Introduction: Epidural extension of infectious phlegmon is a rare but severe complication of necrotizing pulmonary infection.
Description: A 65-year-old male with severe bullous emphysema and prior spontaneous pneumothoraces presented with encephalopathy, dyspnea, and left hemiplegia. He was intubated for GCS < 8. CT brain and spine revealed pneumocephalus with air tracking to the T2 level, pneumorrhachis, and epidural phlegmon. CT chest showed a cystic, air-fluid cavity in the left upper lobe, concerning for necrotizing pneumonia with possible CNS extension.
Empiric broad-spectrum antibiotics were initiated. Lumbar puncture showed WBC 23/uL (83% neutrophils), protein 180 mg/dL, glucose 59 mg/dL. Serum β-D-glucan was 213 pg/mL (ref < 60), and BAL cultures confirmed Aspergillus fumigatus, establishing invasive aspergillosis with likely CNS involvement. EEG showed no epileptiform activity. Despite maximal supportive care, the patient showed minimal neurologic recovery. Repeat EEG revealed diffuse suppression. After goals-of-care discussions, the patient was transitioned to comfort measures.
Discussion: This case represents a rare CNS extension of invasive pulmonary aspergillosis in an immunocompetent host. The patient’s underlying COPD and bullous disease likely predisposed him to cavitary lesions that served as a nidus for fungal invasion. Pneumorrhachis and pneumocephalus were likely due to direct air tracking via fascial planes or neuroforamina, exacerbated by elevated intrathoracic pressures from lung pathology.
Dural invasion likely occurred via contiguous spread of subacute epidural phlegmon, with paraspinal tissue involvement by fungal hyphae leading to CNS dissemination and microembolic strokes seen on MRI. Positive β-D-glucan and classic imaging findings aided diagnosis.
To our knowledge, this is the first report of contiguous spinal and cerebral extension from a cavitary pulmonary lesion due to Aspergillus in an immunocompetent patient, emphasizing the importance of recognizing rare pathways of fungal dissemination.
