{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,3]],"date-time":"2026-04-03T16:52:37Z","timestamp":1775235157349,"version":"3.50.1"},"update-to":[{"DOI":"10.12688\/wellcomeopenres.15026.1","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2019,3,27]],"date-time":"2019-03-27T00:00:00Z","timestamp":1553644800000}}],"reference-count":13,"publisher":"F1000 Research Ltd","license":[{"start":{"date-parts":[[2019,3,27]],"date-time":"2019-03-27T00:00:00Z","timestamp":1553644800000},"content-version":"unspecified","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100004440","name":"Wellcome Trust","doi-asserted-by":"publisher","award":["106680"],"award-info":[{"award-number":["106680"]}],"id":[{"id":"10.13039\/100004440","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["wellcomeopenresearch.org"],"crossmark-restriction":false},"short-container-title":["Wellcome Open Res"],"abstract":"\n A 57 years female from the hills of Nepal presented with upper gastrointestinal bleeding with gastric ulcer evident on endoscopy. Though initially treated with\n Helicobacter pylori<\/ns4:italic>\n (\n H. pylori<\/ns4:italic>\n ) eradication therapy alone, biopsy later on revealed both mucormycosis and\n H. pylori<\/ns4:italic>\n infection. She was then treated with antifungals liposomal amphotericin B followed by posaconazole which led to complete recovery. Mucormycosis is a rare but life-threatening fungal disease of immunocompromised host though our patient was immunocompetent. If recognized and treated at early stage, as in our patient, prognosis is good. A high index of suspicion is required for considering this disease in\n H. pylori<\/ns4:italic>\n endemic regions such as Nepal, and is crucial for early recognition and treatment.\n <\/ns4:p>","DOI":"10.12688\/wellcomeopenres.15026.2","type":"journal-article","created":{"date-parts":[[2019,4,5]],"date-time":"2019-04-05T07:25:06Z","timestamp":1554449106000},"page":"5","update-policy":"https:\/\/doi.org\/10.12688\/wellcomeopenres.crossmark-policy","source":"Crossref","is-referenced-by-count":4,"title":["Case Report: Gastric Mucormycosis- a rare but important differential diagnosis of upper gastrointestinal bleeding in an area of Helicobacter pylori endemicity"],"prefix":"10.12688","volume":"4","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-2659-3425","authenticated-orcid":false,"given":"Sudeep","family":"Adhikari","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ajaya Raj","family":"Gautam","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5119-4082","authenticated-orcid":false,"given":"Buddhi","family":"Paudyal","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Keshav Raj","family":"Sigdel","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1125-2743","authenticated-orcid":false,"given":"Buddha","family":"Basnyat","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"2560","published-online":{"date-parts":[[2019,3,27]]},"reference":[{"key":"ref-1","doi-asserted-by":"crossref","first-page":"5-12","DOI":"10.5847\/wjem.j.1920-8642.2011.01.001","article-title":"Management of upper gastrointestinal bleeding emergencies: evidence-based medicine and practical considerations.","volume":"2","author":"Z Chen","year":"2011","journal-title":"World J Emerg Med."},{"key":"ref-2","first-page":"30-7","article-title":"The prevalence of Helicobacter pylori infection in Sherpa residents of the Upper Khumbu, an isolated community in Eastern Nepal.","volume":"125","author":"T Sherpa","year":"2012","journal-title":"N Z Med J."},{"key":"ref-3","first-page":"4301-4306","article-title":"Fatal gastrointestinal mucormycosis in an immunocompetent patient: a case report and review of the literature.","volume":"11","author":"J Hu","year":"2018","journal-title":"Int J Clin Exp Med."},{"key":"ref-4","doi-asserted-by":"publisher","first-page":"634-653","DOI":"10.1086\/432579","article-title":"Epidemiology and outcome of zygomycosis: a review of 929 reported cases.","volume":"41","author":"M Roden","year":"2005","journal-title":"Clin Infect Dis."},{"key":"ref-5","article-title":"Mucormycosis (zygomycosis)","author":"G Cox"},{"key":"ref-6","doi-asserted-by":"publisher","first-page":"739-741","DOI":"10.2214\/ajr.145.4.739","article-title":"Mucormycoma of the colon: early diagnosis and successful management.","volume":"145","author":"F Agha","year":"1985","journal-title":"AJR Am J Roentgenol."