Case Report
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
Table 1 Case reports of isolated Aspergillus appendicitis without other known Aspergillus infection
Age and sex [reference]Underlying conditionChemotherapy received prior to appendicitisSymptom appearance after initiating chemotherapyNeutropenia at presen- tationAbdominal imagingPathologic findings in resected appendixTherapy and outcome
8-yr-old male[1]ALLInitial therapy: Vincristine, prednisolone, L-asparaginase, intra- thecal methotrexate.Chemotherapy during relapse: not reported14 mo after therapy restarted for a relapseYesUSD: enlarged appendix, cecal wall thickened, and small periappendiceal fluid collectionNecrosis and inflammation in mucosa and nearby muscle consistent with acute appendicitis. Many septated fungal hyphae showing acute-angle branching, characteristic of AspergillusFared 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 transplantation12 d after transplantation; 5 mo after initiation of chemotherapyYesCT: cecal wall thickened, thickened retrocecal appendix, and periappendiceal inflammatory changes; small amount of free fluid presentFull-thickness invasion of appendiceal wall including serosa; fungal angioinvasion with vessels occluded by hyphal forms; positive methenamine-silver stainFared 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- M1Mitozantrone and cytarabine.Later treatment with daunorubicin and cytarabine30 d after diagnosisYes. 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 ureterCoagulative necrosis of appendiceal tip with septate fungal hyphae with dichotomous branching pattern, permeating and occluding arterial branches.Immunoperoxidase stain demonstrated Aspergillus flavusAmphotericin 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 reportedNANANot reportedNot 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 reportedDid 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-M5Daunorubicin, cytarabine, thioguanine, etopiside, and dexamethasone30 dYes. WBC=200/mm3USD: no evident right lower quadrant abscess or free fluid. CT: inflammatory changes in right lower quadrant with thick-walled appendix and dilated appendiceal lumenBranched, septate fungal hyphae invading full thickness of appendiceal wall without discrete perforationUnderwent 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