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Ring Lesions of the Brain

      A 57-year-old man presented to the hospital emergency department with a 2-week history of increasing somnolence, lethargy, anorexia, and headaches. The patient also reported development of left-sided facial droop and left-hand clumsiness 1 day before presentation. Magnetic resonance imaging of the brain showed multiple ring-enhancing lesions in the basal ganglia. The differential diagnosis included multiple abscesses, toxoplasmosis, cytomegalovirus, metastases, and cysticercosis. A biopsy of the brain revealed Aspergillus fumigatu, and the patient was treated with voriconazole, capsofungin, and terbinafine. Testing was negative for human immunodeficiency virus. Subsequent magnetic resonance imaging revealed multiple intracranial lesions with ring enhancement, and the disease progression was considered moderate. Changes were also noted in the left and right maxillary sinuses, and disease was evident in the ethmoid sinuses. Although nonspecific, these findings may represent fungal sinusitis; however, no fungus was isolated from specimens obtained from the patient's sinuses. The fungus was resistant to treatment, and the patient died 3 weeks after presentation.