Invasive fungal infections are associated with increased morbidity and mortality among immunocompromised patients, particularly due to non-specific symptoms, difficulty and delay in diagnosis, and limited therapeutic options. Aspergillosis is the leading cause of invasive fungal infections. Neuroaspergillosis commonly arises from hematogenous dissemination from invasive lung infection in immunocompromised patients and can lead to brain abscess, meningitis, and stroke from angioinvasion. Cerebral aspergillosis has a poor prognosis.

A 62-year-old man with history of chronic lymphocytic leukemia and SARS-CoV-2 pneumonia presented with acute onset right-sided weakness. Head CT exhibited bilateral hypodensities concerning for emboli or metastases. Brain MRI revealed numerous bihemispheric T2 hyperintensities with vasogenic edema. Some lesions demonstrated restricted diffusion and contrast enhancement. At this point, differential diagnosis included septic emboli, abscess, and metastatic disease. TTE did not show signs of infective endocarditis. CT of the chest, abdomen, and pelvis revealed an irregular, centrally necrotic opacity. Bronchoscopy with bronchial lavage was performed, and biopsies were negative for malignancy and positive for Aspergillus species. The patient was started on amphotericin and was switched to voriconazole due to poor tolerance. Because of mental status fluctuation caused by edema, glucocorticoids were used concurrently with antifungal treatment. He had serial head CTs which initially revealed increasing edema and increasing effacement of the left lateral ventricle and third ventricle with development of early hydrocephalus. Neurosurgery was consulted, and family declined any surgical intervention. He was managed with dexamethasone 4 mg daily, and he demonstrated improvement in symptoms and edema on imaging in 1 week.

In immunocompromised patients found to have multiple brain enhancing lesions with unrevealing preliminary work-up, invasive Aspergillosis infection must be considered. Here, we present a case of aspergillus managed concurrently with steroids and voriconazole.  Despite the infectious source, there appears to be a role for steroids in the management of neuroaspergillosis.