Gastrointestinal Mucormycosis following a Streptococcus pyogenes Toxic Shock Syndrome in a Previously Healthy Patient: A Case Report

Mucormycosis is an uncommon opportunistic infection and the gastrointestinal form is the rarest. Rhizopus sp. is the most frequent pathogen and infection occurs almost exclusively in immunocompromised patients. We describe the first case of intestinal mucormycosis occurring after a Streptococcus pyogenes toxic shock syndrome in a previously healthy patient caused by Rhizopus microsporus var. azygosporus. 1. Introduction Mucormycosis is an infection caused by members of the order Mucorales. Relatively uncommon, it is one of the most rapidly fatal infections known to man [1]. The gastrointestinal form is the rarest [1, 2]. Usually, individuals who develop mucormycosis have predisposing risk factors such as diabetes mellitus, deferoxamine chelating therapy, hematological or solid organ malignancies, organ transplantation, neutropenia, and immunosuppressive or corticosteroid therapy [1]. Here, we describe the case of a previously healthy patient who developed a severe form of gastrointestinal mucormycosis a few days after having recovered from a Streptococcus pyogenes toxic shock syndrome (TSS). This is to our knowledge the first case of mucormycosis occurring after a S. pyogenes TSS. 2. Case Report A previously healthy 53-year-old woman, who had been complaining of respiratory tract symptoms and fever for 3 days, was diagnosed with a S. pyogenes necrotizing pneumonia with TSS and transferred to our institution. Upon admission, she was found to have multiorgan failure with acute respiratory distress syndrome and immediately required intubation and vasopressors. She also received IV penicillin, clindamycin, immunoglobulins, activated C-protein, and three days of corticosteroids at physiological dose. Over the following week, the shock resolved and her respiratory parameters improved. However, on day 10 her condition critically deteriorated, vasopressors were resumed and piperacillin-tazobactam was administered. On physical examination, proctorrhagia and abdominal distension were noted, and she developed leukopenia (Table 1). Abdominal CT scan revealed a pneumoperitoneum near the hypogastric region (Figure 1(a)) with parietal pneumatosis of the caecum and sigmoid, compatible with acute ischemia (Figure 1(b)). An emergency laparotomy revealed intestinal and colonic necrosis which necessitated a 100？cm resection of the terminal ileum and subtotal colectomy with terminal ileostomy (Figure 2(a)). An abundant quantity of nonpurulent but foul-smelling fluid was recovered during the surgery but without any frank fecal peritonitis (Figure 2(b)). Peritoneal fluid