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Green ulcer in the stomach: unusual mucormycosis infection
At the Focal Point
Gastroenterology, Department of Internal Medicine, The Catholic University of Korea, Seoul, and Uijeongbu St. Mary’s Hospital, Uijeongbu, Korea
doi:10.1016/j.gie.2008.02.087
Commentary Garlic, named for the spear-shaped leaves (Old English: gar, spear; leac, leek) of its plant, is a member of the lily family (Alliaceae) and is joined by other edible members including the onion, leek, and asparagus. In addition to its widespread culinary use, it has been regarded as healthful; indeed, Galen referred to it as ‘‘nature’s theriac,’’ or cure-all. Although some tout its benefits for atherosclerosis, hyperlipemia, diabetes, cancer, cryptosporidiosis, toxoplasmosis, intestinal worms, and to reduce platelet aggregation, data for these actions are not evidence-based. Garlic also has numerous drug interactions, notably with warfarin, but also others. Dysphagia in a garlic lover raises the issue of botulism after consumption of garlic-in-oil preparations in addition to impaction with mucosal injury, as in this patient. The potentially toxic effect of garlic is further evidenced by allergic dermatitis resembling a chemical burn after its topical application to skin, and also by the irritating effect of raw garlic powder on the gastric mucosa. Better to enjoy the taste sensation of Allium sativa after it has been cooked and its toxic factors reduced than to consume it raw and threaten proximal mucosal surfaces. Well, at least it kept the vampires away for the short time it resided in the esophagus. Lawrence J. Brandt, MD Associate Editor for Focal Points
Green ulcer in the stomach: unusual mucormycosis infection
566 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 3 : 2008
www.giejournal.org
At the Focal Point
A 58-year-old man had been robust until 2 weeks before admission when he had fever, productive cough, epigastric pain, and abdominal fullness. He was intubated for mechanical ventilator support because he developed pneumonia and respiratory failure. A plain film and CT of the abdomen showed only an ileus. He subsequently developed tarry stools, and EGD identified an ulcer with a greenish coating at the greater curvature of the mid-body of the stomach (A). The coating was not detachable from the mucosa by forceps lifting. A biopsy specimen taken from the margin and the center of the ulcer revealed numerous right-angled, pauciseptated, and ribbon-like hyphae compatible with mucormycosis (B, H&E, orig. mag. 400). A change in his level of consciousness prompted magnetic resonance imaging of the brain, which revealed fluid accumulation in the sphenoid and ethmoid sinuses. Endoscopic debridement of the right ethmoid sinus about 1 week after amphotericinB therapy began showed only chronic sinusitis without hyphae. Immunologic screening tests did not show any abnormality except for low fraction of CD4 positive T cells
(15%, absolute count of 257 cells/mL). Two weeks after antifungal therapy, EGD showed improvement in the appearance of the ulcer (C). A biopsy specimen taken from the margin of the ulcer did not show hyphae. DISCLOSURE The authors report that there are no disclosures relevant to this publication. Chen-Shuan Chung, MD, Wen-Lun Wang, MD, Department of Internal Medicine, Kao-Lang Liu, MD, Department of Medical Imaging, Jaw-Town Lin, MD, PhD, Department of Internal Medicine, Hsiu-Po Wang, MD, Department of Internal Medicine and Department of Emergency Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
doi:10.1016/j.gie.2008.02.076
Commentary The color green, so abundant in nature, signifies growth, renewal, health, and the environment, but it also has negative connotations of jealousy, envy, and inexperience. So many meanings for a wavelength of 510 nm! What did it mean in this case? Certainly nothing good. Mucormycosis refers to several different diseases caused by fungi in the class Phycomycetes and of the order Mucorales, Rhizopus being the most frequent species. It is unusual, however, that species is determined, and diagnosis usually doesn’t get more specific than ‘‘mucor.’’ Mucoraceae are ubiquitous fungi that are commonly found in soil or in decaying matter, but disease is unusual because of the low virulence of the organisms, which mainly affect immunocompromised individuals (eg, poorly controlled diabetes, glucocorticosteroid use, neutropenia in the setting of hematological or solid malignancy, transplantation, and burns). Infection usually follows local exposure, and most common is disease of the facial sinuses. Ingestion of conidia leads to GI disease that most commonly affects the stomach, ileum, and colon. Once spores begin to grow, fungal hyphae invade tissue and blood vessels, producing thrombosis, infarction, and necrosis. Invasion must be distinguished from colonization. Did this patient have an ulcer that was colonized by mucormycosis, or did the fungus cause the ulcer? Gastric ulcers occasionally fail to heal with proton pump inhibitor (PPI) therapy because they are colonized and coated with candida; only after adequate anticandidal therapy will PPIs be effective. Mucormycosis may be another colonizing and membrane-producing disease, but in this patient it is more likely to have been causative. Lawrence J. Brandt, MD Associate Editor for Focal Points
