From Breath to Block: Disseminated Invasive Aspergillosis Presenting with Pulmonary, Ocular, Myocardial and Cerebral Involvement, and High-Grade Atrioventricular Block During Acalabrutinib Therapy for Chronic Lymphocytic Leukaemia

Invasive aspergillosis is a rare and often life-threatening manifestation of Aspergillus fungal infection affecting multiple organs. It tends to occur in immunocompromised patients, such as those with haematological malignancy receiving immunosuppressive treatments. Although pulmonary infection following inhalation is the principal route of acquisition, angioinvasive dissemination may result in involvement of multiple highly vascular organs, including the eye, myocardium and brain. This case report describes an 83-year-old man with chronic lymphocytic leukaemia (CLL) receiving the bruton tyrosine kinase (BTK) inhibitor acalabrutinib, who presented with left-sided Aspergillus fumigatus panuveitis and was subsequently diagnosed with disseminated invasive aspergillosis involving the lungs, myocardium and brain. Pulmonary nodules identified on prior surveillance imaging suggested the lungs as the most likely portal of entry, with subsequent haematogenous dissemination to the eye, heart and central nervous system. Cardiac involvement manifested as myocardial infiltration with high-grade 2:1 atrioventricular block. Diagnosis was established using ocular culture and Polymerase Chain Reaction (PCR) confirming Aspergillus fumigatus , positive serum beta-D-glucan and multimodality imaging. The patient was treated initially with intravenous liposomal amphotericin B, before transition to oral isavuconazole following multidisciplinary specialist review. Despite treatment, the patient deteriorated with evidence of progressive disseminated disease. He was eventually palliated due to poor predicted prognosis, and subsequently died. This case highlights the importance of recognising disseminated invasive aspergillosis in patients receiving BTK inhibitor therapy, appreciating that ocular involvement commonly represents haematogenous dissemination rather than the primary site of infection, and considering early multidisciplinary assessment with prompt antifungal therapy when cardiac or central nervous system involvement is suspected.