Primary Duodenal Aspergillosis in a Patient With Alcoholic Cirrhosis and Poorly Controlled Diabetes Mellitus

A 74-year-old recovering alcoholic man presented with progressively increasing epigastric pain for 2 months. The patient had a prior medical history of Child-Pugh Class A alcoholic cirrhosis and esophageal varices, gastric ulcer diagnosed 4 years earlier with documented endoscopic healing of the ulcer after 6 weeks of omeprazole therapy (40 mg/d), and poorly controlled diabetes with a recent hemoglobin A1c level of 9.2%. He had never received corticosteroids or other immunosuppressive therapy and was HIV seronegative. At the time of presentation, he reported nausea and a 10-kg weight loss. Physical examination revealed epigastric tenderness without rebound tenderness. Abdominal computed tomography revealed periduodenal edema. Esophagogastroduodenoscopy revealed duodenitis, a 25-mm ulcer in the descending duodenum, and a 10-mm bulbar ulcer, without stigmata of recent hemorrhage (Figure 1). Histological examination of ulcer biopsies revealed duodenal inflammation and necrotic debris (Figure 2). Grocott’s methenamine silver stain revealed fungal organisms with hyphal forms, highly consistent with Aspergillus. Immunohistochemistry was negative for Helicobacter pylori. Chest x-ray and computed tomography of the sinuses did not reveal evidence of invasive aspergillosis. The patient was treated with voriconazole 100 mg/d for 6 weeks and omeprazole 40 mg twice a day. Repeat esophagogastroduodenoscopy, 4 months later, revealed healed ulcers with minimal scarring. Repeat biopsies demonstrated normal duodenal mucosa without Aspergillus. The patient died 18 months later from liver failure, without recurrent aspergillosis.