Here, we present a 69-year-old male patient who resides in southern Saudi Arabia and works as a farmer. His past medical history includes uncontrolled type II diabetes and laparoscopic cholecystectomy one year prior to presentation. He presents to the emergency department on (day 0), with a two-week history of left lower abdomen pain, a one-year history of intermittent fever, and weight loss.
Initially, abdominal examination revealed paraumbilical and left lower quadrant tenderness with distension but no organomegaly and other systems where unremarkable.
Laboratory investigations showed leucocytosis 22.95 * 10^9/L with a differential of neutrophilia and eosinophilia (21.7 %), Haemoglobin of 126 g/L,Platelets of 518 * 10^9/L,C-reactive protein 262.48 mg/L (rest of labs were normal). Abdominal x-ray showed faecal impaction, nonspecific distribution of bowel gases, no air under diaphragm and no signs of bowel obstruction. CT abdomen and pelvis with contrast showed multifocal segmental wall thickening in the distal ascending, proximal transverse, and distal descending colon, with fluid collections suggesting concealed perforations (day 0).
The patient was admitted to the general surgery unit with a diagnosis of severe diverticulitis, and he was started on Piperacillin/Tazobactam and maintained nothing by mouth. The patient's symptoms worsened, and he had blood-stained stool. As a result, CT abdomen and pelvis with contrast was repeated, demonstrating recurrence of multifocal segmental wall thickening involving the hepatic flexure, proximal transverse, and distal descending colon, as well as evidence of concealed perforation and interval increase in size of surrounding collections (day 4). Overall findings were suggestive of severe diverticulitis versus aggressive infections like basidiobolomycosis and actinomycetes (Fig. 1, Fig. 2, Fig. 3).
Infectious diseases team was involved after release of the second abdominal CT result and recommended for surgical intervention, obtaining biopsy for bacterial, TB, fungal cultures, and histopathology in addition to an empiric start of liposomal amphotericin B, Amoxicillin/Clavulanic acid and tigecycline.
Although kept on broad spectrum antimicrobial agents, patient condition worsened, and he was persistently febrile. His white blood cells increased to 31.7 * 10^9/L with absolute eosinophils count increased to 3.58 * 10^9/L. His haemoglobin dropped to 10 g/dL therefore, a third abdominal CT with contrast was arranged that revealed redemonstration of circumferential wall thickening of the colon but interval increase in size of fluid collection measuring approximately 7.9 x 9 cm, compared to 7.7 x 9.1 cm as well as interval increase in abdominopelvic ascites with surrounding inflammatory changes (day 8).
The patient was taken to operation room and found to have faecal peritonitis due to multiple colon perforation at sigmoid, transverse, and descending colon with small bowel adhesion and adhesions between small bowel and transverse colon. Adhesolysis was done in addition to total colectomy and end ileostomy was created with placement of two drains (day 9).
After the operation, the patient was transferred to intensive care unit (ICU) for close monitoring and observation. Interestingly, his absolute eosinophils count dropped immediately after surgery and reached down to 0.08 * 10^9/L.
While being in ICU, the patient's haemoglobin dropped to 69.0 g/L, and he was started to inotropic support and transfused several units of packed red blood cells. He maintained minimal ventilator settings with minimal respiratory secretions. Abdominal and pelvic CT was repeated two days after surgery and showed no collection found.
Bacterial tissue culture showed heavy growth of Pseudomonas aeruginosa and carbapenem resistant Klebsiella variicola. Blood culture from the central line, showed Bacteroides fragilis. Fungal tissue culture showed Candida glabrata. Histopathology showed extensive inflammation involving the full thickness of the colon tissue and extended to the serosal surface. The inflammation consists of mixed inflammatory cells along with sheets of eosinophils and multiple foci of fungal microorganism. The fungal microorganisms are hyphae that are irregularly branched, thin walled, occasionally septated and surrounded by thick eosinophilic cuff splendore-Hoeppli phenomenon (Fig. 4, Fig. 5, Fig. 6).
Despite surgical intervention, continuing liposomal amphotericin B 5 mg/kg IV once per day, Itraconazole 200 mg orally twice per day and modifying antibacterial agents; patient's condition deteriorated and passed away due to refractory septic shock.