CTICasesInvasive Pulmonary and Cerebral Aspergillosis Mimicking a GPA Flare
Imaging findings
A 76-year-old man with renal insufficiency from small-vessel vasculitis and fever had CT showing a cavitary pulmonary nodule that rapidly enlarged and thickened over 12 days, along with additional nodules, a mass-like consolidative focus, pleural effusion, and dependent consolidation and ground-glass opacity. Brain MRI for new neurologic findings showed a cerebellar vermis lesion with central low signal, peripheral rim enhancement, and restricted diffusion, but no sinus disease. Cultures from the thick-walled cavitary lung lesions grew Aspergillus with positive galactomannan.
Key takeaways
In a patient with known vasculitis who has recently received rituximab and corticosteroids, rapidly evolving cavitary lung nodules and a new ring-enhancing brain lesion should raise suspicion for opportunistic invasive fungal infection rather than a vasculitis flare, since heavy immunosuppression, rather than active granulomatosis with polyangiitis, is the more likely explanation, and the absence of sinus disease further argued against GPA in this case; the presumed source of the cerebellar lesion was hematogenous or contiguous spread of the same invasive Aspergillus infection.
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