A non-diabetic, non-alcoholic 58-year-old gentleman with a previous history of mild COVID-19 infection presented to us with ascites and weight loss for two months. Initially, he got admitted to a local hospital where he was labeled decompensated liver cirrhosis and discharged with conservative management. However, his health deteriorated; he was moved to another tertiary facility, where comprehensive blood tests and laparoscopic exploration revealed numerous tubercles in the parietal peritoneum and liver; multiple biopsy samples were collected. While waiting for the histopathology report, antitubercular treatment was started empirically. Histopathology indicated a lymphoproliferative disease, whilst immunohistochemistry showed an inflammatory lesion. A biopsy of the liver revealed mild chronic hepatitis. Consultation with a hematologist revealed insufficient evidence of lymphoproliferative disease. At that time, the ascitic fluid study showed straw color, exudative, serum ascites to albumin gradient (SAAG) was 10.2 g/L, and negative for nucleic acid amplification test (Xpert MTB/RIF) and malignant cells. In addition, the ascitic fluid culture showed the growth of pseudomonas spp. He was treated with broad-spectrum antibiotics; antitubercular medication was discontinued. But his health deteriorated, so he was transferred to Bangabandhu Sheikh Mujib Medical University.
When we received the patient in June 2021, he was profoundly anorexic, losing 15 kg of body weight and substantial abdominal distension. He had moderate anemia, lymphadenopathies involving cervical and axillary regions, gross ascites with hepatomegaly, and a just palpable spleen, but no palmar erythema, encephalopathy, and jaundice. As the patient vitals were deteriorating, we restarted antitubercular therapy empirically. We sent for blood and ascitic fluid for study. His complete blood counts revealed hemoglobin 10.6 g/dl, ESR 50 mm in the 1st hour, white blood cells 11,000/mm3 with neutrophil 88%, platelets 230,000/mm3, peripheral blood film microcytic hypochromic with target cells, schistocyte, spherocyte, agglutination. Hb electrophoresis showed the Hb E trait. His full liver function tests were normal. His fasting blood sugar was 4.8 mmol/L, and his Hb1Ac was 5.7%. Ascitic fluid results were: WBC 500cells/mm3 (neutrophils 45%, lymphocyte 55%), total protein 39 g/L, ADA 23.6 U/L; serum ascites to albumin gradient 16.61 g/L. Ascitic fluid for gram stain & culture, AFB stain, and nucleic acid amplification test (Xpert MTB/RIF) showed no organism. Viral markers, HBsAg, Anti HCV, Anti HBcAb, and Anti-HIV Ab(1 +2) were negative. D-Dimer 0.86 microg/ml, LDH 355 U/L, C-reactive protein 9.1 mg/L; S. ceruloplasmin:21 mg/dl, ANA was negative, S. CA-19.9 18.5 U/ml, S. CEA 1.51 ng/ml. Abdominal computed tomography revealed hepatosplenomegaly, moderate ascites, and abdominal lymphadenopathy. Chest computed tomography showed mediastinal and bilateral axillary lymphadenopathy with bilateral pulmonary inflammatory lesion with few ground-glass opacities and fibrosis in both lower lobes (Fig. 1a). Echocardiography showed no valvular or pericardial abnormality. Upper gastrointestinal endoscopy was normal. The bone marrow study showed the presence of aseptate hyphae (Fig. 1b), although the bone marrow culture study didn't show any organism growth.
After finding fungal hyphae from bone marrow, we stopped antitubercular therapy. We immediately sent another set of ascitic fluid for fungal stain and culture. In a Sabouraud dextrose agar, the culture of the ascitic fluid showed a cottony white, woolly growth at 48 h. Microscopic examination from culture growth of fungus in SDA agar with lactophenol cotton blue stain showed aseptate irregular hyphae where globose-shaped sporangia were filled with round spores (Fig. 1c). Morphology of organisms in ascitic fluid and bone marrow specimens were consistent with the mucor species.
Tablet posaconazole was started to treat mucormycosis because liposomal amphotericin B was expensive for the patient. It is to be noted that liposomal amphotericin B is supplied free of cost only in the treatment of visceral leishmaniasis by the government of Bangladesh. However, the patient passed away on the fifth day of antifungal therapy. Unfortunately, we couldn't perform an autopsy on the patient as his family refused.