Cerebral Aspergillosis Secundary to Hematoma Drainage in Immunocompetent Patient

Case Presentation: A 48-year-old female is brought to the emergency due to sudden hemiparesis at right associated with mental status impairment (GCS 9) and expression aphasia. CT revealed a massive intraparenchymal hematoma on the left frontal-temporo-parietal region, promoting a midline shift. The patient underwent urgent drainage and the postoperative period was marked by recovery of all neurological symptoms. 6 months later, patient returned due to progressive headache in the right temporal region with no other symptoms. In control MRI, an area of gliosis was identified with peripheral contrast enhancement and restriction of diffusion at the central portion, suggestive of abscess. Surgical drainage was performed with the removal of purulent material and abscess’ capsule. The histological and cultural analysis confirmed the diagnosis of Aspergillus Niger, and treatment with voriconazole was instituted. No lung lesions were found on previous CT. After 30 days of antifungal therapy, imaging revealed no areas of contrast impregnation or edema. She currently has no limitations of daily life and follows-up with neurologist to manage temporal lobe seizures secondary to the prior condition.

Discussion: Cerebral Aspergillus infections are an uncommon complication in immunocompromised and transplanted patients. The presentation in healthy patients is rare and there are less than five cases described of cerebral aspergillosis as a complication of brain surgery. In 90%, the primary site is the lung and, usually, the brain is affected by hematogenic dissemination, affecting 20% of the cases. The diagnosis is difficult due to the vague symptoms: headaches, cranial nerves paralysis, mental confusion or epileptic seizures. Moreover, hemocultures and microbiological examination of the CSF are frequently negative. Diagnostic certainty can be obtained by a biopsy. The best treatment involves surgical drainage and antifungal drugs. The First-line drug is Voriconazole, whose good intracerebral distribution justifies its first use in cerebral aspergillosis. This condition has an unfavourable prognosis and the mortality rate, which oscillates between 80 and 90%, is correlated with the time left before treatment starts.

Conclusion: We present an extremely rare case of cerebral aspergillosis as a complication of brain surgery with a good outcome. Although uncommon, it should be suspected when typical radiologic signs of abscess are present, even when it occurs in immunocompetent patients.