|Year : 2012 | Volume
| Issue : 3 | Page : 192-194
Gastric mucormycosis in an immunocompetent patient
Arindam Dutta1, Mukut Roy1, Th. Dhabali Singh2, Th. Premchand Singh3
1 Department of Medicine, TMC and Dr. BRAM Teaching Hospital, Hapania, Agartala, India
2 Department of Pathology, Jawaharlal Nehru Institute of Medical Sciences, Imphal, India
3 Department of Medicine, Regional Institute of Medical Sciences, Imphal, India
|Date of Web Publication||10-Jun-2013|
Th. Premchand Singh
Professor of Medicine, Regional Institute of Medical Sciences, Imphal - 795 002
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/0972-4958 .113251
Gastrointestinal mucormycosis is an uncommon disease most often occurring in immunocompromised individuals, patients with diabetes, and patients suffering from hematologic and solid malignancy. Rarely, it may occur in normal persons without any contributory factor. We report a rare case of gastric mucormycosis in an immunocompetent individual who recovered with Amphotericin-B treatment.
Keywords: Amphotericin-B, Gastric mucormycosis, Immunocompromised host
|How to cite this article:|
Dutta A, Roy M, Singh T, Singh T. Gastric mucormycosis in an immunocompetent patient. J Med Soc 2012;26:192-4
| Introduction|| |
Mucormycosis is caused by a ubiquitous saprophytic filamentous fungus that belongs to the class Zygomycetes. The common pathogens in this class are Rhizopus, Absidia, and Mucor. These organisms are basically of low virulence while considering the pathogenicity, but they can be fulminant and cause fatal infection in immunocompromised hosts,  in patients suffering from poorly controlled diabetes mellitus, extreme malnutrition, or malignancy, and in organ transplant recipients. The disease has been reported in patients with end-stage renal disease on hemodialysis and patients with iron overload as iron is a growth stimulant for Mucorales.  Rarely, the disease may affect healthy individuals. Due to non-specific signs and symptoms and also due to rarity of cases, diagnosis of mucormycosis is usually not considered in early stage when the patient's life is not at stake.
The spectrum of the disease ranges from localized cutaneous to disseminated systemic infection. Systemic mucormycosis is a rare and fatal fungal infection. It usually involves the nasopharynx and lungs followed by gastrointestinal (GI) tract and rarely even the pericardium. GI mucormycosis is rare, occurring in immunocompromised conditions and with advanced malignancies due to ingestion of contaminated food or drink. All parts of the GI tract may be affected of which stomach, ileum, and colon are the commonest involved. Mortality from GI mucormycosis is very high. Though in a study in late 70s it was reported to have fatal outcome in 98% of patients of GI mucormycosis,  successful outcome with medical and surgical therapy is sometimes achieved. We are reporting this case of gastric mucormycosis in a normal immunocompetent patient because of its rarity.
| Case Report|| |
A 64-year-old female was admitted with loss of appetite, difficulty in swallowing, and generalized weakness for last 2 weeks. She also complained of distension of abdomen, swelling of feet, and low-grade fever. On general physical examination, her condition was found to be very poor. She had pallor, edema, and ascites without generalized lymphadenopathy. Abdomen was tender on palpation without any organomegaly. Other systemic examination was normal. Blood examination showed hemoglobin of 7.5 gm/dl, and total leukocyte count 5900/mm 3 with neutrophils 66%, lymphocytes 24%, monocytes 6%, and eosinophils 4%. Erythrocyte sedimentation rate was 38 mm in the 1 st h. Serum creatinine was 1.1 mg/dl; serum sodium and potassium were 135 meq/l and 2.9 meq/l, respectively. Liver function test was normal. Fasting blood glucose level was 90 mg/dl and postprandial level was 112 mg/dl. Urine and stool examinations revealed no abnormality. Stool for occult blood was also negative. Hepatitis B surface antigen (HbsAg), antibody to hepatitis C virus (HCV Ab), and HIV-I and -II were negative. Ultrasonography of abdomen revealed thickening of the wall of the stomach and omentum along with ascites and right-sided pleural effusion. There was right-sided pleural effusion in the chest X-ray.
Ascitic fluid analysis showed white blood cells 1-2/hpf and protein 2.2 g/dl without any malignant cell, organism, or acid fast bacilli. Upper GI endoscopy revealed grade II esophagitis, esophageal candidiasis, multiple erosive ulcers in the fundus and body of stomach, and healed duodenal ulcer with a possible diagnosis of carcinoma of stomach. Biopsy from multiple sites of erosive ulcers was taken and sent for histopathologic examination. The biopsy report revealed fragments of fibrinopurulent ulcer slough and inflammatory granulation tissue with few clumps of broad, thin-walled, and pleomorphic fungal hyphae [Figure 1]. Gastric mucosal bits showed active gastritis without any feature of neoplasia. The findings were consistent with mucormycosis.
The patient was put on intravenous Amphotericin-B and she showed signs of improvement clinically after around 14 days. Her fever and ascites subsided as evidenced by ultrasonography showing only mild pleural effusion without any ascites. The patient regained her appetite and could swallow solid food. She was improving clinically on subsequent follow-up visits after 3 and 6 months, her hemoglobin improved, and edema subsided.
| Discussion|| |
Mucormycosis is an opportunistic infection, usually involving immunocompromised individuals. Almost all the reported cases are associated with some predisposing factors. Bauer et al. had successfully established the relationship between corticosteroid and mucormycosis by their experimental study long back in 1957. Stratsma et al. had shown that malignancy is a risk factor for mucormycosis in their clinicopathological study of 51 cases. Boelaert et al. found two cases of dialysis-associated mucormycosis who were treated with desferrioxamine and inferred that iron overload may be a risk factor of mucormycosis. Mooney et al. reported a case of GI mucormycosis in a malnourished child. Singh et al. reported a case of invasive GI mucormycosis in a liver transplant recipient.
Though less in number, mucormycosis occurring in immunocompetent host has also been reported. Kamat et al. and Verma et al. reported disseminated mucormycosis in healthy adults. Jain et al. described mucormycosis as the causative factor of necrotizing fascitis in immunocompetent individuals. Vaideeswar and Pandit  reported a case of primary zygomycosis of the pericardium in an immunocompetent individual. Virk et al. reported a case of massive GI bleeding caused by mucormycosis. Shahapure et al.,  Sharma et al., and Shivaprasad et al. also reported cases of GI mucormycosis, and of these, Shahapure et al. treated their patient successfully with Amphotericin-B.
The underlying factors for increased pathogenicity of fungi in a healthy patient could be alteration of bacterial flora or sepsis-induced altered immune response.  Our patient did not have any contributing factor that made her immunocompromised. The only plausible explanation is that she had been suffering from gastric ulceration following which she acquired the infection by ingestion of contaminated food or drinks, and as the organism has the ability to colonize around the ulcer and invade the blood vessels, it caused multiple erosive ulcers.
| Conclusion|| |
Mucormycosis usually affects immunocompromised hosts with a fatal outcome and it rarely affects healthy individuals. A case of gastric mucormycosis is being reported in a normal immunocompetent lady without any predisposing factor who recovered with Amphotericin-B.
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