1. Altered mental status post transplant 66 year-old woman h/o diabetes mellitus s/p deceased donor renal transplantation One year post transplant admit to local hospital w urinary tract infection, cultures positive for Proteus and right arm cellulitis, treated with linezolid, keflex

2. Clinical presentation, cont. Readmit one month later with neutropenic fever, blood cultures positive for Pseudomonas, reportedly chest ab pelvis CT showed evidence of old granulomatous disease in lungs, liver, spleen The following month, admit again with headache, throat pain, diagnosed with thrush and fluconazole started Overnight developed altered mental status

3. MRI post admission Multiple foci of recently completed infarction involving the bilateral cerebral and cerebellar hemispheres, in a distribution suggestive of an embolic etiology. A larger infarct in the right basal ganglia demonstrates associated expansile mass effect and minor petechial bleeding.

4. Chest CT post admission FNA performed showing fungal elements Calcified right paraesophageal lymph nodes and similarly calcified subcentimeter nodule within right lower lobe (3-55), consistent with prior granulomatous disease. 39 x 35 mm lobulated mass-like consolidation within the right lower lobe superior segment, suspicious for bronchogenic carcinoma.

5. Post-lung FNA Aspergillus ag EIA 1.28 TTE negative for vegetations, valvular disease TEE was also negative. However, cardiac bedside TEE did show possible vegetation How to treat? Is this fungal endocarditis?

6. Clinical course Started on IV voriconazole 6mg/kg q12 Amphotericin B lipid complex added to regimen CSF cultures all negative for bacterial and fungal culture No improvement in mental status, family ultimately decided to withdraw care Was this invasive pulmonary disease plus stroke, or fungal endocarditis +/- septic emboli?

7. Brain: histopath Thrombosed vessel, R striatumMicrohemorrhage, R striatum

8. Heart and lung Heart, posterior papillaryLung

9. Take home thoughts Unusual causes of endocarditis may be seen after transplantation although few published cases of endocarditis due to mold exist Aspergillus galactomannan or antigen EIA testing may be useful in making the diagnosis of aspergillosis Choices for empiric antifungal treatment for aspergillosis include voriconazole or Amphotericin B lipid formulations