Case Presentation: A 72 year old male with history of uncontrolled hypertension and obstructive sleep apnea presented to the ER with headache, blurry vision and diplopia for 2 weeks. Positive findings on examination were elevated blood pressure and right lateral rectus palsy. CT scan of the head ruled out intracranial hemorrhage. ESR was 30 s and no tenderness on temporal artery was found. CSF as analysis ruled out encephalitis or meningitis. MRI brain showed no infarcts, and no hypo or hyperdense areas, but demonstrated complete right sphenoid sinus opacification suggestive of mycetoma and bony erosion of lateral sphenoid sinus, along with mucosal thickening of ethmoidal sinus. Concerned about infectious vs neoplastic process involving the sixth cranial, he was started on antibiotics and endoscopic sinus surgery was performed where the contents of the sphenoid sinus were removed. The pathology showed presence of aspergillus and cultures reported achromobacter species. He was started on antifungals and antibiotics guided by the final sensitivity report. He completed the treatment with resolution of his diplopia within 3 months. Investigating the cause of this rare mycetoma, he was seen by his pulmonologist who found that his CPAP equipment was not serviced since many years and showed signs of poor maintenance. He was advised not to use his machine until repeating the polysomnography and change of equipment.

Discussion: Opportunistic infections are common in immunocompromised patients and those with certain co- morbidities as diabetes mellitus, chronic renal insufficiency, malignancies and cystic fibrosis. Here we present a previously healthy and immunocompetent adult who suffered from not one but two species of micro-organisms causing significant neurological deficits.

Conclusions: CPAP is the standard of care for treatment of patients with obstructive sleep apnea, though little data is available on infections associated with use of CPAP machine. Few cases have been reported about CPAP equipment being colonized with organisms and causing sinusitis and pneumonia. This patient had a significant infectious neurological complication for which he underwent extensive work up. As internists, we should be aware of such possibilities and consider it as one of the differentials in such cases. Regular servicing of the CPAP equipment is important to avoid colonization by ubiquitous organisms that may cause complicated illness.