Invasive gastrointestinal aspergillosis in an immunocompromised host.

I Aspergillosis (IA) is a common opportunistic infection in immunocompromised individuals. The IA is an important cause of morbidity and mortality in patients with hematological malignancies and it is particularly common during neutropenic episodes following anticancer chemotherapy.1 While pulmonary aspergillosis involvement is common, gastrointestinal (GI) aspergillosis infection with clinical manifestation is rare. Gastrointestinal aspergillosis is usually seen in the most severely immunocompromised patients, especially those with prolonged, severe neutropenia. We present a case as an invasive gastrointestinal aspergillosis confused with graft-versus-host disease (GVHD) in post bone marrow transplant patient and brief review of the literature of GI aspergillosis. A 16 year-old male presented to the GI service with hematemesis and bloody diarrhea. He was initially diagnosed with standard risk acute lymphoblastic leukemia (L-1 morphology) in March 1994 at the age of 5 years. He had central nervous system involvement. He was treated with standard chemotherapy (Children’s Cancer Group 1992) from March 1994 to May 1997. He initially responded to treatment, but his disease relapsed twice in 1998 and 2002. He received a 4-drug re-induction chemotherapy and a reduced consolidation phase of high dose Ara-C/ Idarubicin with resultant clinical remission. A bone marrow transplant from a matched unrelated donor was performed in May 2002. He relapsed in May 2004 and was treated with a 4-drug re-induction. He subsequently received donor lymphocyte infusions on March 2nd, April 7th, and May 25th, 2005. Following the 3rd lymphocyte infusion, he developed diarrhea, a skin rash and conjugated hyperbilirubinemia with transaminase and Gamma-Glutamyl Transpeptidase elevation. Examination of the skin revealed a diffuse maculopapular rash with exfoliation. He was treated with IV cyclosporine and high dose prednisone (2 then 4 mg/kg) for presumed GVHD with involvement of skin, gut, and liver. Infliximab was added because of worsening symptoms and rising conjugated bilirubin and transaminase levels. Gastroenterology service was consulted because of worsening symptoms, now with bloody diarrhea and minor hematemesis. Endoscopic examination was not performed at the time because