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Journal of Indian Association of Pediatric Surgeons
     Journal of Indian Association of Pediatric Surgeons
Official journal of the Indian Association of Pediatric Surgeons         
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Year : 2023  |  Volume : 28  |  Issue : 1  |  Page : 59-61

Double whammy due to coronavirus disease-2019: Invasive small bowel mucormycosis with recent-onset diabetic ketoacidosis presenting as diffuse fecal peritonitis in a 12-year-old girl

1 Department of Pediatric Surgery, Shri Dharmasthala Manjunatheshwara University, Dharwad, Karnataka, India
2 Department of Pediatrics, Shri Dharmasthala Manjunatheshwara University, Dharwad, Karnataka, India
3 Department of Pathology, Shri Dharmasthala Manjunatheshwara University, Dharwad, Karnataka, India

Date of Submission15-Jul-2022
Date of Decision01-Sep-2022
Date of Acceptance11-Oct-2022
Date of Web Publication10-Jan-2023

Correspondence Address:
Prashant K Zulpi
House No. 322, Vanashri Nagar, Nischal Building, SDM Medical Staff Quarters, Sattur, Dharwad - 580 009, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaps.jiaps_97_22

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Mucormycosis is a fatal fungal infection occurring in immunocompromised patients. Small bowel mucormycosis is extremely rare with a high mortality rate. We report the case of a 12-year-old girl with postcoronavirus disease (COVID) recent-onset diabetic ketoacidosis, who presented with acute abdomen with fecal peritonitis. She was diagnosed with intestinal mucormycosis (post-COVID) and was treated successfully with surgical and antifungal management.

Keywords: Antifungal, bowel mucormycosis, diabetic ketoacidosis, fecal peritonitis

How to cite this article:
Zulpi PK, Kulkarni VK, Rani H, Halgeri A, Agnihotri A. Double whammy due to coronavirus disease-2019: Invasive small bowel mucormycosis with recent-onset diabetic ketoacidosis presenting as diffuse fecal peritonitis in a 12-year-old girl. J Indian Assoc Pediatr Surg 2023;28:59-61

How to cite this URL:
Zulpi PK, Kulkarni VK, Rani H, Halgeri A, Agnihotri A. Double whammy due to coronavirus disease-2019: Invasive small bowel mucormycosis with recent-onset diabetic ketoacidosis presenting as diffuse fecal peritonitis in a 12-year-old girl. J Indian Assoc Pediatr Surg [serial online] 2023 [cited 2023 Feb 2];28:59-61. Available from: https://www.jiaps.com/text.asp?2023/28/1/59/367397

   Introduction Top

Mucormycosis is a fatal fungal infection caused by fungi of the subphylum Mucoromycotina, order Mucorales which mainly involves rhino-orbito-cerebral and respiratory tracts primarily affecting immunocompromised patients.

   Case Report Top

A 12-year-old girl with postcoronavirus disease (COVID) with recent onset of diabetic ketoacidosis (DKA) presented with the acute abdomen (pain abdomen and distension) for 3 days. On examination in the emergency room, the child was in shock with low blood pressure recording and was tachycardic. The child was having sick look with tense and diffuse distension of the abdomen, tenderness, and guarding present all over the abdomen mainly in the lower abdomen with absent bowel sounds. Laboratory investigations revealed a random blood sugar value of 500 mg/dl. After admission, the child was resuscitated with intravenous (IV) fluids and IV antibiotics along with ionotropic support. Routine blood investigations showed raised White blood cell count (WBC), C-reactive protein (CRP), and low protein [Table 1]. Erect X-ray abdomen and pelvis showed multiple air-fluid levels [Figure 1]a. On exploratory laparotomy, multiple large ileal perforations (more than 10 perforations) were noted intraoperatively with many impending perforations in the distal ileum [Figure 1]c. Fecal contamination along with a lot of purulent fluid was noted mainly in the pelvis. The entire small bowel was edematous and inflamed showing enteritis-like features. Around 15 cm of proximal ileum containing 3–4 large perforations, which were almost appearing like near-complete bowel transactions [Figure 1]b was resected with the closing of around 8–9 distal perforations and inverting the areas with impending perforations. Divided small bowel stoma made. The resected segment of the small bowel was sent for histopathological examination which revealed broad aseptate Periodic acid-Schiff (PAS)-positive fungal hyphae with obtuse-angled branching. Angioinvasion was also noted [Figure 1]d. Features were suggestive of small intestinal invasive mucormycosis. The child was immediately started on IV amphotericin B (antifungal) from the 3rd postoperative day for 4 weeks. Subsequently, stoma closure was performed at the end of 4 weeks of the first surgery after confirming no leak or stricture in the distal bowel by performing a dye study through a stoma. Biopsy from the stomal site showed occasional giant cells and was negative for fungal hyphae. Blood sugars were also well controlled by insulin therapy. The child started passing stools and tolerating orally well. Finally, the child was discharged from the hospital in a good condition.
Table 1: Investigations at the time of admission

