New Delhi: A 49-year-old woman presented to Sir Ganga Ram Hospital on 13th May 2021 with complaints of severe abdominal pain, vomiting and constipation. She had undergone mastectomy (removal of breast) for breast cancer and had received her chemotherapy till four weeks ago. At the time of admission, she was in shock and had severe respiratory distress. CT Scan of the abdomen revealed free air and moderate amount of free fluid in the abdominal cavity suggestive of an intestinal perforation.
An emergency Surgery revealed perforation in the lower end of the Esophagus (food pipe). A part of the small intestine had developed gangrene and sloughed off and she had multiple thinned out patches in the wall of the colon with one small leak. The perforations were closed and the gangrenous segment was resected in a difficult surgery lasting for 4 hours after which a piece of intestine was sent for Biopsy
“White Fungus (Candida) causing Multifocal perforations in Oesophagus (food pipe), Small Bowl & Large Bowl in Covid-19 infection has not been reported in literature to the best of our knowledge”, says Dr. (Prof.) Anil Arora,Chairman, Institute of Liver, Gastroenterology and Pancreaticobiliary Sciences. “We immediately placed a tube inside the abdomen and drained about one liter of bile stained pus”, Dr Arora added.
Next day, she was taken for emergency surgery by a team of GI Surgeons lead by Dr. (Prof.) Samiran Nundy of Department of Surgical Gastroenterology & Liver Transplantation and G I SURGERY. According to Dr. Samiran Nundy, “
According to Dr. (Prof.) Anil Arora, “The biopsy of the resected intestinal segment showed the presence of severe ulceration of the intestinal wall with resultant perforation and necrosis caused by invasive Candida pseuodhyphae – the White Fungus. Her total Covid-19 antibody levels were markedly elevated. Her blood as well as peritoneal fluid culture showed exuberant growth of the same Candida species-the WHITE Fungus. She was immediately started on antifungals and showed remarkable improvement”.
However, 5 days later she had to undergo a second surgery for a small leak from the anastomotic site from which she is now recovering says Dr. Aurobindo of Department of Liver Transplantation and G I SURGERY.”
Dr. (Prof.) Anil Arora, further added, “The Covid 19 virus has been known to affect the lungs and upper respiratory tract. Infection of the intestine by the black fungus (Mucormycosis) secondary to steroid use has been recently reported but White Fungus (Candida) causing severe ulceration and gangrene of the intestine presenting with multifocal perforations in esophagus, small bowel and large bowel in the setting of Covid-19 infection has not been reported in literature to the best of our knowledge. As the exact mechanism is unknown, the probable explanation involves an unholy combination of three states causing immunosuppression: a malignancy (carcinoma breast), recent chemotherapy, and a superimposed COVID-19 infection. All three factors conspired together in her case bringing down the immune system to dismally low levels resulting in turncoat of a normal inhabitant of intestine called Candida into a monstrous invasive form resulting in multifocal intestinal perforations with resultant shock and septicaemia.”
Normally the intestine remains in perfect harmony with the fungus called Candida. In immunosuppressed states like diabetes, injudicious use of steroids, overzealous broad-spectrum antibiotics and chemotherapy for an underlying malignancy, there is inward migration of this Candida – the White Fungus – from the intestinal lumen into the body tissues by disrupting the normal gut barriers. This is followed by intestinal complications like ulcers, bleeding, gangrene and perforation followed by transmigration of the Candida across the beleaguered gut barrier into blood culminating in septicemia and multiorgan failure says Prof. Anil Arora.
The affliction of White Fungus is milder than that of mucormycosis (black fungus) but in this Covid era one must definitely be aware of this possibility. Correct diagnosis and timely treatment is important to optimise patient outcome, says Prof. Samiran Nundy
