Objective:

To describe a case of suspected angioinvasion of Aspergillus presenting as
ischemic infarcts across vascular territories.

Background:

Fungal infections in immunocompromised patients can result in stroke
and stroke-like pathology, often from angioinvasion causing ischemia across vascular
territories. Aspergillus is the most common CNS fungal infection to cause both
hemorrhagic and ischemic stroke.

Design/Methods:

Single-patient case review with serial neuroimaging and
multidisciplinary evaluation.

Results:

A 68-year-old male with a past medical history of coronary artery disease,
atrial fibrillation on anticoagulation, hypertension, hyperlipidemia, deep-vein thromboses
(DVT), and hemophagocytic lymphohistiocytosis originally presented with fevers and
worsening right lower-extremity swelling. Blood cultures at the time were positive for
MSSA bacteremia. Stroke neurology was consulted for confusion, and subsequent MRI
demonstrated worsening multifocal infarcts compared to a brain MRI from one month
prior, despite adherence to antiplatelet and anticoagulation therapy. No significant
stenosis or large-vessel occlusion was demonstrated on MRA of the head, and TEE
was without evidence of vegetations, infective endocarditis, or a patent foramen ovale.
Chest CT revealed nodules in the right upper lobe of the lung, which were evaluated
with bronchoscopy and a subsequent VATS wedge resection that demonstrated an
aspergilloma. He was started on voriconazole, and his neurologic symptoms improved,
but he continued to have a mixed expressive and receptive aphasia. Follow-up brain
MRI after one month of antifungal therapy demonstrated no areas of diffusion restriction
and stable hyperintensities on the FLAIR sequence compared with the previous MRI
brain, suggesting no interval progression of infarcts.

Conclusions:

Angioinvasive Aspergillus can present with multifocal ischemic infarcts
that involve multiple vascular territories and progress despite conventional
antithrombotic therapy. In patients, particularly those who are immunocompromised,
who have recurrent infarcts in multiple vascular territories without an identifiable
cardioembolic source, early consideration of invasive fungal infection and prompt
antifungal therapy may improve neurological outcomes.