Case report :systemic torulopsis after gastric bypass operation
Case Report: Computed tomography findings inTorulopsis Glabrata infection after gastric bypasssurgery for morbid obesity.Authors:Ahmed a Bahnassy (1),Faysal Al Ahmary (2 ) ,and Hayfaa Al harby (3)1-Ahmed Atteya Bahnassy MBCHB ,MSc,FRCR-Consultant Radiologist.2-Faysal Al Ahmry MBCHB,SBR-Senior Registrar Radiology.3-Hayfaa Al harby MBCHB,SBR,JBR-Consultant Radiologist.1,2 abd 3 from Radiology department –Riyadh Military HospitalCorrespondence :Ahmed A BahnassyConsultant Radiologist-Riyadh Military Hospital ,Riyadh ,Saudi Arabia.P.O. box 7897Riaydh 11159.Kngdom of Saudi Arabiae-mail:email@example.comTel:0096614777714/23529
Introduction: Gastric bypass is the most common bariatric operation and successfullyprovides significant and long-term weight loss, improvements in quality of life,resolution of obesity-associated comorbidities, and likely extension of life span. Overall complication rate is of 15% to 20%.3-6.However possibility of flaringof infection should be kept in mind as a potential fatal occurrence. While Candida albicans is still the most common cause of infections caused byyeast-like organisms, other species, notably Torulopsis (Candida) glabrata, arebecoming increasingly important, especially in immunocompromised persons.Case report: Our case is a 50 year old lady, known case of morbid obesity ( BMI = 49) forwhich she had laparoscopic RYGB 5 months back, presented to Riyadh MilitaryHospital complaining of generalized fatiguability for 2 months, associated with diffuseabdominal pain, jaundice, abdominal distension, anorexia and weight loss of 30 kgover 2 months after RYGB. CT abdomen performed and revealed:Pulmonary nodules(Figure 1 ),ascitis,liver miliary shadows,splenic focal lesions,hypodense lymph nodes,and gall bladde hydrops.(Figures 2 and 3 )
Figure 1:Lower Chest cuts revealing pulmonary nodules ,with tree in bud appearance(arrow)
Figure 2: CT abdomen showing military liver nosules ,ascitis ,splenic hypodense focallesions and hypodense paraaortic lymph nodes
Figure 3:CT Abdomen showing ascetic fluid ,hypodense and military hepaticnodules,hydrops of gall bladder ,splenic focal lesions and abdominal fatty stranding. The patient deteriorated after night and a second CT revealed presence ofpneumoperitoneum. Patient was taken to theater and intraoperative findings included; 1. Gush of air upon indicative of pneumoperitoneum 2. A perforated stomal ulcer at the gastrojejunostomy 3. Massive bile stained ascitis 4. Shrunken liver with diffuse granular involvement 5. Hugely distended gall bladder 6. Diffusely granular & enlarged spleen 7. Thickened , fibrotic, diffusely granular greater omentum..
Liver and omental biopsies were taken.Results of pathology:Wedge liver biopsy : features of cirrhosis, extensive steatosis > 95% of parenchyma,necrotizing granulomatous inflammation highly suggestive of T.B.Omental biopsy : necrotizing granulomatous inflammation., negative acid fastbacilli….and Heavy growth of candida glabrata (syn.:Torulopsis)Unfortunately the patient developed multiorgan failure and expired after 2 days.Discussion: Here we describe the occurrence of Torulopsis glabrata,as one potential lifethreatening complication after RYGB . The most common fungus to infect the liver and spleen is the Candidaspecies; however, this infection is diagnosed antemortem in only about 9% of cases(2,). A definitive diagnosis is difficult to make because it is based on the findings inbiopsy specimen cultures, which are often negative for Candida organisms (3). Thismay be due in part to delays in performing biopsy in these critically ill patients (4). Contrast material–enhanced CT of the abdomen and pelvis demonstratesinnumerable hypoattenuating areas throughout the liver, and spleen (5) In our case the presence of hydrops of gall bladder was an additional finding,associated with severe infection.The chest radiographic features of Candida pneumonia have been previouslydescribed (6,7). Buff et al (7) identified unilateral and bilateral lobar and segmentalair-space. Small-airway infection leads to inflammatory changes to the walls ofbronchioles, resulting in airway wall thickening and dilatation. Typically, CT findingsconsist of centrilobular opacities arranged in a tree-in-bud pattern manifested bysmall Y- and V-shaped opacities in the lung periphery, which represent bronchiolesthat are impacted with inflammatory secretions. (8). These findings were present in our case where the lower chest cuts revealedmicronodular infiltrations and tree in bud appearance.However the CT manifestations of pulmonary candidiasis are similar to thosedescribed in other pulmonary infections. (9,10) ..Therefore any such CT findingsshould trigger prompt ascetic tapping or liver biopsy to achieve a timely laboratorydiagnosis.
This case highlights the possibility of systemic fungal infection as a potentiallife threatening complications after gastric bypass operation. The CT appearance of systemic torulopsis,were emphasized as well as theimportance of urgent tissue diagnosis ,as any delay can cost the patient life.References: 1. Fidell PL, Vazquez JA, Sobell JD. Candida glabrata: Review of epidemiology, pathogenesis, and clinical disease with comparison to C. albicans. Clin Micro Rev. 1999;12:80–96 2. Pfaffenbach B, Donhuijsen K, Pahnke K, et al. Systemic fungal infections in hematologic neoplasm: an autopsy study of 1,053 patients. Med Klin (Munich) 1994; 89:299-304. 3. Thaler M, Pastakia B, Shawker TH, O’Leary T, Pizzo PA. Hepatic candidiasis in cancer patients: the evolving picture of the syndrome. Ann Intern Med 1988; 108:88-100. 4. Pagano L, Mele L, Fianchi L, et al. Chronic disseminated candidiasis in patients with hematologic malignancies: clinical features and outcome of 29 episodes. Haematologica 2002; 87:535-541. 5. Nicholas J. E. Moore, MD, Johnsey L. Leef, III, MD and Yijun Pang, MD,Systemic Candidiasis PhDRadiographics. 2003;23:1287-1290. 6. Kassner EG, Kauffman SL, Yoon JJ, Semiglia M, Kozinn PJ, Goldberg PL. Pulmonary candidiasis in infants: clinical, radiologic, and pathologic features. AJR Am J Roentgenol 1981; 137:707–716. 7. Buff SJ, McLelland R, Gallis HA, Matthay R, Putman CE. Candida albicans pneumonia: radiographic appearance. AJR Am J Roentgenol 1982; 138:645–648. 8. Leung AN, Gosselin MV, Napper CH, et al. Pulmonary infections after bonemarrow transplantation: clinical and radiographic findings. Radiology 1999;210:699–710. 9. Tomás Franquet, MD, Nestor L. Müller, MD, PhD, Kyung S. Lee, MD, Anastasia Oikonomou, MD and Julia D. Flint, MD. Pulmonary Candidiasis after Hematopoietic Stem Cell Transplantation: Thin-Section CT Findings, Radiology 2005;236:332-337. 10. Hruban RH, Meziane MA, Zerhouni EA, Wheeler PS, Dumler JS, Hutchins GM. Radiologic-pathologic correlation of the CT halo sign in invasive pulmonary aspergillosis. J Comput Assist Tomogr 1987; 11:534–536 .