Basidiobolomycosis is a tropical fungus that primarily affects the skin. The stomach, small intestines, colon, and liver are among the major organs that can be affected [12, 13]. Nonspecific signs and symptoms make diagnosis difficult [14]. A prompt and accurate diagnosis is critical, especially when there are signs of obstruction or sepsis.
Individuals with an increased risk of basidiobolomycosis including past medical history of uncontrolled diabetes mellitus (particularly with ketoacidosis), prolonged neutropenia, prolonged corticosteroid use, hematological malignancy, organ transplant, iron overload, acquired immunodeficiency syndrome (AIDS), injection drug use and trauma/burn [12]. Furthermore, the disease has a male predilection, according to a study [2]. Our patient had risk factors including male gender and history of using corticosteroid for about eight years.
Since this fungus is an environmental saprophyte that can be found in soil and decaying vegetables and fruits, dirt or feces ingestion, or food contaminated by either, appear to be the routes of infection [15]. Our patient had been in contact with soil constantly due to his job as a farmer which could be the source of infection.
Considering that in previous case report and review studies patients were mostly children about one to ten years old, so pediatricians might consider it among their differential diagnosis [16,17,18].
The Patient’s general symptoms like abdominal pain, anorexia, constipation, and weight loss were similar to other reported cases but the patient had no bleeding although GI bleeding does not show a predilection for any particular age group and has been reported in patients aged 1.5 years to 80 years in most of the cases [12,13,14]. The colonoscopy in our case was mostly normal. There was only a pressure effect on the sigmoid.
Pathologic features of basidiobolomycosis include presence of splendore-hoeppli bodies and numerous eosinophils, as well as intensely radiating eosinophilic granular material surrounding the fungal elements [19]. Our pathological findings were in concordance with it.
In our case basidiobolomycosis was confirmed microscopically, though molecular testing for basidiobolomycosis may prove to be the most accurate method of diagnosis. Ribosomal DNA sequencing can precisely confirm the diagnosis of infection in formalin-fixed paraffin-embedded (FFPE) intestinal tissue [20]. Moreover, molecular testing using polymerase chain reaction (PCR) assays with panfungal specific primers that amplified the internal transcribed spacer 1 and 2 regions of ribosomal DNA and sequence analysis of the PCR products using the basic local alignment search tool can also confirm the disease [13].
The gold standard of GIB definite diagnosis is culture [21, 22], but the patient underwent surgery with the preoperative diagnosis of mass. As a result, the specimen was sent to a lab in formalin and no culture was done. However, the histopathology was distinctive enough.
Although the antifungal treatment alone has been described to be effective, treatment is often presumptive because it is difficult to establish a definitive diagnosis [14].
To prevent recurrence, a wide margin radical resection should be used. literatures supports the use of early surgical intervention to reduce mortality [2, 15, 22,23,24].
Our patient underwent laparotomy and was prescribed itraconazole and amphotericin B deoxycholate. Lipid formulation of amphotericin B is preferred due to its low renal toxicity [12], however in our case we did not have access to liposomal amphotericin B.
In conclusion, fungal infection should be among the differential diagnoses for adults taking corticosteroid and presenting abdominal mass. Raising awareness of this condition among infectious disease specialists, and pathologists especially in endemic regions and developing world countries may lead to the discovery of more cases, allowing doctors to make diagnosis earlier and manage the case appropriately.