www.giejournal.org
Volume 68, No. 3 : 2008 GASTROINTESTINAL ENDOSCOPY 567
Gastroenterology, Department of Internal Medicine, The Catholic University of Korea, Seoul, and Uijeongbu St. Mary’s Hospital, Uijeongbu, Korea
doi:10.1016/j.gie.2008.02.087
Commentary Garlic, named for the spear-shaped leaves (Old English: gar, spear; leac, leek) of its plant, is a member of the lily family (Alliaceae) and is joined by other edible members including the onion, leek, and asparagus. In addition to its widespread culinary use, it has been regarded as healthful; indeed, Galen referred to it as ‘‘nature’s theriac,’’ or cure-all. Although some tout its benefits for atherosclerosis, hyperlipemia, diabetes, cancer, cryptosporidiosis, toxoplasmosis, intestinal worms, and to reduce platelet aggregation, data for these actions are not evidence-based. Garlic also has numerous drug interactions, notably with warfarin, but also others. Dysphagia in a garlic lover raises the issue of botulism after consumption of garlic-in-oil preparations in addition to impaction with mucosal injury, as in this patient. The potentially toxic effect of garlic is further evidenced by allergic dermatitis resembling a chemical burn after its topical application to skin, and also by the irritating effect of raw garlic powder on the gastric mucosa. Better to enjoy the taste sensation of Allium sativa after it has been cooked and its toxic factors reduced than to consume it raw and threaten proximal mucosal surfaces. Well, at least it kept the vampires away for the short time it resided in the esophagus. Lawrence J. Brandt, MD Associate Editor for Focal Points
Green ulcer in the stomach: unusual mucormycosis infection
566 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 3 : 2008
www.giejournal.org
At the Focal Point
A 58-year-old man had been robust until 2 weeks before admission when he had fever, productive cough, epigastric pain, and abdominal fullness. He was intubated for mechanical ventilator support because he developed pneumonia and respiratory failure. A plain film and CT of the abdomen showed only an ileus. He subsequently developed tarry stools, and EGD identified an ulcer with a greenish coating at the greater curvature of the mid-body of the stomach (A). The coating was not detachable from the mucosa by forceps lifting. A biopsy specimen taken from the margin and the center of the ulcer revealed numerous right-angled, pauciseptated, and ribbon-like hyphae compatible with mucormycosis (B, H&E, orig. mag. 400). A change in his level of consciousness prompted magnetic resonance imaging of the brain, which revealed fluid accumulation in the sphenoid and ethmoid sinuses. Endoscopic debridement of the right ethmoid sinus about 1 week after amphotericinB therapy began showed only chronic sinusitis without hyphae. Immunologic screening tests did not show any abnormality except for low fraction of CD4 positive T cells
(15%, absolute count of 257 cells/mL). Two weeks after antifungal therapy, EGD showed improvement in the appearance of the ulcer (C). A biopsy specimen taken from the margin of the ulcer did not show hyphae. DISCLOSURE The authors report that there are no disclosures relevant to this publication. Chen-Shuan Chung, MD, Wen-Lun Wang, MD, Department of Internal Medicine, Kao-Lang Liu, MD, Department of Medical Imaging, Jaw-Town Lin, MD, PhD, Department of Internal Medicine, Hsiu-Po Wang, MD, Department of Internal Medicine and Department of Emergency Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
doi:10.1016/j.gie.2008.02.076
Commentary The color green, so abundant in nature, signifies growth, renewal, health, and the environment, but it also has negative connotations of jealousy, envy, and inexperience. So many meanings for a wavelength of 510 nm! What did it mean in this case? Certainly nothing good. Mucormycosis refers to several different diseases caused by fungi in the class Phycomycetes and of the order Mucorales, Rhizopus being the most frequent species. It is unusual, however, that species is determined, and diagnosis usually doesn’t get more specific than ‘‘mucor.’’ Mucoraceae are ubiquitous fungi that are commonly found in soil or in decaying matter, but disease is unusual because of the low virulence of the organisms, which mainly affect immunocompromised individuals (eg, poorly controlled diabetes, glucocorticosteroid use, neutropenia in the setting of hematological or solid malignancy, transplantation, and burns). Infection usually follows local exposure, and most common is disease of the facial sinuses. Ingestion of conidia leads to GI disease that most commonly affects the stomach, ileum, and colon. Once spores begin to grow, fungal hyphae invade tissue and blood vessels, producing thrombosis, infarction, and necrosis. Invasion must be distinguished from colonization. Did this patient have an ulcer that was colonized by mucormycosis, or did the fungus cause the ulcer? Gastric ulcers occasionally fail to heal with proton pump inhibitor (PPI) therapy because they are colonized and coated with candida; only after adequate anticandidal therapy will PPIs be effective. Mucormycosis may be another colonizing and membrane-producing disease, but in this patient it is more likely to have been causative. Lawrence J. Brandt, MD Associate Editor for Focal Points
www.giejournal.org
Volume 68, No. 3 : 2008 GASTROINTESTINAL ENDOSCOPY 567