A Case That Breaks the Mold: Gastric Aspergillosis as a Cause of Recurrent Bleeding

Abstract

Invasive gastric aspergillosis is a rare cause of recurrent bleeding in immunocompromised patients. A 44-year-old man presented with severe sepsis from multi-lobar pneumonia requiring intubation, pressors, and dialysis. He was on IV methylprednisolone 40mg every 6 hours without PPI. On hospital day 9, he developed massive hematemesis. Following transfusion, esophagogastroduodenoscopy (EGD) revealed multiple ulcerations (largest 2 cm) in the gastric body along lesser and greater curves extending into the antrum. Several were oozing or had a visible vessel and were treated with epinephrine injection, gold probe cautery, and clipping. A PPI drip was started. Abdominal angiogram did not reveal extravasation of blood. However, over the next 5 days, he developed recurrent bleeding with 3 additional endoscopies with the same findings and interventions. After each EGD, hemostasis was achieved for 2-3 days but recurred, warranting repeat EGD. Due to lack of response to endoscopic therapy, he underwent total gastrectomy with Roux-en-Y esophagojejunostomy. Gastric ulcer biopsies showed fungal hyphae on Grocott's methenamine silver (GMS) stain. Immunostains were negative for Helicobacter pylori, CMV, and HSV. The gastrectomy specimen showed multiple superficial ulcerations throughout the stomach with pseudohyphal elements. Sputum cultures grew Aspergillus fumigatus and Aspergillus flavus. Therapy with liposomal amphotericin B and intravenous isavuconazole was begun and subsequently changed to oral voriconazole, with plans to continue for at least 3 months. He tested negative for causes of immune deficiency. Invasive aspergillosis typically develops in immunocompromised patients and carries a 50-60% mortality. Most commonly, invasive aspergillosis involves the lungs and rarely the gastrointestinal tract. The 6 reported cases of gastric aspergillosis presented as either ulcers or transmural necrosis. Most had previous chemotherapy or systemic steroid exposure. Four showed deep invasion transmurally or into the blood vessels; however, one case had pulmonary Aspergillus and superficial colonization of the gastric ulcers. Voriconazole is the recommended treatment for invasive aspergillosis and usually requires months to years of treatment. This individual worked in a nursery potting plants, which was likely his exposure. We believe he presented with pulmonary aspergillosis, became immunocompromised from the steroids, and this resulted in secondary infection of the stomach.