Fatal Case of Cerebral Aspergillum in an Immunocompetent Patient

 Cerebral aspergillum is rare and usually misdiagnosed because its presentation mimics tuberculous meningitis, brain abscess, or tumor. The diagnosis and treatment of central nervous system (CNS) infections due to Aspergillus are very difficult because accurate diagnosis is often made intra-operatively.

 Here, we report a case of cerebral aspergilloma in an immunocompetent host. A 35-year-old man admitted with progressive left hemifacial paresthesia followed by severe pain in trigeminal nerve territory. On physical examination, except for fifth nerve palsy and difficult mastication, there was not any sensory and motor deficit. Magnetic resonance imaging (MRI) of the brain showed T1 iso and T2 low signal lesion in the left parasellar region with enhancement. The lesion is extended to the left side of the prepontine cistern in the course of trigeminal nerve, craniotomy, and total surgical resection of the mass was performed. Isolated brain lesion and the pathology from stereotactic biopsy confirmed cerebral aspergillosis. The result of testing for human immunodeficiency virus (HIV) was negative. Although the patient had two subsequent recurrences, at first, good outcome was achieved by treatment with a combination of surgical intervention, and antifungal amphotericin B deoxycholate was administered, then changed to voriconazole. Unfortunately, after two years, he experienced new progressive symptoms, and the patient died despite several reoperations due to malfunctioning of external ventricle devices as well as the treatment of recurrent post-operation meningitis and voriconazole therapy.

 Most cases of intracranial aspergillosis show that this infection is pathogenic in immunocompromised hosts; however, in some cases, invasive Aspergillus was reported as an opportunistic infection in immunocompetent patients. In these patients, though primary cranial aspergillosis is very rare, it is possible that isolated brain involvement in a previously healthy case may be explained by unknown defects in immune pathways or massive exposure to spores.