PMC8645494_01
A 53-year-old male presented to the emergency room with acute abdominal pain, Hematemesis, Malena non-contrast-enhanced computed tomography (axial and coronal reformatted sections) (a and b) - Abdomen shows an exophytic ulcerative lesion seen along the greater curvature of stomach associate with perigastric and peri splenic fat stranding (white arrow).
JCIS-11-62-g001.jpg
PMC8645494_01_JCIS-11-62-g001.jpg
F1
Then, patient was further advised computed tomography (CT) of the abdomen and pelvis, initially, plain CT was advised and it showed an exophytic ulcerative lesion along the greater curvature of the stomach associate with perigastric and perisplenic fat stranding [Figure 1] and further on contrast-enhanced CT and it demonstrated focal asymmetrical wall thickening with exophytic ulcerative component involving fundus and the proximal body along the greater curvature of the stomach extending up to the splenic hilum causing splenic infarction (vascular invasion) and associated perigastric inflammation and reactive adenopathy [Figure 2].
A 53-year-old male presented to the emergency room with acute abdominal pain, Hematemesis, Malena contrast-enhanced computed tomography (axial section and coronal) (a and b) - Abdomen shows an exophytic enhancing ulcerative component seen arising from the proximal body of the stomach and extending up to the splenic hilum with loss of fat plane (white arrow) and non-enhancing wedge-shaped area with the apex toward the splenic hilum - splenic infarction (yellow arrow).
JCIS-11-62-g002.jpg
PMC8645494_01_JCIS-11-62-g002.jpg
F2
Then, patient was further advised computed tomography (CT) of the abdomen and pelvis, initially, plain CT was advised and it showed an exophytic ulcerative lesion along the greater curvature of the stomach associate with perigastric and perisplenic fat stranding [Figure 1] and further on contrast-enhanced CT and it demonstrated focal asymmetrical wall thickening with exophytic ulcerative component involving fundus and the proximal body along the greater curvature of the stomach extending up to the splenic hilum causing splenic infarction (vascular invasion) and associated perigastric inflammation and reactive adenopathy [Figure 2].
A 53-year-old male presented to the emergency room with acute abdominal pain, Hematemesis, Malena contrast enhanced computed tomography - Abdomen on follow-up imaging shows an exophytic enhancing ulcerative component from the proximal body of the stomach and extending up to the splenic hilum with fistulous communication between the spleen and the stomach (white arrow) and few air pockets noted within (yellow arrow).
JCIS-11-62-g003.jpg
PMC8645494_01_JCIS-11-62-g003.jpg
F3
Then, the patient was advised for esophagogastroduodenoscopy (EGD) and it revealed proliferative growth in the region of the gastric fundus with surrounding fresh or altered blood and exudative material [Figure 6], then further, on worsening of pain follow-up contrast-enhanced computed tomography (CECT) was taken and it revealed the formation of the gastrosplenic fistulous communication and liquefaction of the splenic infracted parenchyma [Figure 3], Corresponding USG findings during follow-up revealed presence of few echogenic foci in the splenic parenchyma (air pockets) - [Figure 4] and further on biopsy of the mass revealed as lamina propria showing lymphoplasmacytic and minimal neutrophilic infiltrate, necro-hemorrhagic fragment, infiltration by broad aseptate branched fungal hyphae, with no evidence of intestinal metaplasia [Figure 5].
A 53-year-old male presented to the emergency room with acute abdominal pain, Hematemesis, Malena on follow-up scan - USG image shows - There is the presence of few echogenic foci (air pockets) in the splenic parenchyma (white arrow).
JCIS-11-62-g004.jpg
PMC8645494_01_JCIS-11-62-g004.jpg
F4
Then, the patient was advised for esophagogastroduodenoscopy (EGD) and it revealed proliferative growth in the region of the gastric fundus with surrounding fresh or altered blood and exudative material [Figure 6], then further, on worsening of pain follow-up contrast-enhanced computed tomography (CECT) was taken and it revealed the formation of the gastrosplenic fistulous communication and liquefaction of the splenic infracted parenchyma [Figure 3], Corresponding USG findings during follow-up revealed presence of few echogenic foci in the splenic parenchyma (air pockets) - [Figure 4] and further on biopsy of the mass revealed as lamina propria showing lymphoplasmacytic and minimal neutrophilic infiltrate, necro-hemorrhagic fragment, infiltration by broad aseptate branched fungal hyphae, with no evidence of intestinal metaplasia [Figure 5].
Multiple serial sections studied show (a) H and E stain, scanner view shows fragments of gastric mucosa with the necrotic area on the luminal side. (b) H and E x40, high power view shows enterohemorrhagic fragments with broad aseptate branched fungal hyphae (indicated by arrow) (c) GMS Giemsa stain shows fungal hyphae stained blue (indicated by arrow) (d) GMS stain showing fungal hyphae stained black; however, there is no intestinal metaplasia or dysplasia.
JCIS-11-62-g005.jpg
PMC8645494_01_JCIS-11-62-g005.jpg
F5
Then, the patient was advised for esophagogastroduodenoscopy (EGD) and it revealed proliferative growth in the region of the gastric fundus with surrounding fresh or altered blood and exudative material [Figure 6], then further, on worsening of pain follow-up contrast-enhanced computed tomography (CECT) was taken and it revealed the formation of the gastrosplenic fistulous communication and liquefaction of the splenic infracted parenchyma [Figure 3], Corresponding USG findings during follow-up revealed presence of few echogenic foci in the splenic parenchyma (air pockets) - [Figure 4] and further on biopsy of the mass revealed as lamina propria showing lymphoplasmacytic and minimal neutrophilic infiltrate, necro-hemorrhagic fragment, infiltration by broad aseptate branched fungal hyphae, with no evidence of intestinal metaplasia [Figure 5].
Multiple serial images of esophagogastroduodenoscopy at different angulation show (a) exudative material (indicated by the blue arrow) (b) proliferative growth in the region of the gastric fundus (indicated by white arrows) (c) and (d) fresh or altered blood (indicated by black arrows).
JCIS-11-62-g006.jpg
PMC8645494_01_JCIS-11-62-g006.jpg
F6
Then, the patient was advised for esophagogastroduodenoscopy (EGD) and it revealed proliferative growth in the region of the gastric fundus with surrounding fresh or altered blood and exudative material [Figure 6], then further, on worsening of pain follow-up contrast-enhanced computed tomography (CECT) was taken and it revealed the formation of the gastrosplenic fistulous communication and liquefaction of the splenic infracted parenchyma [Figure 3], Corresponding USG findings during follow-up revealed presence of few echogenic foci in the splenic parenchyma (air pockets) - [Figure 4] and further on biopsy of the mass revealed as lamina propria showing lymphoplasmacytic and minimal neutrophilic infiltrate, necro-hemorrhagic fragment, infiltration by broad aseptate branched fungal hyphae, with no evidence of intestinal metaplasia [Figure 5].