Copyright
©The Author(s) 2015.
World J Gastroenterol. Nov 28, 2015; 21(44): 12713-12721
Published online Nov 28, 2015. doi: 10.3748/wjg.v21.i44.12713
Published online Nov 28, 2015. doi: 10.3748/wjg.v21.i44.12713
Table 1 Case reports of isolated Aspergillus appendicitis without other known Aspergillus infection
Age and sex [reference] | Underlying condition | Chemotherapy received prior to appendicitis | Symptom appearance after initiating chemotherapy | Neutropenia at presen- tation | Abdominal imaging | Pathologic findings in resected appendix | Therapy and outcome |
8-yr-old male[1] | ALL | Initial therapy: Vincristine, prednisolone, L-asparaginase, intra- thecal methotrexate.Chemotherapy during relapse: not reported | 14 mo after therapy restarted for a relapse | Yes | USD: enlarged appendix, cecal wall thickened, and small periappendiceal fluid collection | Necrosis and inflammation in mucosa and nearby muscle consistent with acute appendicitis. Many septated fungal hyphae showing acute-angle branching, characteristic of Aspergillus | Fared poorly for 10 d while treated with conventional antibiotic therapy of ceftazdime and amikacin before undergoing appendectomy. Did well after appendectomy. Discharged in stable condition at postoperative day 10 (not mentioned whether received antifungal therapy after appendectomy) |
41-yr-old male[2] | ALL (B-cell type with BCR-ABL trans-location) | Induction therapy: cyclophosphamide, daunorubicin, vincristine, prednisone, L-asparaginase, and dasatinib; Maintenance therapy: 6-mercaptopurine and dasatinib; Received stem cell transplantation | 12 d after transplantation; 5 mo after initiation of chemotherapy | Yes | CT: cecal wall thickened, thickened retrocecal appendix, and periappendiceal inflammatory changes; small amount of free fluid present | Full-thickness invasion of appendiceal wall including serosa; fungal angioinvasion with vessels occluded by hyphal forms; positive methenamine-silver stain | Fared extremely poorly for 6 d with conventional antibiotic therapy plus acyclovir and fluconazole. Improved after appendectomy and after receiving liposomal amphotericin B and micafungin (switched on day 3 to voriconazole and micafungin due to acute renal injury). Discharged 46 d after appendectomy. Clinically stable 12 mo after hospitalization, without further aspergillus complications |
21-yr-old male[3] | AML- M1 | Mitozantrone and cytarabine.Later treatment with daunorubicin and cytarabine | 30 d after diagnosis | Yes. WBC = 500/mm3 (no neutrophils seen) | USD: dilated bowel loops and right hydronephrosis.CT scan: right hydroureter extending down into pelvis with loss of fat planes in the region, consistent with inflammatory process around distal ureter | Coagulative necrosis of appendiceal tip with septate fungal hyphae with dichotomous branching pattern, permeating and occluding arterial branches.Immunoperoxidase stain demonstrated Aspergillus flavus | Amphotericin BSecond laparotomy 6 d after first showed 3 small bowel perforations. Died at day 49 from bleeding from Aspergillus invasion of iliac vein |
139-yr-old, sex not stated[6] | Not reported | NA | NA | Not reported | Not reported (case published in 1959 before abdominal CT or USD became available) | At surgery: inflamed, enlarged, gangrenous appendix with severe surrounding inflammation. Microscopic pathology not reported | Did poorly postoperatively with high spiking fevers, overwhelming sepsis, and progressive jaundice while receiving streptomycin and 2 other antibacterial antibiotics. On day 9 therapy with antimycotic trichomycin initiated after Aspergillus nidulans isolated from appendiceal culture. Died 3 d later from progressive organ failure |
