INTRODUCTION: Invasive aspergillosis (IA) is the most common invasive fungal infection. It affects mainly immunocompromised patients, rarely affecting immunocompetent individuals. Disseminated aspergillosis is a life-threatening disease that involves 2 or more vital organs of the body1. We present a case of a 31-year-old immunocompetent male with invasive aspergillosis.
CASE PRESENTATION: A 31-year-old male, with no past medical history, presented to Henry Ford ED with new-onset generalized seizures. He reported a lower toothache for 18 months. He denied headache, sinus pain, or constitutional symptoms. No recent travel, HIV risk-factors or tuberculosis exposure. He was a 20 pack-year smoker and reguarly smoked marijuana. He worked removing old carpet. Initial CT head revealed a left frontal mass with vasogenic edema and midline shift. MRI suggested a tumefactive demyelinating lesion. Patient was admitted to the ICU with plans for excisional biopsy. Preoperative CXR revealed right lung masses. CT chest showed bilateral mass-like airspace opacities. Transbronchial biopsies, Autoimmune studies and HIV-elisa were negative. Patient underwent awake craniotomy with neuronavigation given concerns for motor and speech sequelae. Once the cortex was incised, gross purulent material and necrotic core were evacuated. Gram stain was negative, but showed a large amount of PMNs. Patient was started on empiric antibiotic coverage for brain abscess. Biopsy culture results showed Aspergillus fumigatus. CT guided lung biopsy showed Necrotizing granulomatous fungal inflammation with the subsequent also positive for Aspergillus fumigatus. Patient was treated with Voriconazole and was discharged 6 weeks later, seizure-free and with significant motor and speech recovery. To date, he has been readmitted a few times for recurrent seizures secondary to non compliance with medications.
DISCUSSIONS: Aspergillus cause a wide spectrum of illnesses depending on the immune status of the host2. IA is a severe and commonly fatal disease seen in immunocompromised patients. It usually presents in patients who have severe and prolonged neutropenia3, defects in cell-mediated immunity, prolonged high dose steroid therapy, organ transplant, hematologic malignancies, and AIDS4. Evidence that IA is an emerging opportunistic infection in immunocompetent patients is accumulating, especially in ICU patients5. Neuroaspergillosis in patients with apparent intact immune systems is rare, usually due to either intracranial extension of sinus aspergillosis or to direct inoculation following head trauma6. It accounts for about 10% of all cases of IA, with a 90% mortality rate7. IA in immunocompetent hosts has been documented in literature and only few reports have been published8. Our patient had pulmonary and brain involvement. No underlying immunodeficiency was found. The presence of aspergillus in the alveoli is likely secondary to marijuana smoking and potential occupational exposure as his job mainly consisted of removing old carpet. Smoking of marijuana contaminated with fungus spores has been reported to lead to pulmonary aspergillus infections in immunocompromised patients9,10. Voriconazole is the drug of choice for CNS aspergillosis and surgical resection of lesions may be the definitive treatment preventing serious neurological sequelae7.
CONCLUSION: Invasive aspergillosis presents in patients who are severely neutropenic or have defects in cell mediated immunity. Our patient is unique as it is one of the very few cases reported in the literature of invasive Neuroaspergillosis in an immunocompetent host.
DISCLOSURE: Angel Coz Yataco, No Financial Disclosure Information; No Product/Research Disclosure Information