A 54-year old Latin American female, with history of type 2 diabetes mellitus and end-stage renal disease presented to the emergency department with a 10-day history of headache and photophobia. She complained of chronic cough, weight loss, and low-grade fever. She reported close contact with a person with pulmonary tuberculosis three years prior to her admission. On physical examination, she was febrile (38.5  C), tachycardic and had mild impairment of alertness. Pulmonary auscultation revealed diffuse crackles mainly of the left lung. Initial laboratory studies showed white blood cell count (WBC) 4800 cells/muL; absolute lymphocyte count 816 cells/muL; hemoglobin 10.3 g/dL; and blood sugar 111 mg/dL. Liver function tests were normal, creatinine 7.2 mg/dL; and blood urea nitrogen 59 mg/dL. The chest x-ray showed bilateral interstitial infiltrates and brain magnetic-resonance images showed multiple ring-shaped lesions in posterior areas of both hemispheres. Acid-fast bacilli sputum culture was positive on Ziehl-Neelsen stain and grew Mycobacterium tuberculosis complex (MTB) with no evidence of antibacterial resistance. HIV1/2 and toxoplasma serologies were negative. On lumbar puncture, the opening pressure was 30 cm H2O. Analysis of the cerebrospinal fluid (CSF) showed red blood cell count 1000 cells/muL; WBC 114 cells/muL; lymphocytes 92%; glucose 30 mg/dL; and proteins 161 mg/dL. CSF neurocysticercosis serology and cryptococcal antigen were negative. CSF Mycobacterium tuberculosis stain and culture and adenosine deaminase were negative, whereas a polymerase chain reaction (PCR) was positive for MTB.
Anti-TB therapy was started with rifampin, isoniazid, pyrazinamide, ethambutol and pyridoxine with adjunctive dexamethasone planned for 8 weeks. A few days later, her mental status rapidly deteriorated requiring admission to the intensive care unit and initiation of hemodialysis for uremia, which resulted in clinical improvement. After three weeks of hospitalization, she developed acute abdominal pain and hematemesis. A computerized tomography (CT) of the abdomen revealed a loculated multiseptated gas and fluid collection along the posterior aspect of the gastric fundus with free intra-abdominal air consistent with gastric perforation (Fig. 1a). An exploratory laparotomy demonstrated complete stomach necrosis (Fig. 1b). She underwent a total gastrectomy with intestinal discontinuity followed by cervical esophagostomy and jejunostomy tube (J-tube) placement. Oral anti-TB therapy was switched to intravenous treatment with amikacin, linezolid, levofloxacin and rifampin. The patient developed septic shock, requiring intubation and mechanical ventilation. Empiric broad-spectrum antibacterial therapy was initiated with piperacillin-tazobactam for intra-abdominal infection.
Histopathology of gastric tissue on hematoxylin and eosin (Fig. 1c) and Grocott-Gomori methenamine silver stains showed broad, irregularly branched, rarely septate hyphae consistent with angio-invasive gastric mucormycosis. The acid-fast bacilli stain and culture were negative. Liposomal amphotericin B 7.5 mg/kg daily was initiated and TB treatment with levofloxacin, rifampin, isoniazid, and linezolid was maintained for one more month. Then, isoniazid plus rifampin were continued by jejunostomy tube to complete 12 months of treatment. Liposomal amphotericin B was switched to posaconazole as oral suspension 200 mg/6 h per J-tube. Upon clinical stabilization and improvement, she returned to her country of origin in Latin America to finalize her treatment.