Gastrointestinal Bleeding as Manifestation of Intestinal Aspergillosis: Case Report

Abstract

Introduction: Isolated intestinal aspergillosis or as a disseminated infection has been reported in the literature. Characteristic features of gastrointestinal invasive aspergillosis, suggests that the gut could be a portal of entry for Aspergillus in inmunocompromised patients. Recent ingestion of contaminated food or chronic low burden ingestion with asymptomatic gut colonization could cause symptomatic gastrointestinal disease in inmunocompromised patients. Case Report: A 54 years old male with mantle cell non-Hodgkin lymphoma (NHL), who had recently received six cycles of HYPER-CVAD-R, began with malaise, fever up to 38°C, abdominal cramps, nausea, vomiting and diarrhea. The examination revealed an ill looking patient, dehydrated, pale teguments, soft, but tender abdomen in mesogastric and right flank, normal bowel sounds and no evidence of peritoneal irritation. Laboratory data revealed Hb 12 g/dL, Hct 35%, WBC 100/uL, Segs 100/uL, PLT 55,000. Negative C. difficile toxin. Stool culture with no pathogens. He was admitted with a diagnosis of post-chemotherapy myelosupression, severe neutropenia and probably acute neutropenic colitis and started on meropenem, fluconazole, vancomycin and methronidazole. During the first hours he developed hemodynamic instability and was moved to the ICU. He had periorbital cellulitis and sinusitis, ENT took cultures that revealed Aspergillus flavus. Melena and fresh bloody stools occurred, with a fall of 3 g/dL of hemoglobin in 1 day. A first endoscopic study revealed ulcers in body and antrum of stomach, endoclips were placed; numerous blood clots were seen in distal Ileum. Bleeding continued so an enteroscopy was performed, which revealed a yeyunal ulcer, endoclips were placed. Gastric, yeyunal and colonic endoscopic biopsies were taken and pathology report revealed fundic gastric mucosa, with focal acute gastritis and ulcerations associated with fungal hyphae, suggestive of Aspergillus. Grocott's stain was consistent with Aspergillus hyphae. Discussion: Since symptoms resulting from necrotic lesions, obstruction or hemorrhage are non-specific, there would not be a characteristic clinical picture of intestinal Aspergillus and should make differential diagnosis with typhlitis or neutropenic enterocolitis, it is possible that the latter could have preceded the gut lesions and favored colonization on an altered mucosa but may be a severe GI complication in patients undergoing chemotherapy induced mucositis. Intestinal aspergillosis is uncommon.