|Year : 2019 | Volume
| Issue : 4 | Page : 112-115
Abdominal necrosis due to mucormycosis following lower segment cesarean section
Shailesh Shah, Esheet Shah, Riddhi Shah
Dr Shailesh Shah Surgical Hospital and Endoscopy Clinic, Kankaria Mani Nagar, Ahmedabad, Gujarat, India
|Date of Submission||13-Jan-2020|
|Date of Acceptance||05-Jun-2020|
|Date of Web Publication||11-Nov-2020|
Dr. Shailesh Shah
Dr. Shailesh Shah, Surgical Hospital and Endoscopy Clinic, Kankaria Mani Nagar, Ahmedabad, Gujarat - 380008
Source of Support: None, Conflict of Interest: None
Mucormycosis is a rare, invasive infection caused by saprophytic fungi Mucorales. It is predominantly seen in immunocompromised patients with devastating scenario. Clinically, it presents with necrosis of the parts causing ulcers and invasive wounds. Despite treatment it has a high mortality rate. Here we present a rare case of mucormycosis that was secondary to cesarean section in a young female which caused necrosis of the entire abdominal wall and septicemia. Her initial diagnosis was of necrotizing fasciitis but later tissue culture revealed presence of Mucorales. But unfortunately, patient's condition deteriorated despite aggressive treatment and debridement. This clearly reveals the invasive and fatal nature of the fungi with poor prognosis.
Keywords: Mucormycosis, Amphotericin B, wound debridement, necrotising fasciitis
|How to cite this article:|
Shah S, Shah E, Shah R. Abdominal necrosis due to mucormycosis following lower segment cesarean section. Arch Int Surg 2019;9:112-5
| Introduction|| |
Mucormycosis is an uncommon, invasive, fungal infection caused by fungi from the phylum Zygomycota and of Mucorales order. It is also known as zygomycosis and commonly occurs in immunocompromised patients. Patients having diabetes mellitus, neutropenia, organ or stem cell transplant are associated with increased mortality due to mucormycosis. Mucorales affect humans, causing infections related to gastrointestinal, pulmonary, cutaneous, rhino cerebral, and other miscellaneous organs.,, The most common organism affecting humans with mucormycosis is Rhizopus oryzae. However, other genera of Mucorales are Mucor, Absidia, Cuninghamella, and Saksenaea.
Early diagnosis, initiation of antifungals, and debridement are necessary for better survival from mucormycosis. In spite of surgical debridement and antifungals, the mortality rate in these patients still remains high. Detection of acute malignancy and neutropenia in a patient with mucormycosis on admission increases the risk of mortality. Here, we present a rare case of a patient suffering from septicaemia due to mucormycosis secondary to lower segment cesarean section (LSCS).
| Case Report|| |
A 35-year-old woman admitted at tertiary care hospital on 2 August 2017 with chief complain of ulcer on the anterior abdominal wall of one month duration. Patient had a history of LSCS performed at a private hospital, following which suture removal was done 10 days postoperatively. She then developed an ulcer over the wound site. This ulcer gradually increased in size and was responding to antimicrobial agents like nitrofurantoin, colistin, chloramphenicol, amikacin, gentamicin, tobramycin, ertapenem, meropenem, and doripenem. She was treated with antibiotics for 10 days during which she developed fever, nausea, vomiting, and discharge from the wound. Blood investigations were suggestive of septicemia with anemia.
She was admitted at our hospital 15 days later. On examination, she was afebrile with normal blood pressure and varying pulse rate between 96 and 110 beats/min. No other medical history was reported. Contrast-enhanced computed tomography (CECT) of the abdomen revealed a large ulcerated wound in the midline region of the anterior lower abdominal wall with adjacent cutaneous and subcutaneous intramuscular edema. Few pre-paraaortic aortocaval, retrocaval, mesenteric, iliac, inguinal, and obturator lymphadenopathy with mild hepato-splenomegaly were observed. She had a wound debridement [Figure 1]. Tissue histopathological examination was suggestive of necrotizing fasciitis. Culture and sensitivity report of the pus discharge for bacteria was suggestive of Klebsiella Pneumonia. Patient was on targeted therapy namely tetracycline, doxycycline, minocycline, and chloramphenicol but still no improvement was reported and the ulcer continued to grow in size [Figure 2]. The culture and sensitivity report of the fungus confirmed that mucor mycosis was the causative organism. Targeted therapy toward this was given for 10 days. Patient was commenced on treatment with IV meropenem and injection daptomycin 350 mg once daily. Daily debridement of the wound under general anesthesia was performed; however, no clinical improvement was observed. Ultimately, after few days the entire anterior abdominal wall including the skin, subcutaneous tissue, rectus sheath, and abdominal wall muscles necrosed and debrided, leaving only the peritoneum with the abdominal organs visible underneath. Although there was no clinical improvement, patient was discharged on 15 August 2017 at request (discharge against medical advice).
| Discussion|| |
Mucormycosis also known as zygomycosis or phycomycosis is caused by fungi Mucorales. These are classically non-septae, thin - walled hyphae. Though these fungi are omnipresent, they are opportunistic in nature and become pathogenic in patients with certain risk factors. These could be chemotherapy, malignancies, diabetes mellitus, stem or organ transplants, surgeries, and trauma. The most common mode of transmission is inhalation of these spores; hence, its rhinocerebral and pulmonary manifestations are more common. Rarely mucormycosis could be caused during surgery due to contamination of medical equipment in the absence of any other risk factors. Such cases usually present with cutaneous manifestations. Our above case seems to be such a rare occurrence, as patient didn't have any significant medical history prior to LSCS.