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Figure 1: (a) X ray erect abdomen showing multiple air fluid levels (b) Multiple large perforations involving proximal ileum (bold arrow) (c) Areas of impending perforations in distal ileum (linear arrow) (d) Section shows ribbons of broad, aseptate fungal hyphae with obtuse angled branching.(bold triangle)

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   Discussion Top

Novel COVID-2019 (COVID-19) is a contagious disease caused by severe acute respiratory syndrome-coronavirus-2 with a sudden rise in mucormycosis infection following COVID-19 infection was mainly seen during the second wave.

COVID-19 is also emerging as a potential trigger for the development of diabetes in the pediatric age group. There are few case reports of new-onset diabetes in children as post-COVID sequelae like in our case complicating with DKA.[1]

There have been several case reports of rhino-cerebro-orbital mucormycosis as sequelae of COVID-19 infection. However, small bowel invasive mucormycosis due to COVID-19 is extremely rare with very few case reports published in the literature.

Gastrointestinal mucormycosis accounts for 4%–7% of all cases with a high mortality rate of 85%.[2] Considering the very high mortality rates associated with the disease, developing a high degree of clinical suspicion, and establishing an early diagnosis becomes very important in the outcome. The stomach is the most commonly involved site followed by the colon, small intestine, and esophagus.

The hallmark of mucormycosis is tissue necrosis due to the invasion of vessels by fungal hyphae and these infections are rapidly progressive.[3] Very few similar cases of gastrointestinal mucormycosis secondary to COVID-19 infection were reported in adults with dismal outcomes.[4],[5] Probably this could be the first case report of pediatric post-COVID intestinal invasive mucormycosis with a good outcome.

Treatment of the disease is surgical debridement of the involved tissue along with antifungal therapy. Liposomal amphotericin B is the drug of choice for mucormycosis. It is administered as an IV infusion at the dose of 5 mg/kg body weight for 6–8 weeks. Posaconazole is used as step-down/alternate therapy for patients who cannot tolerate amphotericin. Hence, patients during treatment with IV amphotericin B need to be monitored for nephrotoxicity.

   Conclusion Top

To conclude, a high index of suspicion for intestinal mucormycosis is, therefore, necessary in post-COVID-19 patients. Early treatment with surgery and antifungal medication along with diabetic management plays important role in a favorable outcome. Nutritional supplementation in the form of total parenteral nutrition helped in early recovery from this grievous condition.

Declaration of patient consent

The authors certify that they have obtained appropriate consent from parents. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal patient identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Naguib MN, Raymond JK, Vidmar AP. New onset diabetes with diabetic ketoacidosis in a child with multisystem inflammatory syndrome due to COVID-19. J Pediatr Endocrinol Metab 2021;34:147-50.  Back to cited text no. 1
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;41:634-53.  Back to cited text no. 2
Pilmis B, Alanio A, Lortholary O, Lanternier F. Recent advances in the understanding and management of mucormycosis. F1000Res 2018;7:v1000-429.  Back to cited text no. 3
Jain M, Tyagi R, Tyagi R, Jain G. Post-COVID-19 gastrointestinal invasive mucormycosis. Indian J Surg 2022;84:545-7.  Back to cited text no. 4
Varshney VK, Swami A, Thirunavukkarasu B, Agarwal A, Baid G. Synchronous small bowel gangrene with pyelonephritis secondary to mucormycosis: A disastrous complication of COVID-19 pandemic. Cureus 2021;13:e15911.  Back to cited text no. 5


  [Figure 1]

  [Table 1]


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