Invasive Gastric Mucormycosis Which Was Managed Nonsurgically after Deceased Donor Liver Transplantation

Abstract

Introduction: We experienced an unusual infection which was invasive gastric mucormycosis after deceased donor liver transplantation and managed with not surgery but conservative management so that we are reporting it. Case report: A 46 years old female patient was admitted via the emergent center for hepatic encephalopathy. She was diagnosed as liver cirrhosis associated with hepatitis B in 2008. At the time of admission, abdominal CT showed advanced liver cirrhosis with splenomegaly, a duodenoscopy showed portal hypertensive gastropathy and duodenal ulcer scar, and the Model for End-Stage Liver Disease (MELD) score was 30. She underwent uneventful liver transplantation on 17th day after admission and due to massive bleeding she underwent another operation for bleeding control on the next day. At the time of liver transplantation the MELD score was 42. On the postoperative day (POD) 3, she started to eat, and on the POD 7, she was transferred to a general ward. On the POD 9, she presented first fever (38.7°C). Under the impressions of pneumonia, urinary tract infection, catheter related infection, and intra-abdominal infection, piperacillin-tazobactam was started. Vancomycin was added later. On the POD 18, she had a new onset of fever (39.0°C) and abdominal CT showed that disappeared normal mucosal enhancement and thinned wall in stomach greater curvature of cardia, high body (Figure 1).[Figure 1]Endoscopic examination was done and it showed that along with greater curvature side of cardia to mid body of stomach, a 10cm sized yellowish lesion which was thought to be omentum was noticed (Figure 2).[Figure 2]So we went on exploration only to find there was nothing wrong with the stomach, at least outside of the stomach. Gastric biopsies and cultures identified mucormycosis. From the findings of the previous exploration and the condition of the patient including infective endocarditis, we decided not to operate. We started Amphotericin B and had long period of conservative management with some changes in antibiotics. The invasive gastric mucormycosis was improved, but other infections made her worse. At 8 months after transplantation, she died of multiorgan failure. Conclusion: Invasive gastric mucormycosis could be managed with nonsurgically.