Cutaneous mucormycosis is seen in almost 19% of the mucormycosis cases. The fungal manifestation is very invasive penetrating from cutaneous, subcutaneous into the surrounding fat layers, muscles, fascia, and even the adjacent bone. Since mucorales is vasotropic in nature it might even have a hematogenous spread and produce thrombosis and necrosis in the affected area.
Mucormycosis secondary to LSCS is a very rare and life-threatening occurrence. The probable cause of mucormycosis in our above case could be due to contaminated dressing material or poor sterilization. Another probable reason could be the use of multiple antimicrobials for a longer duration. To the best of our knowledge, this is the second case reported where septicemia due to mucormycosis following LSCS resulted in necrosis of abdominal wall was reported. In a similar case series by Tilak, et al., a 24-year-old female developed cellulitis at the cesarean incision site which failed to respond to the standard antibiotics. Following confirmation of growing the fungus in culture, she was commenced on liposomal amphotericin B along with local wound debridement. She responded well and was discharged.
Previous case of necrotizing fasciitis caused by Apophysomyceselegans followed by LSCS was reported in 1997. Initially the patient had intermittent fever, pain, and minimal discharge from wound. She was started on penicillin, gentamicin, and metronidazole but was changed to amikacin and ceftazidime as the infection was not controlled even after multiple debridement. Direct microscopy confirmed the zygomycosis on fungal culture, amphotericin 2 g was given and abdominal wound granulated welland was coveredwith split-thickness skin graft.
A similar case of rhinocerebral mucormycosis due to Rhizopus oryzae was reported with the features of of headache, nasal and left eye discharge. History of diabetes, hypertension, hyperlipoproteinemia, and kidney disfunction was observed. After confirming the diagnosis of mucormycosis, the patient was placed on amphotericin B (50 mg/day) which changed to posaconazole (5 mg/kg) due to renal dysfunction. The standard treatment of choice in patients diagnosed with mucormycosis is amphotericin B as monotherapy or in combination with posaconazole.
A recent study has shown that isavuconazole monotherapy was effective in patients suffering from gastric mucormycosis following renal transplant. Diagnosis was confirmed by upper gastrointestinal endoscopy demonstrating esophagitis and gastric ulceration. Another literature review of 19 case reports showed that ileum and cecum were the most common sites of mucormycosis infection, followed by descending colon and sigmoid colon. The study also showed the overall survival rate in patients with gastrointestinal mucormycosis was only 50%. The European Society for Clinical Microbiology and Infectious Disease (ESCMID) and European Confederation of Medical Mycology (ECMM) joint clinical guidelines recommended the use of direct microscopy with optical brighteners, culture, and histopathology as a standard diagnostic method for diagnosis of mucormycosis. Multiple surgical debridement and initiation of antifungal agent like liposomal or lipid-complex amphotericin B with dose of 5 mg/kg/day is recommended. Posaconazole should be used in recovering patient with dose 4 × 200 mg/day.
Recent case of gastric perforation was reported in a patient with complaint of cellulitis of the arms. History of heroin abuse, diabetes mellitus, hypertension, and chronic kidney disease was present. Histopathology confirmed infection of mucormycosis. Diagnosis of perforated hollow viscus was confirmed on enhanced CT. Exploratory laparotomy was then performed confirming gastric perforation in prepyloric area. Patient then underwent total gastrectomy due to hemodynamic instability. Histological examination confirmed mucormycosis and the patient was treated with meropenem, metronidazole, caspofungin, and adjunctive liposomal amphotericin B. The patient died due to sepsis and multi-organ failure. Diabetes mellitus, neutropenia, solid organ transplantation, human immunodeficiency virus, use of corticosteroid, and hematological malignancies are associated with increased risk and deterioration of mucormycosis.
In the present case, patient had history of LSCS followed by ulcer over the wound. The ulcer gradually increased in size causing septicemia. Patient did not respond to medication and the infection continued to spread resulting in necrosis of the entire abdominal wall leaving only peritoneum with abdominal organs. As the condition was not improving the patient and his guardians refused to continue further treatment and she was discharged on request.
As the nature of infection is aggressive so should be the treatment. Usually any cutaneous infection is treated with standard antibacterial agents which fail to provide any antifungal support, thereby there is a delay in the treatment which favors deeper invasion of the organism. Thus, any doubtful non-healing wound should be considered for fungal smears at the earliest. Amphotericin B is the standard choice for the treatment of mucormycosis. During the treatment a close monitoring should be done for renal toxicity as amphotericin is known for nephrotoxic properties. Surgical debridement of the wound is an important method for wound healing and limiting the infection. Wound debridement is also important for deeper tissues, organs or wounds with bone involvement. Once the infection resolves, reconstructive procedures could be considered.
| Conclusion|| |
Abdominal ulcers leading to septicemia following LSCS is a rare phenomenon. Mucormycosis occurring in the gastrointestinal tract has high mortality rate. Though the symptoms are not specific, diagnosis need to be confirmed by tissue culture, sensitivity, and endoscopy. Early detection and aggressive antifungal therapy are required for improved survival of the patient. Cutaneous mucormycosis can be prevented by taking adequate care before, during, and after surgical procedure.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his/her/their consent for her images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Authors thank Dr. Triveni Bangera for her medical writing assistance.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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