Characteristic clinical features of Aspergillus appendicitis: Case report and literature review

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

GI: Gastrointestinal; AML: Acute myelogenous leukemia; ALL: Acute lymphocytic leukemia; NA: Not applicable; WBC: White blood cell; CT: Computerized tomography; USD: Ultrasound; DIC: Disseminated intravascular coagulation. ThaiPOG protocol: Thailand Pediatric Oncology Group protocol as described in: Seksarn P, Wiangnon S, Veerakul G, Chotsampancharoen T, Kanjanapongkul S, Chainansamit SO. Outcome of childhood acute lymphoblastic leukemia treated using the Thai National Protocols. Asian Pac J Cancer Prev 2015; 16 (11): 4609-4614.