Mucormycosis emboli: a rare cause of segmental bowel ischemia

The patient is a 34-year-old man with a history of primary refractory acute myeloblastic leukemia diagnosed 1 year prior, with multiple relapses. As rescue treatment, he underwent allogeneic bone marrow transplant from cord blood 27 days prior to surgical consult. His post-transplant course has been notable for delayed engraftment, prolonged severe neutropenia, resulting in vancomycin-resistant Enterococcus, Streptococcus viridans and Streptococcus mitis bacteremia for which he treated with tedizolid, cefepime, Flagyl and daptomycin per guidance from the Infectious Disease team. On the day of consultation, he developed acute abdominal pain, he was on filgrastim to promote hematopoiesis, and prophylaxis with acyclovir, Bactrim, and caspofungin as well as the above antibiotics for bacteremia. A second antifungal was not started due to the potential toxicity and data from prior infections that he had. On surgical evaluation, his examination was notable for fever to 38.2°C, tachycardia to 155 basic metabolic panel, hypotension to 99/81 and tachypnea to 36; he was ill appearing with a distended abdomen and localized peritonitis. His white cell count was 0.2 x 109 /L with an absolute neutrophil count (ANC) of zero. Additionally, he was anemic with a hemoglobin of 7 g/L, thrombocytopenic with a platelet count of 10 x 109 /L, and a lactic acid of 3.1 mmol/L. His CT scan earlier in the morning revealed segmental ischemia of the small bowel (figure 1)