invasive aspergillosis ( ia ) is a life - threatening opportunistic infection that usually affects immunocompromised patients . immunsuppressive therapies , high - dose corticosteroids , severe and prolonged neutropenia are the factors that facilitate the infection . majority of the cases are caused by aspergillus fumigatus , followed by aspergillus flavus , aspergillus niger , and aspergillus terreus 
 . ia most commonly involves the respiratory tract , lung or sinus but the central nervous system , cardiovascular system , and other tissues may be infected as a result of hematogenous spread . gastrointestinal ( gi ) aspergillosis , which is associated with high mortality , is a rarely seen form of extra - pulmonary aspergillosis and is most often described in the setting of disseminated disease . gi involvement is rarely seen in mucormycosis , and most reported cases are associated with malignant haematological diseases . here , we describe a child with acute lymphoblastic leukaemia ( all ) who developed probable invasive aspergillosis and diagnosed with gi mucormycosis by histopathologic examination simultaneously . a 5-year - old boy was diagnosed with calla ( + ) , pre - b cell all in july 2013 . he was put on standard risk arm of all bfm 2000 protocol at day 30 . the patient was referred to our intensive care unit because of clinical deterioration and severe lower gastrointestinal system bleeding . at the admission day , at day 0 , the patient 's general condition was poor , with tachycardia and respiratory distress present . his body temperature was 38.5  c , and jaundice , abdominal distension and mucositis were also observed . laboratory test results showed a white blood count of 48/mm , an absolute neutrophil count of 6/mm , haemoglobin of 6.9  g / dl , a thrombocyte count of 35,000/mmand c - reactive protein of 11.7  mg / dl ( n:00.5  mg / dl ) . the prothrombin time and activated partial thromboplastin time were prolonged , with a high international normalised ratio . the patient 's biochemical values revealed a total bilirubin of 7.3  mg / dl , with direct bilirubin dominance , hypokalaemia and hypocalcaemia . erythrocytes , platelet suspension and fresh frozen plasma were administered for continuing upper and lower gi bleeding . broad - spectrum antibiotics ( piperacillin  tazobactam , amikacin and vancomycin ) were started initially . at day + 4 , the antibiotics were changed to teicoplanin and meropenem because of the ongoing fever , and caspofungin was added after yeast ( candida krusei ) growth in a blood culture at day + 6 . abdominal ultrasonography revealed nothing of note , except hepatomegaly and minimal abdominal plastering fluid . at day + 8 , the patient was still febrile but he was no longer neutropenic . gancyclovir treatment was started following a positive result of a polymerase chain reaction ( pcr ) analysis for cytomegalovirus , and voriconazole was added following the detection of mould in a nasopharyngeal swab . at this time , a thoraco - abdominal computed tomography ( ct ) scan showed colonic mural thickening in the splenic flexure and infarct formation in the kidney and spleen that were suggestive of ia . serum galactomannan antigen was positive ( > 4.73 ) , and fungal cultures of sputum , tracheal aspirate were positive for a. flavus . at day + 14 , he was afebrile , and teicoplanin and meropenem were stopped . as no further bleeding had occurred over the previous 48  h , he was taken to the haematology department . despite an initial improvement ( reduced gi symptoms and haemorrhage ) with the voriconazole treatment , the patient developed massive abdominal distension at day + 16 . a new abdominal ct revealed progression of the fungal lesions and peripheral invasion , with a covered perforation in the splenic flexure and a new hypodense lesion in the liver that resembled an aspergilloma ( fig . metronidazole was added to the treatment , caspofungin was stopped , and intravenous liposomal amphotericin b ( amb ) ( 5  mg / kg / day ) was started . the patient showed a clinical improvement after the surgery , with resolution of the abdominal distension and rectal bleeding . however , at day + 20 , he was febrile again , and teicoplanin was added due to the growth of coagulase - negative staphylococci in a blood culture . at day + 22 , he was reintubated because of increased respiratory distress , and a repeat ct scan showed no change in the lesions , which were compatible with aspergillus . at this point , 3 . ) . at day + 29 , a histopathological analysis of resected specimens of the bowel and spleen showed ulceration , with intense inflammation , and non - septate , thick , variable in diameter fungal hyphae , which were compatible with mucormycosis ( fig . 