Aspergillus Appendicitis

Fungi in very rare situations, mostly immunosuppressed children, can cause appendicitis. Aspergillus  is a widespread fungus identified in the environment and usually enter the human body by airborne transmission colonizing the nasal cavities or fascial sinuses. Isolated gastrointestinal aspergillosis arises from ingestion of food contaminated with Aspergillus and colonization by Aspergillus of gastrointestinal ulcers which arise from previous chemotherapy. The diagnosis of isolated (primary) aspergillus appendicitis is very rare, is delayed and associated with profound immunosuppression. This last factor of immunosuppression causes the delay in the clinical features of appendicitis. The very few cases have demonstrated a clinical pentad associated with this disease, namely: clinically-suspected appendicitis, profound neutropenia, recent chemotherapy, acute leukemia (either AML or ALL), and poor clinical course if managed solely with antibiotics or anti-candida medication. Aspergillus fumigatus is the most common and frequent species that causes infection in humans followed by A. Flavus and A. terreus. As mentioned, ingested contaminated food or mucosal ulcers from chemotherapy give rise to Aspergillus infestation. Aspergillus invade the appendicial mucosal wall due to immunosuppression from neutropenia and acute leukemia. The child develops persistent right quadrant pain, fever and systemic GI signs unresponsive to antibacterial or anti-candidal therapy. Ultrasound or with greater accuracy a CT-Scan will show appendicitis. The appendix should be removed promptly and the specimen microscopically examined for Aspergillus with special stains. Anti-Aspergillus therapy with voriconazole or amphotericin should be instituted after removal of the appendix since the child will continue to be colonized with the organism. Surgery is crucial for removing the inflamed appendix, clearing the infection and producing tissue sampling. Positive galactomannan levels guide the decision to change the antifungal therapy regime.  

References:
1- Gjeorgjievski M, Amin MB, Cappell MS: Characteristic clinical features of Aspergillus appendicitis: Case report and literature review. World J Gastroenterol. 21(44):12713-21, 2015
2- Decembrino N, Zecca M, Tortorano AM, Mangione F, Lallitto F, Introzzi F, Bergami E, Marone P, Tamarozzi F, Cavanna C: Acute isolated appendicitis due to Aspergillus carneus in a neutropenic child with acute myeloid leukemia. New Microbiol. 39(1):65-9, 2016
3- Ozyurek E, Arda S, Ozkiraz S, Alioglu B, Arikan U, Ozbek N: Febrile neutropenia as the presenting sign of appendicitis in an adolescent with acute myelogenous leukemia. Pediatr Hematol Oncol. 23(3):269-73, 2006
4- Larbcharoensub N, Boonsakan P, Kanoksil W, Wattanatranon D, Phongkitkarun S, Molagool S, Watcharananan SP: Fungal appendicitis: a case series and review of the literature. Southeast Asian J Trop Med Public Health. 44(4):681-9, 2013
5- Kim HS, Yeo HJ, Shin DH, Cho WH, Kim D: Isolated Acute Appendicitis Caused by Aspergillus in a Patient Who Underwent Lung Transplantation: A Case Report. Transplant Proc. 50(4):1199-1201, 2018
6- Ustun C: Laparoscopic appendectomy in a patient with acute myelogenous leukemia with neutropenia. J Laparoendosc Adv Surg Tech A. 17(2):213-5, 2007



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