Iatrogenic Mixed Fungal Infection with Aspergillus terreus and Aspergillus triticale Postroot Block Procedure in an Immunocompetent Patient

Iatrogenic fungal infections are rare in immunocompetent patients. This report details a unique case of Aspergillus terreus and Aspergillus triticale infection following an epidural root block, highlighting the rare challenges in pathogen isolation, identification, and treatment, which complicate clinical management and patient outcomes. A male in his forties developed fever, headache, and weight loss postprocedure. Initial suspicion of meningitis was confirmed via lumbar puncture. Despite empirical antibiotics, corticosteroids, and antiedema measures, symptoms worsened. MRI revealed exudates on the pons and an infratentorial granuloma. Empirical antifungal therapy was initiated after cerebrospinal fluid galactomannan and beta-D-glucan assays tested positive, though fungal cultures were negative. Despite voriconazole treatment, the patient showed persistent symptoms with subtherapeutic drug levels. Dual therapy with voriconazole and amphotericin B failed. MRI of the lumbar spine revealed an epidural collection, prompting surgical intervention. Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry performed on the purulent discharge from the laminectomy identified A. terreus and A. triticale. Subtherapeutic voriconazole levels, likely due to pharmacokinetics and drug interactions, necessitated switching to isavuconazole, leading to clinical improvement. A mixed fungal infection involving A. terreus and A. triticale is an uncommon occurrence in immunocompetent individuals. This case report delineates the diagnostic challenges encountered in isolating these fungal pathogens and the complexities associated with their management. By detailing our experience, this report aims to provide valuable insights for clinicians who may encounter similar rare infections, thereby aiding in timely diagnosis and optimized therapeutic strategies.