P1.024: Fever, Fatigue, and Focal Neurologic Findings after Foreign Travel

Introduction: From 1996 to 2024, only 9 cases of intracranial aspergillosis in immunocompetent children have been reported. This is the tenth known case, which describes CNS aspergillosis in an immunocompetent pediatric patient.

Case Description: A 2-year-old male presented to the ED with persistent fever, malaise, and progressively worsening headache. He had recently returned from a two-month trip to Gambia, where he had reportedly been admitted and treated for presumed malaria but had continued to have symptoms after discharge, which prompted his ED visit after returning to the US. His head CT was notable for rim-enhancing lesions and ventriculomegaly, and he was admitted to the pediatric ICU.

On hospital day 1, his MRI brain confirmed previous CT head findings. He decompensated on hospital day 2 with posturing, seizure-like activity, and dilated, non-reactive pupils. Critical care interventions included hypertonic saline, sedation, intubation, two rounds of compressions, EVD placement, meningitic dosing of empiric vancomycin and ceftriaxone, steroids, and a nicardipine infusion for hypertension.

On hospital day 6, he underwent surgical resection of a posterior fossa lesion, which was found to be an abscess with purulent drainage. On hospital day 9, the fluid culture grew irregular septate fungal hyphae, which further speciated to Aspergillus nidulantes, and he was started on isavuconazole. Notably, multiple prior CSF studies had all been negative. During his hospital course, he underwent extensive immunologic work-up, which showed no genetic or phenotypic variants associated with primary immunodeficiency or cerebral Aspergillosis. He failed several trials to clamp his EVD and was ultimately discharged with a ventriculoperitoneal shunt and a total 4-month course of isavuconazole.

Discussion: Cerebral Aspergillosis is rarely found in immunocompetent individuals, much less pediatric patients. However, it is an aggressive disease with high mortality and poor prognosis, even in those who are not immunocompromised. Diagnosis often requires direct stereotactic biopsy or complete surgical excision, and CSF samples are not usually diagnostic. This patient was treated with surgical excision, aggressive anti-fungal therapy, and appropriate supportive care. By time of discharge, he had returned to neurologic baseline with only residual right hemiparesis.

Conclusion: This case introduces the need for early recognition and aggressive intensive and surgical management of pediatric patients with suspected intracranial aspergillosis.