S2207 Disseminated Mucormycosis: A Rare Cause of GI Bleeding

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INTRODUCTION: Mucormycosis is an unusual infection in humans, almost always seen in immunocompromised patients. The usual presentations are rhino-orbital-cerebral, pulmonary, or cutaneous mucormycosis. Gastrointestinal involvement is rare, with the stomach, colon, and ileum being potential sites of infection. CASE DESCRIPTION/METHODS: A 74-year-old male with past medical history of cervical schwannoma s/p resection and radiation therapy on steroids due to cord compression was admitted for diabetic ketoacidosis and sepsis secondary to emphysematous pyelonephritis. He underwent bilateral nephrectomy and was admitted to the ICU for CVVHD following which his clinical condition deteriorated and he was intubated. The surgical specimens were concerning for angioinvasive fungal infection, and BAL analysis showed potential mucormycosis. He was started on Amphotericin B and Isavuconazole. 10 days after ICU admission, he had an acute hemoglobin drop and NG tube output showed frank blood. Upper GI endoscopy revealed multiple ulcerations in the nasopharynx, oropharynx and epiglottis. The esophagus had many cratered ulcers, 10mm in largest dimension, and LA Grade D esophagitis. The lesser curvature of the stomach had few oozing, cratered ulcers with a visible vessel. The ulcers, 30mm in largest dimension, were marked by black discoloration with white fuzz on top, concerning for Mucor (Figures 1 and 2). The ulcers were injected with epinephrine and treated with bipolar cautery. Pathology revealed fungal organisms compatible with Mucor, and ulcers with crystalline iron deposits. DISCUSSION: Disseminated mucormycosis occurs in the setting of severely immunocompromised patients with steroid use, diabetes, and deferoxamine being strong risk factors. When the gastrointestinal tract is involved, the stomach is the most common site, showing multiple deep necrotic ulcerations as described above. Diagnosis requires a high index of suspicion, and is by histopathological examination of the affected area showing the characteristic wide, non-septate hyphae. Treatment involves surgical resection of the affected tissue and antifungal therapy with amphotericin B and posaconazole or isavuconazole for several weeks.Figure 1.: Endoscopy showing gastric ulcer with black discoloration and white fuzz.Figure 2.: Endoscopy showing cratered gastric ulcer with black discoloration and white fuzz.