Histopathological evidence of invasive gastric mucormycosis after transarterial chemoembolization and liver transplantation

Kaiser, P. ; Maggio, E. ; Pfammatter, T. ; Misselwitz, B. ; Flury, S. ; Schneider, P. ; Dutkowski, P. ; Breitenstein, S. ; Müllhaupt, B. ; Clavien, P. ; Mueller, N.

In: Infection, 2014, vol. 42, no. 4, p. 779-783

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    Summary
    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 8months earlier and 40days before transplantation were identified in the submucosal tissue. The patient was treated with liposomal amphotericin B (LAB) for 5weeks, followed by 7weeks of posaconazole. Follow-up biopsies after 1 and 5months 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.