A50-04 When Sinusitis Goes Deep: Ventricular Aspergillosis Emerging From Chronic Aspergillus Sinusitis in a Healthy 35 Year-Old Male

Abstract Introduction Aspergillus conidia are typically acquired via inhalation of airborne spores from the environment. These spores may colonize or infect the sinopulmonary tract, giving rise to a spectrum ranging from asymptomatic colonization to invasive disease. In immunocompetent individuals, exposure may result in non-invasive sinopulmonary disease. In contrast, immunocompromised patients (prolonged neutropenia, hematologic malignancies, solid organ transplantation, immunosuppressives use, and structural lung disease, are at greatest risk for invasive aspergillosis. Notably, invasive disease has been reported in immunocompetent individuals. Dissemination proceeds via two mechanisms: hematogenous spread through angio-invasion and hyphal penetration of vascular endothelium, leading to distant-organ involvement (eg,CNS, kidneys, liver) or direct extension from adjacent structures (eg, paranasal sinuses). Invasive intracranial aspergillosis represents a devastating presentation. Clinical features include headache, neurological deficits, and seizures. Radiographic findings may demonstrate cerebral abscesses, infarctions, or meningeal enhancement. Because of non-specific symptoms, and variable imaging findings, recognition is often delayed and mortality remains high.We present a rare case of intracranial aspergillosis in an immunocompetent patient with history of chronic fungal sinusitis. Case presentation A 35-year-old male with persistent fungal sinusitis, prior intracranial stroke secondary to aspergillosis (on posaconazole and terbinafine) presented with new-onset seizures, headache and vomiting. No fevers, vision changes, weakness, B symptoms noted. Neurologic exam was normal. Labs revealed WBC 4.4, negative urine toxicology and HIV, positive Aspergillus antigen (0.84), elevated Fungitell (135). CSF showed lymphocytosis, elevated protein ( 200 mg/dL), normal glucose, negative fungal and AFB cultures. Imaging revealed multiloculated cystic collections and band-like filling defects in the third and fourth ventricles, complete sphenoid sinus opacification with bony wall erosion, and obstructive hydrocephalus, findings consistent with intraventricular fungal masses and basal cisternal adhesions. Neurosurgery emergently placed an external ventricular drain (EVD); he was monitored in the ICU with frequent neurologic exams. Antifungal therapy with voriconazole and antiepileptic therapy with levetiracetam were initiated, and a ventriculo-peritoneal (VP) shunt was placed. Discussion This case highlights key features of intracranial aspergillosis. Imaging evidence of sinus opacification with bony erosion supports skull-base invasion chronic fungal sinusitis. Multi-level CSF obstruction reflects obstructive hydrocephalus, lobulated intraventricular lesions with enhancement suggests fungal aspergilloma. Current guidelines recommend CSF diversion (eg, EVD or VP shunt) and initiation of a CNS-penetrant antifungal (eg,Voriconazole) as first-line therapy. Finally, this case underscores considering CNS aspergillosis even in immunocompetent patients with prior fungal sinus disease who present with seizures, hydrocephalus, or unexplained intraventricular masses, since early use of multimodal imaging and multidisciplinary coordination may improve outcomes. This abstract is funded by: None