title: Histopathological evidence of invasive gastric mucormycosis after transarterial chemoembolization and liver transplantation.
abstract: We describe a case of a 62-year-old diabetic woman with hepatocellular carcinoma due to chronic hepatitis B virus infection. Two weeks after orthotopic liver transplantation, endoscopy for massive upper gastrointestinal bleeding revealed a large necrotic area in the gastric fundus. The patient underwent emergency resection. Histopathologically, angioinvasive mold infection compatible with mucormycosis was diagnosed in a large area of necrosis, mimicking an atypically localized gastric ulcer. Foreign bodies originating from transarterial chemoembolization (TACE) performed 7 and 8 months earlier and 40 days before transplantation were identified in the submucosal tissue. The patient was treated with liposomal amphotericin B (LAB) for 5 weeks, followed by 7 weeks of posaconazole. Follow-up biopsies after 1 and 5 months confirmed successful treatment. Review of the radiological images of the TACE procedure showed that some of the TACE material had been diverted to the stomach via an accessory gastric branch originating from the left hepatic artery. TACE agents may be associated with chronic, refractory gastroduodenal ulcers. We hypothesize that the ischemic lesion was first colonized with presumed Mucorales mold and invasive growth was promoted by the posttransplantation immunosuppression. Careful exploration of extrahepatic collaterals during TACE may prevent this complication.
authors.affiliation: Division of Infectious Diseases and Hospital Epidemiology, Department of Medicine, University Hospital Zürich, Rämistrasse 100/RAE U 70, 8091, Zürich, Switzerland.
authors.forename: P
authors.initials: P
authors.lastname: Kaiser
authors.forename: E M
authors.initials: EM
authors.lastname: Maggio
authors.forename: T
authors.initials: T
authors.lastname: Pfammatter
authors.forename: B
authors.initials: B
authors.lastname: Misselwitz
authors.forename: S
authors.initials: S
authors.lastname: Flury
authors.forename: P M
authors.initials: PM
authors.lastname: Schneider
authors.forename: P
authors.initials: P
authors.lastname: Dutkowski
authors.forename: S
authors.initials: S
authors.lastname: Breitenstein
authors.forename: B
authors.initials: B
authors.lastname: Müllhaupt
authors.forename: P A
authors.initials: PA
authors.lastname: Clavien
authors.forename: N J
authors.initials: NJ
authors.lastname: Mueller
mesh_terms: D000666:Amphotericin B / Q000627:therapeutic use; D000935:Antifungal Agents / Q000627:therapeutic use; D006528:Carcinoma, Hepatocellular / Q000601:surgery; D016461:Chemoembolization, Therapeutic / Q000009:adverse effects*; D048909:Diabetes Complications; D005260:Female; D019694:Hepatitis B, Chronic / Q000150:complications; D006651:Histocytochemistry; D006801:Humans; D016867:Immunocompromised Host; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D008113:Liver Neoplasms / Q000601:surgery; D016031:Liver Transplantation / Q000009:adverse effects*; D008853:Microscopy; D008875:Middle Aged; D009090:Mucorales / Q000302:isolation & purification*; D009091:Mucormycosis / Q000175:diagnosis* / Q000473:pathology*; D013272:Stomach Diseases / Q000175:diagnosis* / Q000473:pathology*; D014230:Triazoles / Q000627:therapeutic use
chemical_list: D000935:Antifungal Agents; D007166:Immunosuppressive Agents; D014230:Triazoles; C068538:liposomal amphotericin B; C101425:posaconazole; D000666:Amphotericin B