Case one:
A 61-year old Tunisian female patient with type 2 diabetes mellitus,
hypertension, dyslipidemia and family history of peptic ulcer presented
to our gastoenterology department with a 7-day history of vomiting
preceded by a 4-month history of dry cough for which she took inhaled
corticosteroids. On physical examination, she had no fever. Her body
mass index (BMI) was 29.8 kg/m2. Her blood pressure
was 120/70 mmHg. Her abdominal exam was normal. Initial laboratory
studies showed renal dysfunction with creatinine 163 µmol/L and
clearance 60 ml/min, Hemoglobin 11.5 g/dL, white blood cell count (WBC)
11100 cells/µL, C-reactive protein (CRP) 132 g/L and blood sugar 20
mmol/L (table1).
Upper gastrointestinal endoscopy revealed budding and infiltrating
greyish process resting on an ulcerated fundic mucosa (figure 1).
Anatomopathological exam concluded to an invasive mucormycosis by
demonstrating zygomycosis hyphae without any malignant signs (figure 2).
These findings were confirmed by parasitological examination (figure 3).
A brain-face-chest-abdomen and pelvis computed tomography (CT) scan
without contrast was practiced to search other sites of mucormycosis
(figure 4). It revealed a fundic mucosal thickening without any other
infection site confirmed by an ENT exam.
Since the liposomal form of amphotericin B which is less nephrotoxic was
not available in our country, therapy based on conventional amphotericin
B was started on the fifth day of diagnosis at progressive dose 5mg/day
on day one until 25 mg/day (0.4 mg/kg/d) on day 5. The evolution was
marked by an aggravation of renal dysfunction: creatinine 208 µmol/L and
clearance 25 ml/min.Thus we stopped the antifungal therapy but though
creatinine levels were still high. In day 19, she was programed for a
total gastrectomy but presented a respiratory distress due to pulmonary
embolism. The patient underwent total gastrectomy two months after
diagnosis. The examination of the stomach showed 2 digging ulcers in the
fundus (figure 5).The patient died 10 days after surgery.