deteriorating despite broad spectrum antibiotics with persisting Fever, acidosis, patient become delirious, and lactate remained high (Table 1). Abdominal examinations showed increased tympanicity and diffuse tenderness. The patient was evaluated by GI surgeon and taken up for diagnostic laparotomy. Subsequently, mini laparotomy and cholecystotomy was done due to severe adhesions. Gall bladder fluid analysis was unremarkable, culture was negative, but histopathologic examination was not done as cholecystectomy was performed. On day 4, colonoscopy was done and sample was sent for histopatholog (...truncated)