Angiographically occult catastrophe: A rare case of aspergillus-induced subarachnoid hemorrhage without mycotic aneurysms following apparent bacterial abscess resolution.

This report details a fatal case of cerebral aspergillosis in a cirrhotic patient where radiographic resolution of a presumed bacterial brain abscess concealed advancing fungal vasculitis, culminating in fatal subarachnoid hemorrhage (SAH). A woman in her 60s exhibited temporal abscess improvement on antibiotics but died weeks later from SAH. Autopsy revealed Aspergillus-driven small-vessel vasculopathy without aneurysms, with lung involvement confirming hematogenous spread. Key findings challenge neuro-infectious norms: (1) fungal progression despite bacterial treatment response; (2) SAH from direct venular invasion, an angiographically silent phenotype; and (3) cirrhosis enabling dissemination without classic immunosuppression. Diagnosis was delayed due to negative cultures and absent pulmonary symptoms. The case mandates aggressive fungal surveillance (CSF PCR, vascular imaging) in cirrhotic patients with CNS infections, even amid antibiotic success, and underscores cirrhosis as a silent risk factor for disseminated fungal disease. It argues for preemptive antifungals in high-risk cohorts and warns against equating radiographic improvement with microbiologic cure.