S5964 Beyond Imaging: A Rare Case of Hepatic Aspergillosis Diagnosed via EUS-Guided Liver Biopsy

Introduction: Hepatic aspergillosis is an uncommon yet potentially fatal opportunistic infection, typically affecting immunocompromised individuals. Diagnosis is often delayed due to vague symptoms and non-specific imaging. Endohepatology/endoscopic ultrasound (EUS) with guided biopsy is an emerging tool for evaluating pathologies, particularly when conventional modalities are inconclusive. This case highlights the successful use of EUS-guided liver biopsy in diagnosing hepatic Aspergillus versicolor infection in a patient with ulcerative colitis and recent corticosteroid exposure. Case Description/Methods: A 57-year-old woman with a history of ulcerative colitis, recently tapered off corticosteroids, presented with fatigue, low-grade fever, anorexia, and diarrhea. Laboratory evaluation revealed leukocytosis, anemia, elevated alkaline phosphatase (391 U/L), aspartate aminotransferase (41 U/L), and CRP (256 mg/L). Stool studies were negative. Abdominal computed tomography and MRCP demonstrated mild hepatic fibrosis and cirrhosis but no discrete hepatic lesions. Due to persistent symptoms and liver test abnormalities, EUS was pursued for further evaluation. EUS revealed subtle parenchymal changes in the liver, and fine-needle biopsy was performed. Histopathology showed caseating granulomas, and polymerase chain reaction testing confirmed Aspergillus versicolor. The patient was initiated on voriconazole therapy, resulting in marked clinical improvement. Discussion: EUS is primarily used for pancreaticobiliary and rectal pathology, but its application in hepatic diagnostics is expanding. Compared to percutaneous or transjugular liver biopsy, EUS offers enhanced imaging resolution, real-time visualization, and precise sampling, even in the absence of focal lesions. This approach is especially valuable when other modalities are limited by anatomical or coagulation constraints. Hepatic aspergillosis is often diagnosed post-mortem due to its rarity and non-specific presentation. This case exemplifies the real-time diagnostic potential of EUS-guided biopsy in identifying a rare fungal infection ante-mortem. EUS-guided liver biopsy can be a pivotal diagnostic tool for hepatic aspergillosis, particularly in immunocompromised patients with persistent liver abnormalities and inconclusive imaging. Its early application may facilitate timely antifungal therapy and improve clinical outcomes in rare but serious infections such as Aspergillus versicolor.