Teaching NeuroImages: Aspergillosis-induced vasculitis presenting as ischemic stroke in an immunocompetent patient

Abstract

A 56-year-old immunocompetent man had surgery for pansinusitis; culture grew Aspergillus fumigatus. Two months later , he suddenly experienced febrile right-sided hemiplegia. Brain MRI revealed a recent infarction of the left lentiform and caudate nucleus (figure, A) with left internal carotid and middle cerebral arteries stenosis (figure, B) caused by a perivascular infiltrative mass (figure, C). CSF analysis revealed lymphocytic meningitis and β-D-glucans levels of 190 pg/mL (negative in serum). MRI worsened despite voriconazole followed by voriconazole/caspofungin (figure, D) but improved with caspofungin and liposomal amphotericin B during 15 months (figure, E). Cerebral aspergillosis-related vasculitis has been rarely reported.1,2