THE SILENT FUNGAL INVASION: ASPERGILLUS BRAIN ABSCESS IN AN IMMUNOCOMPETENT ELDERLY PATIENT

Document Type

Conference Proceeding

Publication Date

7-17-2025

Publication Title

J Gen Intern Med

Keywords

metronidazole, vancomycin, voriconazole, abscess, aged, Alzheimer disease, Aspergillus, atrial fibrillation, blood culture, brain abscess, brain infection, case report, cavernous sinus, clinical article, comorbidity, conference abstract, confusion, coronary artery disease, craniotomy, diagnosis, drug therapy, early intervention, empyema, endophthalmitis, fever, follow up, headache, heart failure with preserved ejection fraction, human, hypertension, intravenous drug administration, leukocytosis, male, MRI scanner, nuclear magnetic resonance imaging, oral drug administration, ptosis (eyelid), risk factor, surgery, urinalysis

Abstract

CASE: An 84-year-old male with Alzheimer's disease, hypertension, coronary artery disease, atrial fibrillation and heart failure with preserved ejection fraction, presented with fever and headache after a fall. CT head showed a right frontal lesion with a differential including trauma, infarction, infection, or neoplasm. After being discharged with outpatient follow-up, the patient re-presented with confusion, prompting imaging that confirmed a persistent frontal lesion. He underwent craniotomy and drainage, confirming an abscess, with cultures growing Aspergillus. Notably, he had no preexisting lung conditions or lung pathology. He was discharged on prolonged voriconazole therapy. Despite treatment, he returned with persistent fever (up to 104.2° F) and new symptoms including ptosis, blurry vision and right eye drainage. Laboratory workup revealed leukocytosis, renal impairment, positive urinalysis with cultures growing Pseudomonas and negative blood cultures. MRI brain showed right post-craniotomy changes, multiple intra-axial brain abscesses, and possible cavernous sinus extension, indicating an unresolved empyema. Endophthalmitis was ruled out. Given poor prognosis, and extensive infection, Neurosurgery deemed surgical intervention unfeasible. Infectious Disease recommended continued voriconazole, vancomycin, metronidazole. Without source control, complete resolution was unlikely. His mentation declined, and he was discharged to hospice for comfort measures. IMPACT/DISCUSSION: This case highlights a rare and challenging presentation of an Aspergillus brain abscess in an elderly immunocompetent patient. Brain abscesses caused by Aspergillus are typically seen in immunocompromised individuals, often due to hematogenous spread from primary pulmonary or sinus infections. However, this patient, despite his advanced age and comorbidities, lacked a primary lung or sinus infection to suggest the typical pathophysiologic route. Aspergillus brain abscesses are notoriously difficult to diagnose early, often presenting with nonspecific symptoms such as headache, fever, and neurological deficits, delaying diagnosis. The patient's condition deteriorated despite voriconazole therapy, which typically offers effective coverage for Aspergillus infections. The presence of multiple abscesses, subdural fluid collections, and the involvement of critical structures such as the cavernous sinus likely contributed to the difficulty in achieving source control. This case emphasizes the need for heightened awareness and early intervention in managing fungal brain infections, especially in patients with significant comorbidities. CONCLUSION: - Consider brain abscess in elderly with fever, headache, and neurological changes, even in immunocompetent patients with no typical risk factors. - Early multidisciplinary consultation is essential for complex cases and poor prognosis.

Volume

40

First Page

S347

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