Scedosporium apiospermum is an emerging opportunistic mold that causes invasive infections, particularly central nervous system (CNS) involvement with multiple brain abscesses in near-drowning victims exposed to contaminated water. We describe a 20-month-old immunocompetent boy from rural Maharashtra, India, who developed multiple brain abscesses following accidental near-drowning in a household biogas tank. He presented with aspiration pneumonitis, acute respiratory distress syndrome, refractory seizures, and left hemiparesis. Initial broad-spectrum antibiotics (ceftriaxone, metronidazole, vancomycin, meropenem) failed to resolve lesions on serial neuroimaging. High clinical suspicion, informed by literature on scedosporiosis in polluted-water near-drowning and biogas-related accidents, prompted empirical addition of oral voriconazole. Pus from surgical drainage of a parieto-occipital abscess revealed septate hyphae on calcofluor staining, with culture confirming S. apiospermum. Antifungal susceptibility testing showed low MICs to voriconazole (0.125 μg/mL), posaconazole, and itraconazole. Combination therapy with voriconazole and terbinafine, alongside surgical drainage, led to defervescence, seizure freedom, and gradual neurological recovery over four weeks. This case highlights the critical role of literature-guided suspicion for Scedosporium in atypical CNS infections refractory to antibacterials, especially in settings with household biogas exposure. Early voriconazole initiation and surgical intervention are essential for improved outcomes in this high-mortality infection.

Keywords:Scedosporiosis; Invasive Fungal Diseases; Tropical Infections; CNS Infections