S3109 Gastric Mucosal Necrosis Due to Mucormycosis in COVID-19 Patient

Abstract

Introduction: COVID-19 patients, especially severely ill have a higher probability of suffering from invasive mycoses. That was noticed in our practice, and reported in literature.1 Our review of the literature found only one case of COVID-19 related gastric mucormycosis. Here we present a second one. Case Description/Methods: 71-year-old male with Hx of T2DM who presented with shortness of breath, dry cough and fever of 5 days and tested positive for COVID-19. He was admitted for AHRF, given remdesivir and dexamethasone for 2 days and discharged home to continue 10 days course of dexamethasone. Over the course of 1-week, patient's symptoms continued to progress, and he was brought again for shortness of breath and altered mental status. In ED, patient was febrile, hypoxic and was admitted for AHRF due to SARS-Cov-2 pneumonia with possible superimposed bacterial pneumonia. He was intubated and started on pressors, empirical antibiotics, dexamethasone and remdesivir to finish another 10-day course of the latter 2. He remained intubated with multiple failed weaning attempts, and after 2 weeks, tracheostomy tube was placed, and decision was made to proceed with PEG tube placement. Endoscopic mucosal examination was suggestive of diffuse proximal gastric mucosal necrosis sparing the antrum and distal body. PEG placement was cancelled and gastric biopsies histopathology showed invasive fungal disease consistent with Mucormycosis. The patient was started on liposomal amphotericin B and isavuconazonium. After a multidisciplinary discussion, the patient was deemed as a very high risk for gastrectomy and hence surgical intervention was deferred. MRI brain and sinuses showed no signs of invasive fungal disease. 3 weeks after the diagnosis of gastric Mucormycosis he was discharged on antifungals but unfortunately, he expired a few days after discharge. Discussion: In a recent systemic review, they found that 101 cases of mucormycosis in patients with COVID-19 have been reported, of which one of them was gastrointestinal. Pre-existing DM was present in 80% of cases and corticosteroid intake was recorded in 76.3% of cases. Mucormycosis involving nose and sinuses 88.9% was most common followed by rhino-orbital 56.7%. Only one case with gastric Mucormycosis was purported, the patient presented with melena during his stay and unfortunately died in seven days. Clinicians should have a high level of suspicion for concomitant fungal infections in patients with COVID-19 to allow for prompt diagnosis and early intervention.Figure 1.: a. Axial CT image of the upper abdomen. The two open (blue) arrows indicate visualized portions of the distended stomach. The solid (yellow) arrow shows severe hydronephrosis. b. Upper GI image. The solid yellow arrow shows the obstructed proximal duodenum. Note that contrast flows freely from the stomach into the anastomosed limb (solid white arrow) status post diverting jejunostomy c. Microscopic examination of the right ureter biopsy reveals invasive urothelial carcinoma with high grade nuclei.