A rare cause of obstructive hydrocephalus: Cerebral aspergillosis presenting as an intracranial space-occupying lesion in an immunocompetent adult.

Background: Cerebral aspergillosis (CA) is a rare fungal infection and life-threatening disease often associated with immunocompromised patients but can occasionally be present in immunocompetent individuals, mimicking an intracranial neoplasm. CA is highly linked to reduced immunity and is commonly seen in patients with background immunodeficiency, such as acquired immunodeficiency syndrome, chemotherapy, organ transplant patients on immunosuppressive therapy, and those with long-term steroid use. Diagnosis and management of CA can be quite challenging in immunocompetent individuals due to its unusual presentation, non-specific symptoms, and resemblance to tumors in imaging, the necessity of invasive procedures for diagnosis confirmation, complex surgical management, and the need for prolonged antifungal treatment with possible side effects.

Case description: The case of a 36-year-old immunocompetent male who presented with a 2-year history of recurrent headaches, vomiting, seizures, inability to walk, and altered sensorium, with no history of immunosuppression. Clinical examination revealed a chronically ill patient with multiple cranial nerve palsies, and magnetic resonance imaging revealed a fourth ventricular mass with pan ventriculomegaly causing obstructive hydrocephalus. Initial management of the patient included a ventriculoperitoneal shunt followed by a midline suboccipital craniectomy and excision of the mass lesion 5 days later. Histopathology confirmed CA diagnosis, and the patient was treated with intravenous voriconazole, after which improvement in his clinical status was observed.

Conclusion: This case emphasizes the importance of early detection of unusual CA in immunocompetent individuals and the importance of combining surgical intervention with antifungal therapy. The patient presented with a rare form of CA as an intracranial mass causing obstructive hydrocephalus, which initially mimicked a tumor. Early diagnosis and effective management, including surgery and antifungal treatment with voriconazole, led to significant improvement despite incomplete mass removal. Multidisciplinary care and long-term monitoring are crucial for managing such complex cases.