8-yr-old male[Current Case Report] | AML-M5 | Daunorubicin, cytarabine, thioguanine, etopiside, and dexamethasone | 30 d | Yes. WBC=200/mm3 | USD: no evident right lower quadrant abscess or free fluid. CT: inflammatory changes in right lower quadrant with thick-walled appendix and dilated appendiceal lumen | Branched, septate fungal hyphae invading full thickness of appendiceal wall without discrete perforation | Underwent appendectomy: Did poorly initially postoperatively while receiving antibacterial antibiotics. Recovered after receiving amphotericin B and discharged after 21 d of this therapy.No signs of disseminated Aspergillosis during 8 mo of follow up while receiving prophylaxis with itraconazole |
Table 2 Reported cases of Aspergillus appendicitis with additional gastrointestinal involvement
Age and sex. areas of aspergillus infection [reference] | Underlying condition | Chemotherapy received prior to appendicitis | Presentation with symptoms after initiation of chemotherapy | Neutropenia at time of developing symptoms | Abdominal imaging | Pathologic findings in resected appendix | Antifungal therapy: Outcome |
11-yr-old male.Extensive GI involvement including appendix and cecum (typhlitis)[28] | AML | Cytarabine, daunorubicin, and etoposide | Day 12 after initiating chemotherapy | Yes | USD: thickened intestinal walls with indistinct hypoechogenic area reaching from cecal pole to mesenteric root | Performed cecal resection and appendectomy. Chronic, partially hemorrhagic inflammation of intestine infiltrated by Aspergillus. Fungal hyphae also demonstrated within blood vessels | Amphotericin B and fluoro-cytosine: Patient succumbed to septic shock while on persistent antifungal therapy 6 wk after admission. Autopsy demonstrated disseminated Aspergillosis |
38-yr-old male. Only appendix and cecum infected[26] | ALL | Vincristine and prednisone and intrathecal methotrexate. Later changed to cytoxan and adriamycin | Hospital day 7 | Yes, WBC = 100/mm3 | Gallium scan: increased uptake in midabdomen and pelvis consistent with infectious process.CT: increased density in right lower quadrant consistent with an abscess or fluid-filled cecum | Laparotomy: appendix not found (apparently due to destruction), but cecal perforation with surrounding abscess with multiple coloenteric fistulas found. Resected specimen showed Aspergillus hyphae in necrotic area of bowel wall invading peritoneal surfaces | Amphotericin B: Stable at 6 mo follow-up, with right lung infiltrate that identified on previous X-ray, being stable in size |
62-yr-old female.Appendix, cecum, ascending colon and ileum infected[27] | AML M6 | Induction therapy: cytarabine for 7 d and idarubicin for 3 d | Day 16 after initiating chemotherapy | Yes, WBC = 600/mm3, no neutrophils | CT: inflammatory changes and fat stranding surrounding dilated appendix. Small amount of adjacent free fluid in pelvis | Resected 2.5 cm segment of small bowel and 60 cm segment of cecum and ascending colon. Microscopic evaluation of sections of bowel and appendix showed transmural intestinal infarction with hemorrhagic plugs within intestine blood vessels and fungal hyphae with septation and acute branching angles. Fungal stain revealed morphology consistent with Aspergillus | Voriconazole started empirically 20 d after admission, before surgery: Patient expired from cardiac arrest 26 d after admission |
5-yr-old female. Appendix involved with widespread GI infection[29] | AML and diffuse large B-cell lymphoma | 6 cycles of ThaiPOG protocol | Not specified | Yes | CT: early abscess formation in distal ileum and appendix | Pathological confirmation of appendicitis caused by invasive aspergillosis | Amphotericin B, metronidazole and piperacillin with tazobactam: Died 1 d later from septicemia with DIC; Autopsy disclosed fungal infection disseminated throughout body |
-
Citation: Gjeorgjievski M, Amin MB, Cappell MS. Characteristic clinical features of
Aspergillus appendicitis: Case report and literature review. World J Gastroenterol 2015; 21(44): 12713-12721 - URL: https://www.wjgnet.com/1007-9327/full/v21/i44/12713.htm
- DOI: https://dx.doi.org/10.3748/wjg.v21.i44.12713