Candida-Induced Emphysematous Gastritis and Wilkieʼs Syndrome

Abstract

Destruction of protective gastric mucosa can predispose to Emphysematous gastritis (EG), a rare and lethal entity. Co-occurrence of candida induced EG with gastric perforation and superior mesenteric artery (SMA) syndrome is extremely rare. A 21-year-old African American man with poorly controlled type 1 diabetes mellitus presented with diffuse abdominal pain, nausea, and vomiting. He was cachectic, afebrile, with RR 45/min, pulse 130/min, BP of 80/45 mmHg, with dry mucous membranes, and diffuse abdominal tenderness. Laboratory data showed blood glucose 55 mg/dL, Cr 2 mg/dL, WBC of 19,100/microliter, lactate 5.2 mmol/L, with normal lipase level. He was started on 5% dextrose-normal saline with bicarbonate and meropenem. CT abdomen showed markedly distended stomach with gas bubbles in gastric wall and fluid filled loops of proximal small bowel. Nasogastric suction revealed dark colored aspirate. General surgery recommended explorative laparotomy for possible small bowel obstruction. Laparotomy showed 60% gastric necrosis with proximally dilated and distal compressed duodenum with a narrow SMA angle. This suggested EG with Wilkie's (SMA) syndrome. Partial gastrectomy, and Roux-en-Y procedure with a duodenojejunostomy were done. Gastrectomy specimen showed mural necrosis with abundant fungi consistent with Candida. While hepatectomy specimen showed focal nodular hyperplasia. Blood cultures grew Candida albicans. The patient was treated with micafungin and sepsis resolved. EG is characterized by gas within stomach wall due to invasion by microbes like Streptococci, Escherichia coli, Enterobacter, Clostridium welchii, and Candida. Predisposing factors are alkali/acid ingestion, alcohol abuse, immunosuppression, prior abdominal surgery and diabetes (as in our case). EG presents as acute abdomen with fever, chills, hematemesis and decreased bowel sounds. Laboratory findings include lactic acidosis and leukocytosis. Diagnosis is suggested by CT abdomen showing gas bubbles in the stomach wall that are unaffected by positional change. Complications include gastric infarction, gastric perforation (as seen in our case) with high mortality. Prompt management requires fluid resuscitation; antibiotic therapy to cover gram negative bacteria and anaerobes with de-escalation based on nasogastric aspirate, blood, and stomach wall specimen cultures. Deterioration despite optimal medical management and gastric perforation are the indications for emergent surgery.