S2600 Gastric Mucormycosis: A Case of a Rare Infectious Cause of Upper GI Bleeding

Abstract

Introduction: Gastric mucormycosis is a rare clinical entity that mandates upper endoscopic evaluation and specific histopathologic findings for a diagnosis. Due to its non-specific clinical presentation, it poses a diagnostic challenge for providers. We present a case of gastric mucormycosis in a critically ill and immunosuppressed patient that was discovered in the setting of evaluation of upper gastrointestinal bleeding. Case Description/Methods: A 66-year-old man with a history of a kidney transplant two years prior, with a recent diagnosis of post-transplant lymphoproliferative disorder (PTLD) and who had recently undergone an initial round of R-CHOP chemotherapy four weeks prior was admitted to the hospital with altered mentation and neutropenia. His hospital course was prolonged with multiple cardiac arrests in the setting of septic shock from his profound neutropenia. He was noted to have dark blood from his nasogastric tube and a concomitant drop in his hemoglobin, for which the Gastroenterology service was consulted. He underwent urgent upper endoscopic evaluation and was found to have both significant clot in his stomach and an ulcerated fungating lesion along the greater curvature of the stomach which was biopsied. Pathology results showed fungal organisms with special GMS stain showing morphologic features consistent with mucormycosis. The Infectious Diseases service was urgently consulted and he was started on triple anti-fungal therapy with amphotericin, micafungin and posaconazole. Otolaryngology evaluated the patient due to these endoscopic findings, with laryngoscopy negative for head and neck involvement of this infection. Surgery was consulted for evaluation of subtotal gastrectomy, but he was deemed an unsuitable surgical candidate. The patient eventually succumbed to this and passed away during his hospitalization. Discussion: Gastric mucormycosis is a rare infection that often manifests in the setting of immunosuppression as seen in solid organ transplant recipients or in patients with diabetes. The most often clinical manifestation is upper gastrointestinal bleeding, and thus endoscopic evaluation is part of the work-up to exclude other diseases that could mimic its presentation. This diagnosis often results in fatal outcomes, so early recognition is critical for both medical management with anti-fungal therapy, along with surgical management given the high failure rate of medical management alone for this diagnosis.