CNS MIXED FUNGAL BALL IN AN IMMUNOCOMPETENT PATIENT - A RARE ENTITY!
S Chennapragad MD, A Netzel MD, C Graham MD, R Mansour MD. Department of Medicine, Louisiana State University, Shreveport, LA
INTRODUCTION Aspergillus species are ubiquitous fungi in the environment and readily acquired through inhalation. Immunocompromised individuals are at particularly high risk of progressing to invasive fungal infections following inhalation. It can present with deep-seated invasive infections in immunocompromised hosts such as HIV/AIDS and acute leukemias.
CASE: A 64-year-oldmanwith acutemyeloid leukemia (AML), currently in remissionwho presented fromhis ophthalmologist with left sided visual disturbances and facial numbness. He was found to have retinal hemorrhages and left sided hemianopia. A magnetic resonance imaging (MRI) of the brain showed an enhancing right occipital mass measuring 2.5x2.1x1.8cm with surrounding vasogenic edema. The initial differential diagnosis was broad, ranging from infectious, benign to malignant causes. Of note, he had a history of invasive pulmonary aspergillosis during his induction phase of chemotherapy for AML which was promptly treated. This time, he was empirically started on liposomal amphotericin B while awaiting results of the biopsy, but steroids were held. The biopsy showed extensive angio-invasive fungal organisms. Some appeared as septate hyphae with 45 angle branching, with features of aspergillosis, while other hyphae were non-septate with 90 angle branching, demonstrating features of phycomycosis such as Mucorales. The mass was completely removed during surgery and the patient was continued on Amphotericin B which was later shifted to Isavuconazole due to renal failure. Post treatment MRI of the brain and aspergillus antigen were negative for residual disease. DISCUSSION: Central nervous system (CNS) aspergilloma is a rare form of invasive aspergillosis associated with high morbidity that can be difficult to diagnose and treat. The gold standard for diagnosis remains direct histopathology as most forms of imaging poorly differentiate between CNS aspergilloma and alternative infections or neoplasms. The combination of aspergillosis and mucormycosis in the same fungal element is exceedingly rare with only one other case published. This case shows that both diseases can be treated with surgical excision with Isavuconazole treatment.
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