CNS-invasive aspergillosis following ibrutinib therapy

Ibrutinib is Bruton’s tyrosine kinase inhibitor that now become the standard of care for the treatment of CLL (chronic lymphocytic leukemia) and other lymphoid cancers. With its increasing usage, oncologists must become more aware of their potential side effect profile. Ibrutinib is typically thought to be less immunosuppressive than standard immunotherapy; however, can still cause devastating side effects. We present a case of CNS-invasive aspergillosis in a patient with Waldenstrom’s macroglobulinemia being managed with ibrutinib. We hypothesize that treatment with ibrutinib can resemble those with X-gammaglobulinemia, thus putting our patient at risk of developing such an invasive fungal infection. Traditional risk factors for CNS-invasive aspergillosis include neutropenia, systemic glucocorticoid treatment, mastoidectomy, spinal anesthesia and paraspinal glucocorticoid injections. Oncologists need to weigh the risks and benefits of ibrutinib therapy in certain populations and more data in the future may suggest potentially adding empiric antifungal coverage with its usage.