A diagnostic riddle in an immunocompetent adult: Meningioma or intracranial fungal granuloma?

Clinically, central nervous system (CNS) fungal infections are difficult to diagnose and often have a deceptive presentation. In an immune-competent adult, an enhancing mass on magnetic resonance imaging (MRI) in the greater sphenoidal area has a high possibility of being a tumor like meningioma. An intracranial mass of fungal etiology in such patients is a highly unsuspected diagnosis. We report such a case eventually diagnosed as aspergilloma on biopsy. Instituting oral voriconazole resulted in complete resolution of the lesion. In the absence of predisposing factors or extracerebral foci of infection, direct CNS seeding by aspergillus is a poorly understood and rare occurrence. This case highlights the possible pathogenesis, challenges in diagnosis and eventually successful treatment protocol employed in an uncommon clinical scenario.