Gastrointestinal mucormycosis in a child with acute lymphoblastic leukemia: An uncommon but ominous complication

Gastrointestinal mucormycosis: A periodic systematic review of case reports from 2015 to 2021

BACKGROUND

GI mucormycosis (GI) is a rare but highly lethal infection in patients. There is no single comprehensive review of the literature that demonstrates the various clinical aspects of this infection.

METHODS

A structured search of PubMed/Medline was used to collect case reports of GI mucormycosis in patients of all ages published between 2015 and November 2021.

RESULTS

Eighty-seven cases were identified through PubMed bibliographic database searches, and final analyses were conducted on 70 adults and ten neonatal patients with GI mucormycosis. Asia had the highest number of reported cases, with 46 (57.5%). Neonatal cases had a mortality rate of 70%, while other cases had a mortality rate of 44%. Corticosteroid therapy and diabetes were the most significant risk factors in patients, while 11% were immunocompetent with no apparent underlying condition. COVID-19 positivity was detected in four adult patients. Moreover, neonatal cases included premature and low-weight infants, metabolic acidosis, and malnutrition. Abdominal pain, fever, and GI perforation were the most common signs of infection, while vomiting occurred in 40% of neonatal cases. In 97% of patients, a histopathologic examination was used to detect infection, whereas culture and molecular methods were used in only 28% and 17% of patients, respectively. Surgery plus anti-infection therapy, anti-infection therapy alone, and surgery alone were used in 61%, 28%, and 11% of patients, respectively. Nonetheless, all neonatal patients underwent surgery. Although used in a small number of patients, posaconazole (30%) and isavuconazole (11%) demonstrated high efficacy in treating patients.

CONCLUSION

GI mucormycosis is a rare but highly lethal disease. Treatment of underlying conditions, the use of multiple diagnostic techniques, and appropriate antifungals in conjunction with surgery can all contribute to infection control.

Case reports of invasive mucormycosis associated neutropenic enterocolitis in leukemic children: diagnostic and treatment challenges and review of literature

Background

Bacterial enterocolitis is one of the most common neutropenic fever complications during intensive chemotherapy. Despite aggressive antibacterial treatments, this complication usually imposes high morbidity and mortality in cancer patients. Management of bacterial neutropenic enterocolitis are well known; however, management of fungal neutropenic enterocolitis may be more challenging and needs to be investigated. Prompt diagnosis and treatment may be life-saving, especially in patients at risk of mucormycosis-associated neutropenic enterocolitis.

Case presentation

We report two mucormycosis-associated neutropenic enterocolitis cases in pediatric leukemic patients receiving salvage chemotherapy for disease relapse. Both patients' clinical signs and symptoms differ from classical bacterial neutropenic enterocolitis. They were empirically treated as bacterial neutropenic enterocolitis with anti-gram-negative combination therapy. Despite broad-spectrum antimicrobial treatment, no clinical improvement was achieved, and both of them were complicated with severe abdominal pain necessitating surgical intervention. Mucormycosis is diagnosed by immunohistopathologic examination in multiple intraoperative intestinal tissue biopsies. Both patients died despite antifungal treatment with liposomal amphotericin-B and surgical intervention.

Conclusion

Mucormycosis-associated neutropenic enterocolitis is one of the most unfavorable and untreatable side effects of salvage chemotherapy in leukemic children with disease relapse. This report could be of considerable insight to the clinicians and scientists who counter the enigma of fungal infections during febrile neutropenia and help to understand better diagnosis and management.