Introduction: Invasive aspergillosis is most often seen in immunocompromised patients, although there are rare case reports of infection in immunocompetent hosts. We present a case of an immunocompete..
Introduction: Invasive aspergillosis is most often seen in immunocompromised patients, although there are rare case reports of infection in immunocompetent hosts. We present a case of an immunocompetent patient with isolated hepatic aspergillosis. Case presentation: A 77-year-old male with chronic kidney disease stage III and history of Whipple procedure for a benign pancreatic mass 12 years prior presented with 1.5 months of fatigue, decreased appetite, chills, nausea, vomiting and diarrhea. Prior to the onset of his illness he was active and functional. Exam was pertinent for right upper quadrant tenderness. Imaging at an outside institution revealed a large heterogeneous liver mass, which on biopsy showed granulomatous inflammation and fungal forms identified as aseptate hyphae concerning for mucormycosis. He was transferred to our hospital for surgical resection. A review of the pathology slides and repeat biopsy revealed fungal forms identified as acute angle branching septate hyphae most consistent with Aspergillus. Concurrent cultures grew Aspergillus fumigatus. Extensive work-up including imaging of the sinuses, lungs and abdomen, along with bronchoscopy, colonoscopy, and endoscopy were negative. He was started on amphotericin B and anidulafungin but amphotericin was changed to voriconazole when diagnosis of aspergillosis was confirmed. He was deemed high risk for surgery, given the extent of resection that would be required. Work up for malignancy was negative. His hospital course was complicated with worsening respiratory, liver and renal failure, and he expired on day 25. Discussion: Hepatic invasion by Aspergillus is uncommon, including in the immunocompromised. Our patient was immunocompetent but did have altered anatomy from his Whipple procedure and underwent regular instrumentation every few years with upper endoscopy. It is feasible that this allowed a portal of entry for Aspergillus to his GI tract. Another possibility is that he ingested food highly contaminated with Aspergillus which has been reported. Given the paucity of data for hepatic aspergillosis, optimal therapy remains unclear, and a rational approach is to combine medical and surgical therapy. Conclusion: This is a rare case of an immunocompetent patient with primary hepatic aspergillosis without another focus of infection. It highlights the diagnostic and management challenges faced with invasive gastrointestinal aspergillosis.