ABSTRACT
Introduction: Young patients presenting with stroke to the emergency department (ED) is more uncommon. Atypical presentations of stroke in young patients presenting to ED include loss of consciousness, headache, vomiting, and blurring of vision. Young patients may present with stroke of infective causes which include bacterial, viral, fungal, and parasitic origin. Case discussion: A 24-year-old male presented to the ED in semiconscious state with decreased responsiveness along with complaints of fever since 2days and giddiness since 2days, followed by two episodes of vomiting and loss of consciousness. His vital data are blood pressure of 90/60mm Hg, and on examination, Glasgow Coma Scale (GCS) was E3V2M2, pupils are 1mm sluggishly reacting to light and showing upbeat and downbeat nystagmus on both sides, horizontal gaze palsy was present on the right side, all four limbs are in paraplegia and hyperreflexive to deep tendon reflexes, and ankle clonus is present. In view of poor GCS, the patient was intubated in the ED. The patient had a history of right maxillary fungal sinusitis 7 years back for which Functional Endoscopic Sinus Surgery (FESS) was done. The patient denied COVID infection and immunization. Neuroimaging and magnetic resonance imaging (MRI) brain plain with contrast revealed right maxillary fungal sinusitis extending up to the base of the skull with bilateral pontine and cerebellar infarcts, and there was complete occlusion of basilar artery occlusion. The patient was shifted to the intensive care unit (ICU);on further evaluation, the patient's serum homocysteine, protein C, and protein S were normal. Carotid Doppler was normal. Infective workup was done for TB and herpes simplex virus (HSV), bacterial workup was done, and then fungal workup was done for KOH mount, and tissue fungal smear revealed Aspergillus which was managed with antifungals like liposomal amphotericin B and voriconazole;FESS was done during hospitalization. The patient improved clinically and was discharged to the rehabilitation center. Conclusion: In this case, the cause of stroke was an improperly treated fungal sinusitis which invaded the basilar artery. Being an emergency physician, we should have high index of suspicion in the case of young patients presenting with stroke to ED;we need to consider their past history which gives clue toward the diagnosis of infective causes besides routine workup.