Gastrointestinal mucormycosis is a rare infection in solid organ transplant recipients. Our patient, a 79-year-old male, presented with severe dysphagia and odynophagia about 2 weeks after receiving a renal transplant. An upper gastrointestinal (UGI) endoscopy revealed esophagitis and gastric ulceration, the cultures from which grew Rhizopus species. A usual treatment strategy should include Amphotericin B as monotherapy or in combination with Posaconazole or Isavuconazole for such infections. Our patient was treated with Isavuconazole monotherapy, in an effort to minimize renal toxicity from Amphotericin B to the new allograft. Unique to our case was a successful clinical response and resolution of UGI lesions with Isavuconazole monotherapy. Due to the vagueness of presenting symptoms, such infections can be easily missed in an immunocompromised patient which can have tragic outcomes. Prompt diagnosis and modulation of immunosuppression are essential to decrease mortality and morbidity. Isavuconazole is a novel agent and can be used as a monotherapy for such infections, especially in renal transplant recipients.
Mucormycosis has emerged as a debilitating infection in renal transplant patients with a high incidence of allograft loss if the infection is disseminated. It carries high morbidity and mortality rates despite treatment. Rhizopus species has been reported to be the most common cause of mucormycosis infection in immunocompromised patients. Isavuconazole so far has not been used as monotherapy for the first line treatment for gastric mucormycosis in a renal transplant patient due to lack of clinical data.
We present a rare case scenario of a 79-year-old African-American male who developed severe gastrointestinal mucormycosis from Rhizopus species infection 2 weeks after receiving a renal transplant and was successfully treated with Isavuconazole monotherapy.
Our patient, a 79-year-old African-American male with a past medical history of end-stage renal disease secondary to hypertension, DM Type 2, coronary artery disease received an uneventful deceased donor kidney transplantation. His induction immunosuppression consisted of antithymocyte immunoglobulin and steroids and his maintenance regimen consisted of Mycophenolate Mofetil, Tacrolimus, and Prednisone. He received Trimethoprim-Sulfamethoxazole, Valgancyclovir, and Nystatin for opportunistic infection prophylaxis. His immediate posttransplant course was complicated by transient delayed graft function and Clostridium difficile diarrhea which resolved after treatment by postoperative day 10.
On postoperative day 16, he started experiencing dysphagia and odynophagia and was unable to take solid food. An esophagogastroduodenoscopy (EGD) was performed revealing Los Angeles Grade D esophagitis, 20 cm in length (Figure
Endoscopic imaging showing severe esophagitis.
Endoscopic imaging of gastric lesion before the initiation of treatment.
Fungal elements in a background of necrotic and acute inflammatory exudate and unremarkable gastric foveolar epithelia. No evidence of malignancy (x2000).
Fungal hyphae highlighted by Grocott-Gomori’s Methenamine Silver (GMS) stain in a background of necrotic and acute inflammatory exudate and unremarkable gastric foveolar epithelia. No evidence of malignancy (x1000).
Endoscopic images of the gastric lesion after treatment with Isavuconazole.
Gastrointestinal (GI) infections are common in recipients of solid organ transplant patients due to underlying immunosuppression. Common causes include Clostridium difficile, Cytomegalovirus, Herpes Simplex Virus, Helicobacter pylori, and enteric bacteria (Campylobacter, Escherichia coli, Salmonella). Other infectious agents implicated include parasites (Giardia intestinalis, Strongyloidiasis) and viruses (Norovirus and Rotavirus) [
Mucormycosis can be a life-threatening opportunistic fungal infection. The incidence of mucormycosis among solid organ transplant recipients is 0.4-16 % depending upon the organ being transplanted, and it is 0.2% – 1.2% in renal transplant recipients [
Mucormycosis involving the stomach in a renal transplant patient has been reported before [
Despite antifungal therapy, surgical debridement/debulking and reduction of immunosuppressive therapy, mortality can be high due to the aggressive nature of this fungus. The most commonly used antifungal agent for mucormycosis treatment is Amphotericin B [
To the best of our knowledge, this is the first reported case of a patient with gastric mucormycosis after renal transplant successfully treated with Isavuconazole monotherapy. There has been one previous case report published where there was a successful result using Isavuconazole in addition to Amphotericin B and surgical debridement in disseminated pulmonary infection in a renal transplant patient [
We report a rare case of gastric mucormycosis successfully treated with Isavuconazole monotherapy in a renal transplant patient. Mucormycosis, though rare, can affect gastrointestinal tract in immunocompromised solid organ transplant patients. Symptoms are nonspecific; therefore a high index of suspicion is required to make the diagnosis by endoscopy. Timely introduction of antifungal therapy and the reduction of immunosuppression is the standard of care.
An informed consent was obtained from the patient.
The authors declare that there are no conflicts of interest regarding the publication of this paper.