S2183 Mucormycosis: An Unusual Cause of Gastrointestinal Bleeding in an Immunocompetent Host

Abstract

INTRODUCTION: Mucor is rarely pathogenic in immunocompetent hosts. Gastrointestinal (GI) mucormycosis accounts only for 7% of total cases and is a rare cause of lower GI bleed. We present a case of a 58-year-old immunocompetent woman who developed lower GI bleeding. Colonoscopy revealed cecal ulcer and biopsy showed evidence of mucormycosis. CASE DESCRIPTION/METHODS: A 58-year-old Hispanic woman with history of diabetes mellitus and esophagitis presented with altered mental status. Her family reported that she complained of heartburn, nausea, and vomiting with hematemesis for 2 weeks. After arrival, she developed pulseless cardiac arrest. Cardiopulmonary resuscitation was initiated and return of spontaneous circulation was achieved. Frank blood was noticed from the orogastric tube. On exam, she was malnourished, abdomen was soft and non-tender. Rest of the exam was normal. Work up showed: hemoglobin 4.6 gm/dl, WBC 10.4 k/ul, platelets 276 k/ul, INR 1.2, prothrombin time 13 seconds and hemoglobin A1C 5.4%. Esophagogastroduodenoscopy showed grade D esophagitis with no definitive bleeding source. Two weeks into admission, she had an episode of bright red bleeding per rectum. Colonoscopy showed a sessile polyp and non-bleeding cecal ulcer, biopsy of the ulcer showed colitis with broad based aseptate hyphae consistent with mucormycosis. She was started on isavuconazole with plans to repeat colonoscopy in 2 months to evaluate for surgical resection if the ulcer persists given the patient overall stable condition. DISCUSSION: Mucormycosis is an angio-invasive fungus that can cause bleeding and thrombosis in virtually any organ system. GI mucormycosis is exceedingly rare and reported to occur from ingestion of contaminated food or herbal medicines. Rhino-orbital-cerebral mucormycosis is the most common presentation and more commonly reported in immunocompromised hosts, patients on long term steroid therapy, and poorly controlled diabetes. Stomach is the most common site of GI mucormycosis, followed by the colon and ileum. It usually presents as ischemic bowel disease or GI bleeding. Diagnosis requires biopsy with demonstration of tissue invasion by mucor. Mucormycosis is a fatal opportunistic infection with a reported mortality rate of 50%. Early diagnosis and correction of the predisposing risk factors are keys to improved outcomes. It is typically treated with combination of surgical resection and anti-fungal therapy. Liposomal amphotericin and isavuconazole have been approved for treatment of mucormycosis.Figure 1.: Cecal ulcer with fibrin clot.Figure 2.: broad based aseptate hyphae consistent with Mucor.Figure 3.: broad based aseptate hyphae consistent with Mucor.