PMC10220263_01
Axial and coronal contrast-enhanced abdominopelvic CT scan depicts increased density of ileal mesentery, representing an infiltrative process (yellow arrow). An ileal loop shows pneumatosis intestinalis in RLQ suggestive of transmural bowel necrosis (red arrow).
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No major pathology was detected in other viscera of the abdomen (Fig. 1).
a: The organisms are broad and aseptate (arrowhead), and are surrounded by an eosinophilic material (Splendore-Hoeppli reaction) (arrow), (H&E, 400 x). b: Mucosal necrosis and capillary micro thrombi (arrow) in favor of ischemic pattern of injury are identified. (H&E, 100 x). c: Necrosis and inflammatory response and fungal organisms (arrow) are seen in the mesenteric mass. (H&E) element (red arrow). H&E stain, 100 x. C. a multinucleated giant cell with an ingested fungal element. H&E 1000 x. The inset highlights the micro-organism by special staining. Gomori Methenamine Silver (GMS) stain, 1000 x. The yellow arrows point to the micro-organism. D. Splendore Hoeppli phenomenon. H&E stain, 1000 x.
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An extension of organisms into the blood vessel walls was identified (Fig. 2a). Sub mucosal hyalinization of thrombotic blood vessels and some irregular crypts in favor of ischemic ileitis were evident (Fig. 2b). One of them showed extensive necrosis and scattered basidiobolomycosis associated with granulomatous inflammation (Fig. 2c).
PMC10220263_02
An infiltrative soft tissue is seen in the pelvic and perineum. It infiltrates the perineal skin and both labia major, and bilateral internal obturator muscles leading to the enlargement of these structures. presacral fat, and mesorectal fascia in the right side and the bladder neck were also involved. The lesion had an iso signal on T1 weighted, and a mildly high signal on T2 weighted images, showing mild enhancement and restriction of diffusion on DWI sequences. (from top to bottom first row: T2 weighted, second row: T1 weighted with contrast,third row: DWI and the fourth row:ADC).
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It also showed pan colitis and terminal ileitis with an active pattern in the rectosigmoid (Fig. 3).
Histopathology of perineal biopsies taken under CT guide. A. Panniculitis with marked eosinophilic infiltration. H&E stain, 100 x. B. Granulomatous reaction with necrosis. The yellow arrows point to multinucleated giant cell. The black arrow depicts the necrotic areas and the Splendore Hoeppli phenomenon H&E stain, 40 x. The inset depicts a high-power view of the giant cell bearing a fungal.
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The pathologist diagnosed basidiobolomycosis by viewing the Splendore Hoeppli phenomenon and fungal element in GMS staining in samples of perianal biopsy (Fig. 4).
Photos from patient's home showing sesame cultivation.
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We were curious about the source of the infection and after asking for possible exposures we found out that the patient had been culturing sesame in her house for her Ph.D. thesis (Fig. 5).
Abdominopelvic CT scan of the second patient after treatment shows resolution of inflammation and obstruction.
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Three and twelve-month later at the follow-up CT scan there were no obstructions and the distension was attributed to the dysmotility of the sigmoid part of the colon which is a sequela of sigmoid involvement by basidiobolomycosis (Fig. 6).