},{"key":"ref-7","doi-asserted-by":"publisher","first-page":"952-954","DOI":"10.1002\/bjs.1800780819","article-title":"Gastrointestinal mucormycosis.","volume":"78","author":"S Thomson","year":"1991","journal-title":"Br J Surg."},{"key":"ref-8","doi-asserted-by":"publisher","first-page":"820-822","DOI":"10.1002\/dc.23518","article-title":"Gastric mucormycosis: Diagnosis by imprint cytology.","volume":"44","author":"S Tathe","year":"2016","journal-title":"Diagn Cytopathol."},{"key":"ref-9","doi-asserted-by":"publisher","first-page":"905-909","DOI":"10.1016\/j.transproceed.2017.11.036","article-title":"Gastric Mucormycosis in a Liver and Kidney Transplant Recipient: Case Report and Concise Review of Literature.","volume":"50","author":"G Alfano","year":"2018","journal-title":"Transplant Proc."},{"key":"ref-10","doi-asserted-by":"publisher","first-page":"714-8","DOI":"10.1111\/myc.12419","article-title":"Gastrointestinal mucormycosis in immunocompromised hosts.","volume":"58","author":"M Dioverti","year":"2015","journal-title":"Mycoses."},{"key":"ref-11","doi-asserted-by":"publisher","first-page":"45-50","DOI":"10.1111\/myc.12393","article-title":"Burden of serious fungal infections in Nepal.","volume":"58 Suppl 5","author":"U Khwakhali","year":"2015","journal-title":"Mycoses."},{"key":"ref-12","article-title":"Estimating fungal infection burden in India using computational models: mucormycosis burden as a case study","author":"A Chakrabarti"},{"key":"ref-13","doi-asserted-by":"publisher","first-page":"4-8","DOI":"10.3126\/kumj.v11i1.11015","article-title":"Benign sinonasal masses: a clinicopathological and radiological profile.","volume":"11","author":"A Nepal","year":"2013","journal-title":"Kathmandu Univ Med J (KUMJ)."}],"container-title":["Wellcome Open Research"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/wellcomeopenresearch.org\/articles\/4-5\/v2\/xml","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/wellcomeopenresearch.org\/articles\/4-5\/v2\/pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/wellcomeopenresearch.org\/articles\/4-5\/v2\/iparadigms","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2019,5,13]],"date-time":"2019-05-13T05:50:40Z","timestamp":1557726640000},"score":1,"resource":{"primary":{"URL":"https:\/\/wellcomeopenresearch.org\/articles\/4-5\/v2"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2019,3,27]]},"references-count":13,"URL":"https:\/\/doi.org\/10.12688\/wellcomeopenres.15026.2","relation":{"has-review":[{"id-type":"doi","id":"10.21956\/wellcomeopenres.16593.r35470","asserted-by":"subject"},{"id-type":"doi","id":"10.21956\/wellcomeopenres.16593.r35144","asserted-by":"subject"},{"id-type":"doi","id":"10.21956\/wellcomeopenres.16593.r35144","asserted-by":"object"},{"id-type":"doi","id":"10.21956\/wellcomeopenres.16593.r35470","asserted-by":"object"},{"id-type":"doi","id":"10.21956\/wellcomeopenres.16593.r35145","asserted-by":"object"}]},"ISSN":["2398-502X"],"issn-type":[{"value":"2398-502X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2019,3,27]]},"assertion":[{"value":"Indexed","URL":"https:\/\/wellcomeopenresearch.org\/articles\/4-5\/v2#article-reports","order":0,"name":"referee-status","label":"Referee status","group":{"name":"current-referee-status","label":"Current Referee Status"}},{"value":"10.21956\/wellcomeopenres.16593.r35144, Gaetano Alfano, Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy, 05 Apr 2019, version 2, indexed","URL":"https:\/\/wellcomeopenresearch.org\/articles\/4-5\/v2#referee-response-35144","order":0,"name":"referee-response-35144","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.21956\/wellcomeopenres.16394.r34802, M. Veronica Dioverti, John Hopkins University, Baltimore, MD, USA, 20 Mar 2019, version 1, 1 approved with reservations, 1 not approved","URL":"https:\/\/wellcomeopenresearch.org\/articles\/4-5\/v1#referee-response-34802","order":1,"name":"referee-response-34802","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"Sudeep Adhikari<\/b>; \nPosted: 23 Mar 2019<\/i>; Thank you for your constructive feedback to our manuscript. The grammar has been reviewed and corrected as suggested by the reviewer. \nQuestion #1<\/u> - Background history\/case progression: Histopathology: granulation tissue suggesting