Question: A 48-year-old Hispanic man developed melena after 25 days of hospitalization. He was initially brought to the emergency department after a motor vehicle accident that resulted in hemopneumothorax, multiple fractures, and blunt abdominal trauma. No past medical history was reported. After emergent endotracheal intubation and chest tubes placement, he underwent splenectomy, subtotal colectomy, and distal ileum resection. In the intensive care unit (ICU), he developed septic shock requiring broad-spectrum antibiotics, vassopressors, corticosteroids, and hemodialysis. Repeat laparotomy on day 9 revealed colocolostomy disruption, requiring additional bowel resection. Vassopressors and steroids were stopped after 5 days. His course was complicated by pulmonary embolism and persistent hyperglycemia. Multiple intra-abdominal washouts were required and abdominal cavity was closed on day 24. On day 25, melena was noted. He was tachycardic, afebrile, and normotensive. Surgical wound was clean, and abdominal examination revealed diffuse tenderness. Hemoglobin acutely dropped from 9 to 6.7 g/dL. Anticoagulation was stopped and an inferior vena cava filter placed. Upper endoscopy showed diffuse friable mucosa of the entire stomach. Large exudative ulceration was found in the gastric body (Figure A) from where biopsy specimens were taken. Other, scattered, clean-based ulcers were seen in the antrum and fundus (Figure B). The esophagus and duodenum were normal. A representative histopathology is provided (Figure C, D). What is the diagnosis? Look on page 1136 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Histopathology revealed necroinflammatory exudate with marked inflammation and broad aseptate fungal hyphae with right angle branching consistent with gastric mucormycosis. Staining for Helicobacter pylori was negative. Treatment with liposomal amphotericin B and micafungin was started. Repeated endoscopic samples were sent for fungal cultures on day 28 and failed to reveal organisms. Antifungals were switched to posaconazol after 1 month and completed 3 months. He has survived at 6 months of follow-up with no recurrence of bleeding. The first case of mucormycosis was described in 1885, in a patient with concomitant gastric and rhinocerebral disease. Gastrointestinal involvement is rare, with about 100 cases reported and mortality rate close to 85%.1Petrikkos G. Skiada A. Lortholary O. et al.Epidemiology and clinical manifestations of mucormycosis.Clin Infect Dis. 2012; 54: S23-S34Crossref PubMed Scopus (713) Google Scholar It most commonly affects the stomach (58%), followed by the colon (32%) and ileum (7%). Clinical manifestations include mass, gastrointestinal bleeding, and perforation.2Spellberg B. Gastrointestinal mucormycosis: an evolving disease.Gastroenterol Hepatol. 2012; 8: 140-142PubMed Google Scholar Management includes prompt diagnosis, reversal of predisposing factors, surgical debridement, and antifungal therapy. Diagnosis relies on histologic findings of fungal organisms consistent with the disease. Microbiologic isolation is difficult and polymerase chain reaction techniques are not readily available. Operative management was not attempted owing to the multiple comorbidities in our patient. The combination of lipid polyenes and echinocandins seems promising, but prospective trials need to define the optimal antifungal therapy.2Spellberg B. Gastrointestinal mucormycosis: an evolving disease.Gastroenterol Hepatol. 2012; 8: 140-142PubMed Google Scholar Emergence of healthcare-associated mucormycosis (HCM) has been seen in the last 40 years, as transplants, malignancy, diabetes, and immunosuppressive agents, have become more common.3Rammaert B. Lanternier F. Zahar J.R. et al.Healthcare-associated mucormycosis.Clin Infect Dis. 2012; 54: S44-S54Crossref PubMed Scopus (171) Google Scholar Portals of entry include surgical wounds as well as the use of medical devices such as catheters, adhesive tape, and wooden tongue depressors. This may explain why skin and gastrointestinal involvement are more frequent in HCM, compared with common mucormycosis.3Rammaert B. Lanternier F. Zahar J.R. et al.Healthcare-associated mucormycosis.Clin Infect Dis. 2012; 54: S44-S54Crossref PubMed Scopus (171) Google Scholar Multiple compounding risk factors including multiple abdominal surgeries, prolonged ICU stay, corticosteroids and uncontrolled hyperglycemia, played a role in the life-threatening infection acquired by our patient. In summary, gastrointestinal HCM may become more common because its risk factors are widely distributed.