Aspergillus niger infection in an immunosuppressed patient confined solely to the brain

A 68-year-old woman with a background of hypertension, stroke and rheumatoid arthritis presented to her local hospital after a 4-week history of gradual deterioration and increasing confusion with new onset right-sided weakness. Her initial CT scan revealed a rim enhancing mass lesion with surrounding oedema in the left parietal lobe for which she underwent CT stealth-guided biopsy. Microbiology culture of the 2 biopsy samples yielded Aspergillus niger and she was started on the antifungal agent voriconazole. MRI 2 weeks after the procedure also demonstrated radiological findings consistent with intracranial aspergillosis. She later developed leucopenia with neutrophils of 1.5×10⁹/L and her methotrexate and voriconazole were stopped. Voriconazole was changed to oral posaconazole. She did not undergo surgical resection and has continued to improve clinically on posaconazole, with recovery in her white cell count.