fungal invasion? Was there fungal invasion or no? This should be discernable on path, there should be clear necrosis and vascular invasion in order to make a diagnosis of invasive mucor. Was surgical intervention entertained? This is a crucial component of mucormycosis management  Was posaconazole level checked? This is important for treatment follow up Response to question 1 In the histopathology examination there was no evidence of fungal invasion, as necrosis and vascular invasion were not present. Changes have been made in the revised manuscript. Surgical intervention was not done, as our patient had early form of the disease. Case reports where medical therapy alone was used for the management, have been cited in the revised manuscript. (1,2) The need of overlapping amphotericin and posaconazole before stopping amphotericin till the therapeutic level of posaconazole is achieved has been discussed in the revised manuscript. (3) But the unavailability of the test of blood level of posaconazole in our setup hindered the use of the standard management practice in our case. \nQuestion #2:<\/u> Physical exam\/labs: only physical exam comments were that patient was "pale" and they provided blood pressure\/heart rate. How about abdominal pain, guarding? Any other ominous signs\/symptoms? Was imaging obtained? Oftentimes, mucor will invade nearby tissue. For laboratory, was there a culture sent? In terms of treatment follow up, did she tolerate high doses of amphotericin? Was a posaconazole level checked prior to stopping amphotericin? Response to question 2 Other physical examinations were unremarkable, including the abdominal exam. Abdominal imaging to exclude the invasion of nearby tissue was not done, as our patient had non-invasive form of the disease. Confirmation of the infection via culture was not done, because this test is not readily available in our setup. Our patient had no complication on using amphotericin B. The hospital stay was uneventful. Posaconazole level testing is not available in our setup. \nQuestion #3: <\/u> Authors should extend discussion to include how were other patients managed? Typically, management includes surgery. Duration of antifungal therapy is typically longer that 1 month, indicating that perhaps this was not the correct diagnosis? How long were the other case reported treated for?   Response to question 3 Case reports of using medical therapy alone without the surgery, have been included in the discussion. Our patient received posaconazole for 2 months only due to financial constraints. But she had clinical as well as histopathological remission from the disease. One case was treated for 6 months with antifungal therapy. (1) \nQuestion #4:<\/u>  More details need to be included as mentioned above Response to question 4 Details have been added as suggested. \nReferences<\/b>  Alfano G, Fontana F, Francesca D, Assirati G, Magistri P, Tarantino G, Ballarin R, Rossi G, Franceschini E, Codeluppi M, Guaraldi G, Mussini C, Di Benedetto F, Cappelli G: Gastric Mucormycosis in a Liver and Kidney Transplant Recipient: Case Report and Concise Review of Literature.\nTransplant Proc<\/i>. 2018; \n50<\/b> (3): 905-909 Tathe SP, Dani AA, Chawhan SM, et al.: Gastric mucormycosis: Diagnosis by imprint cytology. \nDiagn Cytopathol.<\/i> 2016;44(10):820\u2013822. 27321416 10.1002\/dc.23518 Dioverti MV, Cawcutt KA, Abidi M, Sohail MR, Walker RC, Osmon DR: Gastrointestinal mucormycosis in immunocompromised hosts.\nMycoses<\/i>. 2015; \n58<\/b> (12): 714-8 PubMed Abstract |Publisher Full Text ","URL":"https:\/\/wellcomeopenresearch.org\/articles\/4-5\/v2#referee-comment-3830","order":2,"name":"referee-comment-3830","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.21956\/wellcomeopenres.16593.r35470, Raju Pangeni, HAMS Hospital, Kathmandu, Nepal, 13 May 2019, version 2, indexed","URL":"https:\/\/wellcomeopenresearch.org\/articles\/4-5\/v2#referee-response-35470","order":3,"name":"referee-response-35470","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"This work was supported by the Wellcome Trust [106680]. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.","order":4,"name":"grant-information","label":"Grant Information"},{"value":"This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.","order":0,"name":"copyright-info","label":"Copyright"}]}}