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CORRESPONDENCE
Year : 2012  |  Volume : 30  |  Issue : 3  |  Page : 373-374
 

Ileocolic mucormycosis causing intestinal obstruction


CRL Clinical Reference Lab, VIMTA Labs Ltd., Hyderabad, Andhra Pradesh, India

Date of Submission05-May-2012
Date of Acceptance06-Jun-2012
Date of Web Publication8-Aug-2012

Correspondence Address:
Nitin Chawla
CRL Clinical Reference Lab, VIMTA Labs Ltd., Hyderabad, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0255-0857.99512

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How to cite this article:
Chawla N, Reddy S J, Agrawal M. Ileocolic mucormycosis causing intestinal obstruction. Indian J Med Microbiol 2012;30:373-4

How to cite this URL:
Chawla N, Reddy S J, Agrawal M. Ileocolic mucormycosis causing intestinal obstruction. Indian J Med Microbiol [serial online] 2012 [cited 2019 Aug 17];30:373-4. Available from: http://www.ijmm.org/text.asp?2012/30/3/373/99512


Dear Editor,

Intestinal mucormycosis is a rare infection which is fatal due to its nonspecific presentation and delayed diagnosis. [1] We report a case of 65 years old male patient who was a sanyasi and admitted to the hospital with symptoms of acute intestinal obstruction. On initial evaluation, the patient had hemoglobin of 13 gm % with blood picture showing neutrophilic leucocytosis. His blood sugar levels and blood pressure were within normal limits. He was nonreactive for HIV and HBsAg. Patient had never undergone any invasive surgical procedure, organ transplantation or blood transfusion. He had not received any immunosupressive drugs. However, the patient gave a history of long term intake of Bhang golis (Leaves and flower buds of female Cannabis plant) and smoking Marijuana. Intra-operatively, the surgeon found ischemic areas in distal ileum with a large growth in the ascending colon obstructing the lumen. Right hemi colectomy was performed and specimen was sent to our lab. Gross examination of the specimen showed a large grey white to grey yellow irregular firm mass measuring 7×4×4 cm in the ascending colon region on the serosal surface causing external compression on it [Figure 1]. Cut surface of the mass showed grey yellow to grey white areas with foci of necrosis. There were multiple firm grey white areas seen on the mesenteric pad of fat in ileum as well as ileocolic junction. Similar areas were seen on ascending colon and caecum. A portion of ileum was thinned out with loss of mucosal folds 5 cm away from the ileocecal junction. The proximal and distal resected margins were free from such lesions. Fourteen lymph nodes were resected from ileocecal junction, largest measuring 1.5 cm across. Histopathological examination of the tissue showed multifocal lesions of fat necrosis in mesentery, mesocolon as well as serosa, subserosa of colon, caecum and ileum along with presence of fungal hyphae and spores. Few fungal hyphae were seen in vascular lumina. Gomori Methanamine Silver stain on tissue showed spores and pauciseptate fungal hyphae branching at right angles suggesting a diagnosis of Mucormycosis [Figure 2]. All fourteen lymph nodes showed sinus histiocytosis. Fungal culture on tissue could not be performed as the hemi colectomy specimen was sent in 10% neutral buffered formalin which would have definitely aided in confirmation of genus and species of the fungus.
Figure 1: Gross photograph of the specimen showing right hemi colectomy specimen with an irregular mass lesion in the ascending colon region outside the intestine

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Figure 2: Photomicrograph from intestinal lesion showing branching fungal hyphae and spores (Black colored) (GMS, ×400 )

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Mucormycosis is a fungal infection of order Mucorales of Zygomycetes family. These fungi are found in soil, decaying vegetation, manure and a variety of foodstuffs including bread, fruits and seeds. Most infections are acquired by inhalation, implantation and ingestion. [2],[3] Infection by Zygomycetes is common however, gastrointestinal, mesenteric and mesocolonic infections are very rare. [2],[4] Gastrointestinal mucormycosis usually involves stomach, ileum and colon. [4] Risk factors for development of infection with the zygomycetes include poorly controlled diabetes mellitus, hematologic malignancies, receipt of a solid-organ or hematopoietic stem cell transplant, desferrioxamine therapy for iron or aluminum overload states, burn wounds and corticosteroid therapy. [3],[4] In our case, the patient possibly developed infection due to pronounced immunosupressive effects caused by chronic Cannabis intake and Marijuana smoking. The possibility of mode of infection through ingestion of infected Cannabis leaves was bleak as all the lesions were in mesentery, mesocolon extending into the serosa and subserosa of intestine; though it cannot be completely ruled out. The patient was on supportive treatment till the diagnosis was made with no improvement in his condition. But on receipt of report, the surgeon put him on IV antifungal agents. The patient responded well to the treatment and survived. A delay in report could have led to loss of patient's life. So, it is advisable to consider gastrointestinal mucormycosis as a histopatholgical emergency and the clinician should be informed about it on an urgent basis so that the treatment can be started at the earliest.

 
 ~ References Top

1.Ribes JA, Vanover-Sams CL, Baker DJ. Zygomycetes in human disease. Clin Microbiol Rev 2000;13:236-301.  Back to cited text no. 1
[PUBMED]    
2.Yeung CK, Cheng VC, Lie AK, Yuen KY. Invasive disease due to Mucorales: A case report and review of the literature. Hong Kong Med J 2001;7:180-8.  Back to cited text no. 2
[PUBMED]    
3.Chakrabarti A, Das A, Sharma A, Panda N, Das S, Gupta KL, et al. Ten years ' experience in zygomycosis at a tertiary care centre in India. J Infect 2001;42:261-6.  Back to cited text no. 3
    
4.Kontoyiannis DP, Lewis RE. Invasive zygomycosis: Update on pathogenesis, clinical manifestations, and management. Infect Dis Clin North Am 2006;20:581-607.  Back to cited text no. 4
    


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