Mucormycosis mimicking as G-junction malignancy, Ritesh Prajapati Pankaj Desai, Mayankabravala, Chintan Patel These are our disclosures Mucormycosis is a life-threatening infection mostly occurring in immunocompromised patients with high mortality in them. Mucormycosis most commonly affects lungs and paranesal sinuses. In the gastrointestinal tract, stomach, colon, and ileum are commonly involved, with stomach being the commonest. We report a patient with G-junction mucormycosis mimicking as malignancy. A 62-year-old male presented with complaint of dysphagia to solids for one month. There was no history of pain abdomen, weight loss, anorexia, vomiting, heartburn, or regurgitation. Per-abdomen examination was normal. Blood investigations revealed RBS of 252 mg per deciliter, HbA1c was 7.6. Rest of the hematological workup was normal. Barium swallowed and elsewhere showed dilated esophagus with smooth tapering or G-junction with holdup of contrast. An upper GI endoscopy revealed an ulcer at 33 cm from the incisors. Mucosa beyond the ulcer up to GE junction was normal. On retroflexion, GE junction showed circumferential infiltration with extension to the cardia and fundus with overlying ulceration. This showed chronic inflammation with dense eosinophilic infiltrate, no evidence of malignancy. T-abdomen showed a well-defined hypo-enhancing wall thickening in the lower esophagus extending into the fundus and lesser curvature of the stomach. EOS showed a circumferential esophageal wall thickening beginning at 35 cm from incisors. It was hypoechoid with heterogeneous ecotexture and extending to fundus and lesser curvature of the stomach. Wall layers were not preserved. Fat planes with pleura and pericardium were preserved. Multiple sub-centimeter lymph nodes in periesophageal, periesagus, periaortic and in the neck region were seen. Fine needle aspiration and biopsy was taken from the wall thickening. It showed dense tissue eosinophilia with rounded hollow and filamentous structures suggestive of fungal spores and hyphae and surrounded by intensely eosinophilic granular radiating material suggestive of splendory hopele phenomenon. No angioinvasion by fungus was seen. Overall morphological features were suggestive of basidiomycosis and rarely myocormycosis. Patient was started on tetragonazole and anti-diabetic medication. Repeat EUSFNB was done and tissue was sent for fungal culture which was negative. From cell block showed Rhizopus microsporus. Patient was started on intravenous liposomal amphotericin B for 10 days which was followed by oral posaconazole. Esophagia improved at 1 month. Endoscopy done at 1 month showed a healed esophageal ulcer. Infiltrative lesion at GE junction also regressed completely. EOS done at 1 month showed residual disease. However, there was regression in the wall thickening. On follow-up at 3 months, there was complete resolution of lesion on endoscopy as well as on EUS. GI mucormycosis usually presents as active abdomen and hence has high mortality. Angioinvasion provides pathway for hematogenous spread, local ischemia and necrosis. Rapid treatment initiation improves survival. Our patient presented with dysphagia with lesion on OGD, CT and EUS mimicking as GE junction malignancy. Lack of angioinvasion on biopsy and timely diagnosis and management led to favorable outcome. Identification of GI mucormycosis requires high index of suspicion and can rarely mimic as malignancy. Early diagnosis and treatment reduces mortality.

dysphagia

G-junction malignancy

gastrointestinal mucormycosis

immunocompromised individuals

early diagnosis