A fatal case of gastric mucormycosis in a 46-year-old diabetic is described. The pathological findings at laparotomy and postmorte'm examination are discussed. An interesting feature was a massive splenic infarction.S. Afr. Med. J., 48, 838 (1974)

Dannheimer, IPL

Fouche, W

Nel, C

English

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~38 S.-A. MEDIESE TYDSKRIF 20 April 1974.Gastric Mucormycosis in a Diabetic PatientI. P. L. DANNHEIMER, W. FODCHE, C. NELSUMMARYA fatal case of gastric mucormycosis in a 46-year-olddiabetic is described. The pathological findings at laparo-tomy and postmorte'm examination are discussed.An interesting feature was a massive splenic infarction.S. Afr. Med. J., 48, 838 (1974).The Mucoraceae, especially Rhizopus, members of theclass Phycomycetes, are ubiquitous soil saprophytes whichcomplicate malignancy, diabetic acidosis, prolonged steroidand antibiotic therapy and leukaemia. These opportunisticfungal infections are frequently fatal and often onlydiagosed at necropsy.In 1943 Gregory et al. described the first case ofmucormycosis, and in over 200 cases' described in theliterature, death was related to the infection in about halfof these. Cranial, digestive, pulmonary and systemicinvolvement has been reported due to Rhizopus, Absidiaand Mucor.'" Other members are solely subcutaneousphycomycoses.CASE REPORTA 46-year-old Black diabetic was hospitalised because ofincreasing peri-umbilical pain, a dry mouth and malaise.Diabetes mellitus and liver cirrhosis had been discoveredone month earlier, and the patient had been given 70units of lente insulin and Insoral TD daily.On admission he was severely ill, dehydrated and slightlyconfused (keto-acidotic with blood sugar 562 mg/lOOm!). The liver was 3 fingers palpable, with a fine nodularsurface. On therapy the confused state continued and aparalytic ileus set in. On day 8 a laparotomy was per-formed. The whole abdomen was filled with a thick,dark, pus-like fluid, but no visceral perforation was found.Two big, roundish, black areas (Fig. 1) could be seenon the stomach surface. He died on the fourth post-operative day.NECROPSY FINDINGSThe stomach showed black discoloration of the mucosa aswell as numerous fairly well-circumscribed necrotic areasof varying size, which, microscopically, were large areasof infarction involving mainly the mucosa and submucosa.H. F. Venvoerd Hospital, Pretoria1. P. L. DA TNHEIMER, M.MED. (INT.)W. FOUCHE, D.G.P.C. NEL, M.B. GH.B.Daie received: 11 Ociober 1973.Fig. 1. Stomach showing large necrotic areas.Numerous fungal elements with non-septate hyphae andbranching at obtuse angles were present in the necrotictissue and in the lumina and walls of submucosal arteriesand veins (Fig. 2). Septic thrombi were present in sub-mucosal arteries.Fig. 2. Fungal elements with non-septate hyphae andbranching at obtuse angles present in the necrotic tissue.The liver (mass 2500 g) appeared rusty-brown in colourand was finely nodular. Massive haemosiderin depositswere present in the Kupffer cells and portal tracts. Thefeatures were those of siderosis and micronodular cirrhosis'complicated by oesophageal varices. Small infarcts werepresent, and septic thrombi containing fungal elementsccmld be demonstrated in the portal veins.20 April 1974 S.A. MEDICAL JOURNAL 839The spleen (mass 670 g) was brown in colour due tosiderosis, and showed massive infarction due to a recentthrombus in the splenic artery. Fungal elements werepresent in the infarcted tissue and in the splenic sinusoidsadjacent to the infarction. Incidental findings were cerebralcysticercosis and a haemorrhagic bilharzial cystitis. Nodiabetic nephropathy could be demonstrated.DISCUSSIONThis rare and mostly fatal infection by an opporturust1cfungus is seen in patients with severe diabetes. acidosis.leukaemia, renal disease, septicaemia, burns, malnutrition,lymphoma and after long-term treatment with steroidsand antibiotics.The host response to this generally non-pathogenic fun-gus is poorly understood.' Possible aetiological factorsare a decrease in the mucor-inhibiting ability of normalserum; a depressed polymorph leucocyte migration secon-dary to a decrease in mast-cell degranulation, and abnor-malities in leucocyte mobilisation or phagocytosis.Pulmonary infection results from the inhalation ofspores produced under aerobic conditions in the nose or. nasopharynx. Devitalised tissue and local acidosis producedby bacterial infection enhance the growth and invasive-ness of the fungu .Thrombosis with infarction involving stomach, spleenand liver was seen in this case. The predilection forinvading blood vessels, Iymphatics and nerves with throm-bosis and infarction seems a unique feature of thisorganism. The majority of cases are diagnosed at necropSYwhen the typical non-septate hyphae are seen. Only in500 0 of cases was infected material isolated. The difficultyin treating mucormycosis is due to the debilitated staleof the patient or the failure of the drug to reach thefungus because of the tissue infarction, rather thanresistance to amphotericin-B. Subcutaneous forms havebeen treated with trimethoprim sulphamethoxazole.REFERENCES1. Palmer, D. L., Weitzner and Simpson, 1. C. F. (1970): Diabetes. 19,881.2. Hal, L. M. (1971): Arch. Ophthalmol., 86,39.3. Reich, J. and Renzeui, A. (1970): Amer. Rev. Resp. Dis., 102, 959.4. Satlr, A. A., Mahgoubs, M. D. A. S. and Mousa, A. R. (1971):Brit. Med. J., I, 440.5. Medoff, G and Kobayashi, G. (1972): New Engl. J. Med., 286, 86.Prune Belly SyndromeJ. A. HAMMOND, E. W. VAN DEN ENDE, R. G. BOARDMAN, B. P. MATHERSUMMARYTwo cases of prune belly syndrome in Black infantsare presented. The prune belly syndrome, or congenitalabsence of abdominal muscles, is accompanied byhydro-ureter, hydronephrosis, megalocystis and usuallyundescended testes. Other associated congenital defectsoccur, of which orthopaedic defects appear to be themost prevalent. Others are patent urachus, congenitalheart malformation, anomalies of the eyes and ears, ecto-dermal dysplasia, torticollis and micrognathia.S. Afr. Med. l., 48, 839 (1974).Department of Paediatrics, Kimberley Hospital, Kimberley,CPJ. A. HAMMOND, B.Se.. M.B. B.CH.E. W. VAN DEN ENDE, M.B. CRB.R. G. BOARDMA_J, B~A., M.B. B.CH.B. P. MATHER, M.B. CH.B., M.MED. (P.-I.TH.)Date received: 4 December 1973.CASEIA male Black child presented at 18 days of age with ahistory of having been born with an abnormal abdomen.Obstetric and family history was normal.On examination the abdomen was lax and floppy, withlateral distension. Overlying skin was wrinkled and slightlyhyperpigmented. Both testes were undescended. No ortho-paedic abnormalities were present. The rest of the exami-nation, special investigations and X-ray films of chest.skull and skeleton were normal.The child contracted gastro-enteritis and died at theage of 46 days.Autopsy FindingsThere were no apparent orthopaedic defects. The skinover the abdomen was wrinkled and hyperpigmented.The musculature of the anterior abdominal wall wasvirtually absent. with only a thin streak of muscle

Gastric Mucormycosis in a Diabetic Patient

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Gastric Mucormycosis in a Diabetic Patient

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