{
  "abstract": "Prompt recognition of angioinvasive Aspergillus is critical, as delays in diagnosis are associated with rapid vascular progression and high mortality. However, in patients presenting with altered mental status, the differential diagnosis is often broad and includes metabolic derangements, toxic exposures, malignancy, and other infectious etiologies, which can obscure early consideration of invasive fungal disease. Clinical presentation is frequently non-specific; while pulmonary involvement classically presents with cough and fever, pleuritic chest pain and hemoptysis may also occur. However, the absence of overt respiratory symptoms, does not exclude invasive disease, particularly hematogenous dissemination to the central nervous system. This diagnostic complexity may contribute to delayed initiation of antifungal therapy with central nervous system penetrance, allowing continued fungal vascular invasion and progression to cerebral infarction or hemorrhage. Therefore, clinicians should maintain a high index of suspicion for angioinvasive fungal infection in patients with rapidly evolving intracranial arteriopathy, unexplained recurrent multifocal infarcts, or concurrent sinus or orbital involvement, particularly when clinical deterioration outpaces initial imaging diagnostic findings.A 58-year-old woman with end-stage renal disease secondary to hypertension status post deceased donor kidney transplant (May 2025), complicated by delayed graft function and CMV infection, presented with fever, lethargy, and headache. She was found to be leukopenic with altered mental status and no clear infectious source, prompting admission for sepsis evaluation and initiation of broad-spectrum antimicrobials.Her course was complicated by acute hypoxic respiratory failure requiring ICU transfer, with imaging demonstrating multilobar pneumonia. Neurologic workup revealed acute ischemic changes on MRI and cerebrospinal fluid consistent with bacterial meningitis; however, despite appropriate antimicrobial therapy, she exhibited progressive clinical deterioration with persistent encephalopathy, recurrent fevers, and worsening cytopenias in the setting of immunosuppression.Further evaluation with advanced infectious diagnostics ultimately identified angioinvasive fungal infection (mucormycosis), raising concern for disseminated disease with possible central nervous system involvement contributing to multifocal infarcts.Antimicrobial therapy was escalated to include amphotericin B, and immunosuppression was minimized. Despite these interventions, her course remained complicated by progressive neurologic decline and systemic illness.In our case, serial MRA demonstrated evolving intracranial arterial narrowing consistent with likely progressive fungal angioinvasion, underscoring the aggressive nature of this disease. These findings suggest that in high-risk patients, there should be a low threshold to obtain baseline vascular imaging with CTA or MRA at initial presentation, even when early neuroimaging is unrevealing. Establishing a vascular baseline may facilitate earlier detection of rapidly progressive arteriopathy and prompt timely initiation of antifungal therapy before ischemic or hemorrhagic complications occur. Even with aggressive therapy, the prognosis of cerebral angioinvasive aspergillosis is poor, with a high mortality rate of 85%-100%. Early initiation of targeted antifungal therapy, consideration of surgical debridement, and multidisciplinary vascular evaluation may be essential in providing the maximal opportunities for patient survival.Disclosures S. Patel: None.",
  "authors": [
    {
      "affiliations": [
        "Neurology, University of Illinois College of Medicine, Chicago, IL"
      ],
      "name": "S Patel"
    }
  ],
  "title": "E-251 The fungus that narrowed the arteries: imaging evolution of cerebral angioinvasive aspergillosis",
  "uid": "d150ad0c-c62e-5e2c-92bb-4ddf698a5883"
}