J Korean Soc Radiol.  2015 Nov;73(5):328-332. 10.3348/jksr.2015.73.5.328.

CT and MR Imaging Findings of Appendiceal and Hepatic Mucormycosis in a Patient with Acute T-Lymphoblastic Leukemia

• Choi SY
• Lee MH
• Lee HK
• Yi BH
• Chin S
• Park SK
• Chung JC

• KMID: 2079568
• DOI: http://doi.org/10.3348/jksr.2015.73.5.328

Abstract

Fungal infections occur in severely immunocompromised patients having profound and prolonged neutropenia. Here, we report a case of a 41-year-old female who, at the conclusion of induction chemotherapy for acute T-lymphoblastic leukemia, developed angioinvasive mucormycosis involving the appendix and liver, which presented as abdominal pain. This case is the first to provide detailed computed tomography and magnetic resonance imaging findings of angioinvasive appendiceal and hepatic mucormycosis. The implications of these findings as well as the diagnosis and management of mucormycosis, is further discussed.

MeSH Terms

Abdominal Pain
Adult
Appendix
Diagnosis
Female
Humans
Immunocompromised Host
Induction Chemotherapy
Leukemia*
Liver
Magnetic Resonance Imaging*
Mucormycosis*
Neutropenia

Figure

• 

  Fig. 1 A 41-year-old female with appendiceal and hepatic mucormycosis. A. Coronal image: multiple, variable-sized, non-enhancing hypodense lesions are seen in the liver. At same time, the appendix shows decreased mural enhancement (arrow) with mild periappendiceal fat infiltration. B. Follow-up CT scan obtained 2 weeks later: hepatic lesions show clearer margins with peripheral enhancement. Hepatic and appendiceal lesions extending to the fat beyond the involved organs are confined by enhancing rim-like lesions (arrowheads). C-F. Liver dynamic MRI: an axial T2-weighted image shows high signal intensity (SI) hepatic lesions surrounded with intermediate SI rims (C). Peripheral thick rims show slightly low SI on T1-weighted image, while inner portion of lesions show high SI (D). Peripheral enhancing rims on portal phase scan (E) are correlated with high SI on high b-value (800 s/mm2) diffusion weighted image (F). G. The hepatic parenchyma shows extensive necrosis surrounded by karyorrhectic debris and dense collagenous fibrosis (hematoxylin-eosin stain, × 100). Many fungal hyphae are noted in the necrosis. H. Gomori Methenamie-Silver (GMS) stain highlights broad, nonseptated hyphae, consistent with mycormycosis (GMS, × 400).

Reference

1. Kontoyiannis DP, Lewis RE. Invasive zygomycosis: update on pathogenesis, clinical manifestations, and management. Infect Dis Clin North Am. 2006; 20:581–607. vi

2. Pagano L, Offidani M, Fianchi L, Nosari A, Candoni A, Piccardi M, et al. Mucormycosis in hematologic patients. Haematologica. 2004; 89:207–214.

3. Bow EJ, Loewen R, Cheang MS, Schacter B. Invasive fungal disease in adults undergoing remission-induction therapy for acute myeloid leukemia: the pathogenetic role of the antileukemic regimen. Clin Infect Dis. 1995; 21:361–369.

4. Thomson SR, Bade PG, Taams M, Chrystal V. Gastrointestinal mucormycosis. Br J Surg. 1991; 78:952–954.

5. Suh IW, Park CS, Lee MS, Lee JH, Chang MS, Woo JH, et al. Hepatic and small bowel mucormycosis after chemotherapy in a patient with acute lymphocytic leukemia. J Korean Med Sci. 2000; 15:351–354.

6. Hagspiel KD, Kempf W, Hailemariam S, Marincek B. Mucormycosis of the liver: CT findings. AJR Am J Roentgenol. 1995; 165:340–342.

7. Roden MM, Zaoutis TE, Buchanan WL, Knudsen TA, Sarkisova TA, Schaufele RL, et al. Epidemiology and outcome of zygomycosis: a review of 929 reported cases. Clin Infect Dis. 2005; 41:634–653.

8. Gleissner B, Schilling A, Anagnostopolous I, Siehl I, Thiel E. Improved outcome of zygomycosis in patients with hematological diseases. Leuk Lymphoma. 2004; 45:1351–1360.

9. Antman KS, Griffin JD, Elias A, Socinski MA, Ryan L, Cannistra SA, et al. Effect of recombinant human granulocyte-macrophage colony-stimulating factor on chemotherapy-induced myelosuppression. N Engl J Med. 1988; 319:593–598.

10. Lee JH, Ha HK, Yoo E, Yang SK, Min YI, Auh YH. CT and sonographically guided biopsy in a patient with intestinal mucormycosis. AJR Am J Roentgenol. 2000; 175:129–131.