Nosocomial Jejunal Mucormycosis - an Unusual Cause of Perforation Peritonitis

Chandan Kumar,Neelam Wadhwa,Preeti Diwaker,Pragya Jain,Nirupma Khan

doi:10.30699/ijp.2017.25840

Abstract

Mucormycosis is a rare but highly invasive opportunistic fungal infection. Gastrointestinal disease although uncommon is highly fatal. We report a case of jejunal mucormycosis in a 24 year old undernourished female with preceding surgical intervention for acute intestinal obstruction of tubercular etiology. On 8th post-operative day, she developed oozing from suture line, prompting exploratory laparotomy, bowel resection, jejunostomy and ileal mucus fistula. Resected bowel showed one perforation and several areas of impending perforations. Characteristic broad, pauci-septate hyaline, empty looking hyphae with infrequent branching were found transmurally and showing angio-invasion. Local intestinal tissue trauma coupled with her sub-normal immune status permitted this unusual nosocomial infection. Histopathological demonstration of the fungus in surgical specimens remains cornerstone of diagnosis of mucormycosis in view of its non-specific symptoms, low isolation rates of mycological culture and lack of other rapid tests.

Highlights

Mucormycosis is a rare but highly invasive opportunistic infection of ubiquitous fungi of order Mucorales
Multiple episodes of vomiting, abdominal pain, distention and non-passage of stools for three days
Larger hyphae size and other morphologic features help in excluding candidiasis. Special stains such as Periodic acid Schiff (PAS) with diastase and silver stains are useful for highlighting organism morphology and demonstration of vascular invasion

Summary

Introduction

Mucormycosis is a rare but highly invasive opportunistic infection of ubiquitous fungi of order Mucorales It is the third most common nosocomial fungal infection following candidiasis and aspergillosis (1). A 24-year-old average built, HIV negative underweight (43 kg) woman presented with symptoms of acute bowel obstruction She complained of fever, multiple episodes of vomiting, abdominal pain, distention and non-passage of stools for three days. The resected small bowel segment (15 cm) showed one stricture with luminal narrowing and three perforations (Fig. 1a). The hyphae were Periodic Acid Schiff positive and stained dark brown to black with Grocott-Gomori methenamine silver method These morphological features were consistent with diagnosis of GI mucormycosis. Review of previous sections did not reveal fungal organism She was hemodynamically unstable and died on sixth postoperative day of the second surgical intervention

Findings

Discussion

Conclusion