# A breakthrough invasive Aspergillus granulosus infection following azole antifungal therapy in a patient with primary myelofibrosis: case report

## TL;DR

A rare case of deadly invasive Aspergillus granulosus infection occurred in a patient with myelofibrosis after azole antifungal treatment.

## Contribution

This is the first reported non-transplant case of fatal A. granulosus breakthrough infection following azole therapy.

## Key findings

- A. granulosus can cause breakthrough invasive aspergillosis after azole therapy.
- Cryptic species and antifungal resistance complicate diagnosis and treatment.
- Early and accurate identification is critical for managing such infections.

## Abstract

Invasive aspergillosis (IA) primarily affects immunocompromised patients, with Aspergillus granulosus being a rare cause. Most cases occur in transplant recipients, and breakthrough infections may develop after azole therapy due to cryptic species and antifungal resistance. Here, we present the first non-transplant case of breakthrough A. granulosus infection following azole therapy with a fatal outcome. This case highlights the importance of early diagnosis, accurate species identification, and appropriate antifungal treatment for breakthrough invasive fungal infections.

•Aspergillus granulosus is a rare cause of invasive aspergillosis (IA).•It can lead to breakthrough IA after azole therapy.•Its cryptic phenotypes and antifungal resistance challenge the management.•Early diagnosis with appropriate antifungal therapy is crucial to improve outcomes.

Aspergillus granulosus is a rare cause of invasive aspergillosis (IA).

It can lead to breakthrough IA after azole therapy.

Its cryptic phenotypes and antifungal resistance challenge the management.

Early diagnosis with appropriate antifungal therapy is crucial to improve outcomes.