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Resident PGY 2
Henry Ford Hospital
Introduction: Intraventricular aspergillus infections are a rare manifestation of fungal infections of the central nervous system (CNS). Intraventricular aspergillus infections have most commonly been identified in immunocompromised patients. Spread to the central nervous system is thought to occur hematogenously (usually from pulmonary infection) or directly from the paranasal sinuses. Clinical diagnosis is difficult, as symptoms are nonspecific, but imaging can be used to create a more accurate differential. This case report describes the rare diagnosis of an intraventricular aspergillus infection in an immunocompromised patient presenting with ventricular entrapment and demonstrates the role of imaging in making the diagnosis.
Case Report: We present the case of a 59-year-old male with a history of renal transplant on immunosuppressive therapy, presenting with a two-week history of right-sided weakness and speech difficulty. Of note, patient was diagnosed with acute invasive pulmonary aspergillosis during a prior admission this year and had just completed a 12-week course of antifungal therapy. CT of the head at that time demonstrated only slight asymmetry of the ventricles without definite intracranial lesion. Initial non-contrast CT of the head demonstrated a complex cystic mass within the left lateral ventricle with asymmetric ventricular enlargement. CT of the head with contrast demonstrated a complex lesion within the left ventricle with peripheral enhancement and enlargement of the ventricle. MRI demonstrated a cystic lesion within the left lateral ventricle with a hyperintense FLAIR component anteriorly with restricted diffusion. Post-contrast MRI showed enhancement at the periphery of the complex lesion. There was also entrapment of the left lateral ventricle. After placement of an external ventricular drain for hydrocephalus, surgical biopsy of the lesion demonstrated numerous uniform, septate, fungal hyphae with rare acute angle branching consistent with aspergillus. Throughout the admission, there had been slow, but progressive, decline in neurological function. The patient has been continued on antifungal therapy pending improvement in neurological function.
Conclusion: Isolated intraventricular aspergillus infection is a rare manifestation of CNS fungal infection, most commonly seen in immunocompromised patients. Given the nonspecific clinical symptoms of this diagnosis, imaging can localize and narrow the vast differential for these CNS lesions. Patients that have been diagnosed as such require immediate, long-term, and systemic antifungal therapy. With the mortality rate of patients with intraventricular aspergillus infections being highly dependent on accurate and immediate diagnosis, recognizing key imaging features can aid in improving current poor outcomes.
Patel, Parth Y.; Patel, Suresh; Noujaim, Daniel; Corrigan, John; and Griffith, Brent, "Ventricular Entrapment Due To Isolated Intraventricular Aspergillus Infection" (2020). Case Reports. 37.