This document describes a case study of a 69-year-old diabetic male who presented with an ischemic stroke caused by invasive aspergillosis in his nasopharynx. Despite initially negative diagnostic tests, the patient was empirically treated with voriconazole, an antifungal medication. However, he still experienced permanent neurological damage from the stroke even after completing three months of voriconazole therapy. The case demonstrates the importance of clinical suspicion for invasive fungal infections and considering non-traditional risk factors like marijuana use.

1. Nasopharyngeal Aspergillosis and Acute Ischemic Stroke
in a Diabetic Patient
N. Grauman Neander, MASc, OMSIII; C. Marske, DO; A. Forrester, MD; J. Grauman, MA, MSIII
Western University of Health Sciences COMP-NW, Lebanon, OR
Diagnosis & Treatment of Aspergillosis
•Specific lung CT findings5 GM (No findings in this patient)
• Halo sign
• Air Crescent sign
•Culture 33% sensitive6 (Negative in this patient)
•Biopsy with acute angle branching on histopathology5 (Initially
negative in this patient)
•GM assay 87% sensitive6 (Not performed)
•Treatment: Voriconazole (200mg Q12H minimum 6-12 weeks)7
•Patient survived and continues on Voriconazole
References
History of Present Illness
Unique Aspects of Case
1. Patient’s unique risk factors of chronic ear infection,
marijuana use and diabetes demonstrate importance of
clinical suspicion in spite of negative diagnostic testing
and considerations when advising a patient on marijuana
use
2. Patient had irreversible ischemic stroke even after
completion of 3 months of voriconazole treatment
.
Invasive Aspergillosis
◦ To recognize and diagnose aspergillosis
as a rare and serious cause of vascular compromise in the
immunocompetent
◦ To recognize Galactomaman (GM) assay as an important
screening test for suspected aspergillosis
◦ To understand the importance of empiric treatment with
voriconazole (a riazole antifungal medication)
Learning Objectives Imaging Reveals Nasocranial Invasion
• 69 year old male
• Presents to emergency department after wife found him
lying on floor unable to move his right arm and leg
Past Medical History
• Hypertension, hyperlipidemia, Diabetes mellitus T2
• Bladder carcinoma (2010), BPH
• Chronic resistant otitis media , hearing loss (2010-2014)
• Dramatic weight loss (2013)
• Dementia, depression, insomnia (2014)
• Hyperplasia on biopsy placed on hospice (2014)
• Invasive aspergillosis (09/2014 )
• Acute Ischemic Stroke (01/2015)
Social History
• Former cigarette smoker and marijuana user
• Former construction worker from Southern California
large area of restricted
diffusion in the upper pons
just to the left of midline and
just below the level of the
interpeduncular cistern.
Complex stellate rim-
enhancing collection
(MRI) - 09/2014
Worrisome for abscess
Bilateral mastoid effusions
(MRI) -09/2014
Consistent with chronic
omits media
Absent right vertebral flow
void (MRI) -09/2014
First evidence of vascular
involvement
Effacement of fossa of
Rosenmüller
(CT) -07/2014
Suspicion of Brain Mass
Stroke Evaluation
(01/2015)
•Angioinvasive fungus
with affinity for small
vessels2 &
atherosclerosis3
•2.5% Prevalence in
asthma1, often
asymptomatic1
•Associated with
handling of marijuana4
•100% mortality in
untreated cases with
neurological
symptoms7, 27.3% for
treated patients8
1.Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 08 Sept. 2014. Web. 16 Jan. 2015.
2. Norlinah MI, Ngow HA, Hamidon BB. Angioinvasive cerebral aspergillosis presenting as acute ischemic stroke in a patient with diabetes mellitus. Singapore
Med J 2007; 48:e1-e4.
3.E. Moalic, J.-P. Elkaim, J. Mansourati, P. Gouny, L. Doucet, J.-J. Blanc, A.-M. Le Flohic. Are Fungi Involved in the Atherosclerosis Process? Clinical
Microbiology and Infection 8; 2012.
4.Kagen SL: Aspergillus: An inhalable contaminant of marihuana. N Engl J Med 304:483-484, 1981
5. Denning DW. Invasive aspergillosis. Clin Infect Dis 1998;26:781-803.
6.Pfeiffer CD, Fine JP, Safdar N. Diagnosis of invasive aspergillosis using a galactomannan assay: a metaanalysis. Clin Infect Dis 2006;42:1417-1427.
7.Treatment and Prevention of Invasive Aspergillosis." Treatment and Prevention of Invasive Aspergillosis. N.p., n.d. Web. 16 Jan. 2015.
8. Kourkoumpetis TK, Desalermos A, Muhammed M, et al. Central nervous system aspergillosis: a series of 14 cases from a general hospital and
review of 123 cases from the literature. Medicine (Baltimore) 2012; 91:328-336.
9. Marr K, Schlamm H, Maertens J, et al. Combination Antifungal Therapy for Invasive Aspergillosis. Annals Of Internal Medicine [serial online]. January 20,
2015;162(2):81-89. Available from: Academic Search Elite, Ipswich, MA. Accessed March 5, 2015.
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