case of fulminant lethal infection of a healthy lady after gastric bypass operation for obesity.

1. Case Report: Computed tomography findings in
Torulopsis Glabrata infection after gastric bypass
surgery for morbid obesity.
Authors:
Ahmed a Bahnassy (1),Faysal Al Ahmary (2 ) ,and Hayfaa Al harby (3)
1-Ahmed Atteya Bahnassy MBCHB ,MSc,FRCR-Consultant Radiologist.
2-Faysal Al Ahmry MBCHB,SBR-Senior Registrar Radiology.
3-Hayfaa Al harby MBCHB,SBR,JBR-Consultant Radiologist.
1,2 abd 3 from Radiology department –Riyadh Military Hospital
Correspondence :
Ahmed A Bahnassy
Consultant Radiologist-Riyadh Military Hospital ,Riyadh ,Saudi Arabia.P.O. box 7897
Riaydh 11159.Kngdom of Saudi Arabia
e-mail:aatteya2001@yahoo.com
Tel:0096614777714/23529

2. Introduction:
Gastric bypass is the most common bariatric operation and successfully
provides significant and long-term weight loss, improvements in quality of life,
resolution of obesity-associated comorbidities, and likely extension of life span.
Overall complication rate is of 15% to 20%.3-6.However possibility of flaring
of infection should be kept in mind as a potential fatal occurrence.
While Candida albicans is still the most common cause of infections caused by
yeast-like organisms, other species, notably Torulopsis (Candida) glabrata, are
becoming increasingly important, especially in immunocompromised persons.[1]
Case report:
Our case is a 50 year old lady, known case of morbid obesity ( BMI = 49) for
which she had laparoscopic RYGB 5 months back, presented to Riyadh Military
Hospital complaining of generalized fatiguability for 2 months, associated with diffuse
abdominal pain, jaundice, abdominal distension, anorexia and weight loss of 30 kg
over 2 months after RYGB.
CT abdomen performed and revealed:
Pulmonary nodules(Figure 1 ),ascitis,liver miliary shadows,splenic focal lesions,
hypodense lymph nodes,and gall bladde hydrops.(Figures 2 and 3 )

3. Figure 1:Lower Chest cuts revealing pulmonary nodules ,with tree in bud appearance
(arrow)

4. Figure 2: CT abdomen showing military liver nosules ,ascitis ,splenic hypodense focal
lesions and hypodense paraaortic lymph nodes

5. Figure 3:CT Abdomen showing ascetic fluid ,hypodense and military hepatic
nodules,hydrops of gall bladder ,splenic focal lesions and abdominal fatty stranding.
The patient deteriorated after night and a second CT revealed presence of
pneumoperitoneum.
Patient was taken to theater and intraoperative findings included;
1. Gush of air upon indicative of pneumoperitoneum
2. A perforated stomal ulcer at the gastrojejunostomy
3. Massive bile stained ascitis
4. Shrunken liver with diffuse granular involvement
5. Hugely distended gall bladder
6. Diffusely granular & enlarged spleen
7. Thickened , fibrotic, diffusely granular greater omentum..

6. Liver and omental biopsies were taken.
Results of pathology:
Wedge liver biopsy : features of cirrhosis, extensive steatosis > 95% of parenchyma,
necrotizing granulomatous inflammation highly suggestive of T.B.
Omental biopsy : necrotizing granulomatous inflammation., negative acid fast
bacilli….and Heavy growth of candida glabrata (syn.:Torulopsis)
Unfortunately the patient developed multiorgan failure and expired after 2 days.
Discussion:
Here we describe the occurrence of Torulopsis glabrata,as one potential life
threatening complication after RYGB .
The most common fungus to infect the liver and spleen is the Candida
species; however, this infection is diagnosed antemortem in only about 9% of cases
(2,). A definitive diagnosis is difficult to make because it is based on the findings in
biopsy specimen cultures, which are often negative for Candida organisms (3). This
may be due in part to delays in performing biopsy in these critically ill patients (4).
Contrast material–enhanced CT of the abdomen and pelvis demonstrates
innumerable hypoattenuating areas throughout the liver, and spleen (5)
In our case the presence of hydrops of gall bladder was an additional finding
,associated with severe infection.
The chest radiographic features of Candida pneumonia have been previously
described (6,7). Buff et al (7) identified unilateral and bilateral lobar and segmental
air-space.
Small-airway infection leads to inflammatory changes to the walls of
bronchioles, resulting in airway wall thickening and dilatation. Typically, CT findings
consist of centrilobular opacities arranged in a tree-in-bud pattern manifested by
small Y- and V-shaped opacities in the lung periphery, which represent bronchioles
that are impacted with inflammatory secretions. (8).
These findings were present in our case where the lower chest cuts revealed
micronodular infiltrations and tree in bud appearance.
However the CT manifestations of pulmonary candidiasis are similar to those
described in other pulmonary infections. (9,10) ..Therefore any such CT findings
should trigger prompt ascetic tapping or liver biopsy to achieve a timely laboratory
diagnosis.

7. This case highlights the possibility of systemic fungal infection as a potential
life threatening complications after gastric bypass operation.
The CT appearance of systemic torulopsis,were emphasized as well as the
importance of urgent tissue diagnosis ,as any delay can cost the patient life.
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