GASTROINTESTINAL MUCORMYCOSIS IN A PERITONEAL DIALYSIS PATIENT WITH END STAGE RENAL FAILURE SECONDARY TO AA AMYLOIDOSIS: A CASE REPORT

B ZAHOROWSKA1, K ISMAIL2, G NARAYANAN1

1Liverpool Hospital, Liverpool, New South Wales; 2Department of Anatomical Pathology, Liverpool Hospital, Liverpool, New South Wales

Background: Gastrointestinal mucormycosis is a rare opportunistic infection predominately affecting individuals with immune deficiency and predisposing conditions including gastric ulcers and severe malnutrition. It is acquired by ingestion of fungal-contaminated food and initial manifestations include abdominal pain, distention and haematochezia. The diagnosis of gastrointestinal mucormycosis is often delayed, with only 25% of cases diagnosed ante-mortem and 85% mortality rate.

Case Report: We report a unique case of gastrointestinal mucormycosis caused by Rhizopus species resulting in splenic, stomach and colonic infarction diagnosed post-mortem in a peritoneal dialysis patient. A 50 year old female initially presented with Acinetobacter baumanni peritonitis ten months post commencement of peritoneal dialysis (PD) for renal failure secondary to systemic AA amyloidosis of unknown underlying aetiology. Her amyloidosis had previously manifested with intermittent non-bloody diarrhoea and had been treated with low-dose prednisone. The peritonitis episode presented with typical abdominal pain and cloudy effluent complicated by septic shock due to delayed presentation and resulted in PD catheter removal. Her abdominal pain persisted and was investigated with a CT mesenteric angiogram, which was unremarkable. The patient developed new dysphagia and gastroscopy identified a large ulcerated lesion in the gastric fundus comprised of amyloid deposition. The patient deteriorated with further septic shock and underwent laparotomy with findings of necrotic stomach, spleen and colonic splenic flexure and she deceased post-operatively, three weeks after the initial peritonitis diagnosis.  Amyloid vasculopathy and superimposed angioinvasive mucormycosis was identified post-mortem as the cause of organ infarction.

Conclusions: This rare case of mucormycosis in an immunosuppressed patient demonstrates the high index of suspicion required for diagnosis, particularly in the setting of presentation with overlapping symptoms from PD peritonitis.

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