A Rare Cause of Massive Upper Gastrointestinal Hemorrhage in Immunocompromised Host

Mucormycosis is an invasive and aggressive opportunistic fungal infection that usually presents with rhinocerebral or pulmonary involvement and rarely involves the gastrointestinal tract. The disease is acute with mortality rate up to 100%. A 68-year-old male was undergoing treatment at a local hospital for COPD exacerbation with IV steroids and antibiotics. Two weeks into his treatment he suddenly developed massive upper GI bleeding and hemodynamic instability that necessitated transfer to our tertiary care hospital for further treatment and management. An urgent upper endoscopy revealed multiple large and deep gastric and duodenal bulb ulcers with stigmata of recent bleeding. The ulcers were treated endoscopically. Biopsies showed fibrinopurulent debris with fungal organisms. Stains highlighted slightly irregular hyphae with rare septa and yeast suspicious for Candida. The patient was subsequently placed on fluconazole. Unfortunately, the patient's general condition continued to worsen and he developed multiorgan failure and died. Autopsy revealed disseminated systemic mucormycosis. Most of the cases of gastrointestinal mucormycosis were reported from the tropics and few were reported in the United States. The disease occurs most frequently in immunocompromised individuals. The rare incidence of GI involvement, acute nature, severity and the problematic identification of the organisms on biopsies make antemortem diagnosis challenging. Treatment includes parenteral anti-fungals and debridement of the infected tissues. Gastroenterologists should be aware of this rare cause of gastrointestinal bleeding and understand the importance of communication with the reviewing pathologist so that appropriate, and often lifesaving, therapies can be administered in a timely manner.