SHM Converge Scientific Abstract ePoster Gallery-A Hidden Target: Reverse Target Sign in Cerebral Aspergillosis and Varicella Zoster Encephalitis

Pdf Summary

This case describes a 37-year-old woman with high-grade glioma and recent leptomeningeal disease who presented with several days of altered mental status, aphasia, and bilateral leg weakness. She had recently received corticosteroids, radiation, bevacizumab, and tovorafenib.<br /><br />On admission, she was lethargic, hypoxic, and found to have leukopenia and severe thrombocytopenia. CT chest showed bilateral pulmonary emboli and right lower lobe necrotizing pneumonia. Blood cultures grew Streptococcus pneumoniae, and she was started on anticoagulation and broad-spectrum antibiotics. However, her mental status did not improve.<br /><br />MRI brain raised concern for septic emboli and showed lesions with a “reverse target sign,” also called a reverse halo sign. This imaging pattern is a rounded area of ground-glass opacity or abnormal signal surrounded by a ring of consolidation and is highly suggestive of early angioinvasive fungal infection in immunocompromised patients.<br /><br />Further workup showed positive Aspergillus antigen, positive beta-D-glucan, and positive varicella zoster PCR. CSF analysis revealed neutrophilic pleocytosis, elevated protein, and low glucose. Metagenomic testing identified both VZV and Aspergillus terreus in the CSF, confirming disseminated invasive aspergillosis with VZV encephalitis.<br /><br />Treatment was expanded to include voriconazole, caspofungin, and acyclovir. She had only modest neurologic improvement and ultimately required enteral feeding, which was not consistent with her goals of care. She was transitioned to comfort care and died surrounded by family.<br /><br />The case emphasizes the need to avoid anchoring on known cancer progression when evaluating altered mental status in immunocompromised patients and highlights the value of advanced and serial imaging in identifying opportunistic infections.

Asset Subtitle

Abigail Withers

Meta Tag

Author List Abigail Withers, Jacob Zinn

Category Clinical Vignettes

Distinguished Non-Finalist

Presenter Organization University of Pennsylvania

Presenting Author Abigail Withers

Track Adult

Keywords

high-grade glioma

leptomeningeal disease

altered mental status

reverse target sign

angioinvasive fungal infection

disseminated aspergillosis

Aspergillus terreus

varicella zoster encephalitis

immunocompromised patient

opportunistic infection