An under-recognised rapidly fatal condition: phlegmonous gastritis

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Phlegmonous gastritis is a rare condition, characterised by an infectious process in the gastric wall. There is an association with haemolytic Streptococcus infection in approximately 70% of cases, less frequently with other infectious agents such as Staphylococcus aureus, Pneumococcus and Enterococcus. Diagnosis is often delayed due to non-specific symptoms, such as abdominal pain, nausea, vomiting and fever. Abdominal computed tomography (CT) typically reveals thickening of the gastric wall, low-intensity areas within the gastric wall and gas accumulation. The therapeutic approach includes broad-spectrum antibiotics, and surgical resection of the gastric area involved in complicated cases. The authors present the clinical case of a 58-year-old male admitted to the hospital with headache, vomiting, abdominal pain and fever. Laboratory evaluation showed increased inflammatory parameters. An abdominal CT scan showed markedly diffuse parietal thickening of the stomach with increased mucosal enhancement and densification of perigastric fat. There was rapid progression to septic shock and the patient was admitted to the intensive care unit. An urgent upper gastrointestinal endoscopy revealed diffuse oedema of the gastric mucosal with no signs of tumour infiltration, confirming the diagnosis of phlegmonous gastritis. Broad-spectrum antibiotic therapy was started, and the patient underwent an urgent total gastrectomy. Despite the interventions carried out, refractory shock with multi-organ dysfunction occurred, resulting in death. Histopathologic findings in the gastrectomy specimen were compatible with phlegmonous gastritis. The clinical case presented demonstrates the need for high clinical suspicion for an early diagnosis of phlegmonous gastritis, especially in patients with gastrointestinal symptoms and clinical severity, for early treatment and improvement of the prognosis.