A Rare Case of Gastric Zygomycosis Mimicking Malignancy: Case Report with Review of Literature

Case Report

J Bacteriol Mycol. 2020; 7(2): 1126.

A Rare Case of Gastric Zygomycosis Mimicking Malignancy: Case Report with Review of Literature

Madireddy N1, Patil R2, Uppin SG1 and Uppin MS1*

¹Department of Pathology, Nizam’s Institute of Medical Sciences, Hyderabad, India

²Department of Surgical Oncology, Nizam’s Institute of Medical Sciences, Hyderabad, India

*Corresponding author: Uppin MS, Department of Pathology, Nizam’s Institute of Medical Sciences, Hyderabad, India

Received: April 13, 2020; Accepted: May 06, 2020; Published: May 13, 2020

Abstract

Gastrointestinal mucormycosis, is an extremely rare, angioinvasive fungal function most commonly encountered in immunocompromised patients and associated with catastrophic outcomes. It can affect any part of alimentary tract with stomach being most common site followed by large intestine. The diagnosis of gastric mucormycosis is often delayed due to its vague symptomatology and a need for invasive investigations. It usually presents as ulcers in the stomach, however mass forming lesions mimicking malignancy are extremely rare. Despite aggressive treatment with anti-fungals and surgical debridement of the affected portion the mortality rates in these cases remain quite high. We report a case of gastric mucormycosis mimicking malignancy in a young, diabetic patient, who was successfully treated with timely diagnosis, aggressive antifungal regimen and radical gastrectomy.

Keywords: Gastrointestinal; Diabetes; Invasive Gastric Mucormycsosis; Mimicking Malignancy

Introduction

Mucormycosis, a lethal fungal infection has been steadily gaining interest in recent decades due to its increasing incidence in immunocompromised patients [1,2]. It is an aggressive angio-invasive infection caused by the subphylum Mucormycotina belonging to the Zygomatica phylum and is associated with an extremely dismal prognosis [1-4]. The most important predisposing factor for this infection is an immunocompromised state, seen in patients with neutropenia, hematological malignancies, diabetes mellitus, transplant recipients and in patients with severe malnutrition [1,2,4-8]. Mucormycosis has a varied clinical presentation ranging from localized cutaneous to fatal disseminated disease with rhinoorbito- cerebral and pulmonary mucormycosis accounting for the majority of the cases [6-9]. Gastrointestinal mucormycosis is the least common form of this disease and any portion of the alimentary tract can be affected [10-12]. However, the stomach has been identified as the most vulnerable site followed by ileum and colon [2,3,9]. The diagnosis of gastric mucormycosis is often delayed due to its nonspecific clinical presentation resulting in extremely high mortality rates. Despite several advances in diagnostic modalities, an alarmingly small percentage of cases are diagnosed antemortem [3,8-14]. Mass forming fungal infection in GI tract is a rarity. We report a case of gastric mucormycosis in a young male with diabetes mimicking a malignancy.

Case Presentation

A 28-year-old, male presented with retrosternal pain, nausea, and malena since two weeks. He was both a smoker and alcoholic and was diagnosed with Type II diabetes mellitus one year back. He was taking a combination of Metformin and Tenogliptun for diabetes. On examination, the patient was afebrile with mild abdominal tenderness and distension. The other systemic examination was unremarkable. The routine investigations including hemogram, urine examination, renal and liver function tests were within normal limits. The random blood sugar level was 150mg/dl. The urine sugar and ketone bodies were not detected. Cardiac evaluation revealed no abnormalities and lab investigations were negative for viral markers. The computed tomography of abdomen showed a heterogeneously enhancing polypoid growth in the fundus with perigastric lymphadenopathy.

An endoscopy was performed which revealed an ulceroproliferative, friable growth in the fundus of the stomach which was also thought to be malignant.

The biopsy from the mass revealed only necrotic mucosal bits however malignancy was not identified. The patient underwent a proximal gastrectomy which was sent for further histopathological examination. The gross examination revealed a large ulcer proliferative growth measuring 10.5x4.8x1.5cm in the fundus of the stomach. The microscopic sections showed extensive ulceration of the mucosa and dense eosinophilic infiltrate. Multiple granulomas were seen in all the layers of the wall of stomach which were mainly comprised of epithelioid cells and foreign body giant cells. Many broad, a septate hyphae were seen within the giant cells as well as extracellularly which were highlighted by silver meth enamine stain. The radiology, gross features and microscopy has been highlighted in (Figure 1). Nine lymph nodes isolated showed only reactive changes. Unfortunately, culture could not be submitted since the tissue was formalin fixed and there was no preoperative suspicion of fungal infection. The patient was started on Amphotericin (50mg) and Posaconazole (300mg). After two months postsurgery, patient is doing well.

Citation: Madireddy N, Patil R, Uppin SG and Uppin MS. A Rare Case of Gastric Zygomycosis Mimicking Malignancy: Case Report with Review of Literature. J Bacteriol Mycol. 2020; 7(2): 1126.