2728 An Unexpected Cause of a Gastric Ulcer

Abstract

INTRODUCTION: Mucormycosis is a rare rhino-orbital-cerebral fungal infection. The GI tract is involved in approximately 7% of the patients; however, this incidence may not be exact since several cases have been diagnosed postmortem. Within the GI tract, the stomach is the most frequently compromised organ, followed by the colon. CASE DESCRIPTION/METHODS: 46-year old man presented to the ED with 1-week history of diffuse, crampy abdominal pain. His pain was associated with nausea, non-bloody vomiting, anorexia and watery non-bloody diarrhea for the past 3 days. His PMH is significant for HIV, well controlled on ART and DM complicated with gastroparesis. Laboratory results showed a CD4 of 540, normal WBC, A1C of 10.3% and negative infectious stool studies. The patient was admitted to the hospital and was placed on supportive treatment. Due to persistence of his symptoms, a CT of the abdomen was done showing gastric wall abnormalities (Figure 1). GI was consulted and a decision to perform an EGD was made. The EGD showed a large ulcerated irregular area in the stomach fundus (Figures 2 and 3). Biopsies were taken showing positive fungal stain compatible with mold from the order Mucorales. The patient was started on amphotericin B and then underwent a total gastrectomy with roux en Y reconstruction. Pathology results confirmed biopsy findings and culture was positive for Rhizopus species. DISCUSSION: Mucormycosis is an opportunistic infection that mainly occurs in immunocompromised states like DM, uncontrolled HIV infection and hematopoietic and solid organ transplant. GI invasion caused by Mucorales does not have a clearly understood mechanism; however, many authors propose that this starts after ingestion of fermented foods. Fungal hyphae can invade the blood vessels, leading to local ischemia, ulceration, infarction and necrosis of the affected tissue. Patients can present with nonspecific symptoms, which can delay the diagnosis, leading to mortality in 85% of the cases. EGD elucidates large ulcers that can be associated with emphysematous changes, as in our patient, but the diagnosis is made by fungal cultures of biopsies, since histopathological examination can be misleading. Treatment is based on amphotericin B or posaconazole, but surgical resection is necessary for cure. We report this case to increase awareness of mucormycosis as a cause of gastric ulceration in an immunosuppressed patient. Surgical treatment is encouraged, since delays are related to high mortality rates.