4 ) . culture or pcr for pathogenic fungi from resected material could not be performed . the dose of liposomal amb was increased to 10  mg / kg / day , posaconazole was started , and voriconazole was stopped . at day + 34 , bone marrow aspiration was performed and resulted in haematological remission . at day + 37 repeated thoracal tomography revealed an increase in the number and size of the nodules in the lung . the patient had fever intermittently between the + 40 and + 54th days of hospitalisation , but blood cultures remained sterile . at the end of a 62-day follow - up , he was afebrile , no further gastrointestinal bleeding episodes were seen , a galactomannan test was negative , and the liposomal amb dose was reduced to 5  mg / kg / day ( fig . 5 ) . the patient was referred to the centre that he had been followed up for his haematological malignancy with triple anti - fungal therapy . the frequency of ifi has increased over the last years because of the more intensive cytotoxic agents . with the widespread use of azole prophylaxis candidiasis became less frequent while ia and mucormycetes increased in patients with haematologic diseases . other extrapulmonary locations of the infection include the central nervous system , eyes , skin , kidneys , heart , bones , joints and gi tract . aspergillosis is a highly lethal infection in the gi tract , which is the second most common site of ia . it usually occurs via dissemination from a primary pulmonary infection , and its frequency is estimated to be about 17% . primary gi aspergillosis , causing focal invasion as a primary site of inoculation is rarely reported . patients with gi aspergillosis can present as neutropenic enterocolitis ( typhlitis ) , appendicitis , ileus , colonic ulcers , abdominal pain or gi bleeding . mucormycosis is a systemic opportunistic , fatal infection in immunocompromised patients which most commonly affects the paranasal sinuses ( 39% ) and lungs ( 24% ) , more likely skin ( 19% ) , brain ( 9% ) and gi tract ( 7% ) . due to the invasion of mesenteric arteries and intravascular thrombosis , tissue ischaemia leading to infarction and perforation of the diagnosis is delayed because the organism can seldom be isolated from blood or tissue culture . it is difficult to discriminate between ia and mucormycosis on the basis of a radiological examination alone . however , for an accurate diagnosis , clinicians are unable to provide appropriate conditions at all times and can not get sufficient material for examination . there are no specific radiological findings that suggest gi aspergillosis or mucor . abdominal ct scans may show diffuse thickening of the intestinal wall or diffuse bowel distention . the choice of antifungal agent must be based on the clinical characteristics of the ifi and the local epidemiology with considering the increase in the incidence of mucormycetes . voriconazole is the primary therapy for ia while high doses of liposomal amb are recommended for gi mucormycosis . adjuvant surgery is essential in the management of mucor and recommended in case of intestinal aspergillosis to avoid perforation or obstruction . in our case , the strongly positive galactomannan test ( > 4.73 ) , together with the growth of a. flavus in sputum and tracheal aspirate , and the radiological findings , especially the lung involvement , pointed to ia . however , it was surprising that the histological findings were consistent with mucormycosis because mucor was not detected in the previous microbiological examinations . this raises questions about the actual diagnosis : was it only ia , co - infection or breakthrough infection under voriconazole therapy ? clinicians must be aware of the unexpected involvements and also the possibility of coinfection and breakthrough infection . survival of these patients will improve with early surgical intervention in addition to aggressive antifungal treatments .
invasive fungal infections are most commonly seen in immunocompromised patients and usually affect the respiratory system . gastrointestinal system involvement of mucormycosis and invasive aspergillosis is rarely reported in childhood . here 
 we describe a 5 year old boy with acute lymphoblastic leukaemia who developed invasive fungal infection particularly affecting the lower gastrointestinal system to emphasise the difficulties in diagnosis and management of invasive fungal infections in immunocompromised patients .