COVID-19-associated pulmonary aspergillosis
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Background
- Defined as invasive pulmonary aspergillosis following COVID-19
- Similar to influenza-associated pulmonary aspergillosis
Pathophysiology
- Viral infection damages airway epithelium, allowing Aspergillus to invade
- May also be a component of immune dysfunction, with COVID-19 affecting T cells
- Probably also made more likely by treatment for COVID-19, including corticosteroids and IL-6 inhibitors
Clinical Manifestations
Prognosis
- Mortality increased 16 to 25% compared to patients without aspergillosis
Investigations
- CT chest for COVID-19 can mimic IPA and vice-versa, made more complicated in patients with ARDS
- Multiple pulmonary nodules or lung cavitation is suggestive, since they are less likely to be due to COVID-19 alone
- Halo sign indicates local infarction, which can occur with COVID-19 even in the absence of IPA
- BAL for galactomannan is highly suggestive of IPA
- Serum galactamannan is insensitive (positive in about 20% of patients)
Diagnosis
- Diagnostic criteria have been developed by ECMM/ISHAM1
- Criteria only apply to patients with COVID-19 needing intensive care and who have a temporal relationship
- Proven tracheobronchitis or other pulmonary form:
- At least one of the following:
- Histopathological or direct microscopic detection of fungal hyphae, showing invasive growth with associated tissue damage
- Aspergillus recovered by culture or microscopy or histology or PCR obtained by a sterile aspiration or biopsy from a pulmonary site
- At least one of the following:
- Probable tracheobronchitis
- Tracheobronchitis, indicated by tracheobronchial ulceration, nodule, pseudomembrane, plaque, or eschar seen on bronchoscopy
- At least one of the following:
- Microscopic detection of fungal elements in BAL, indicating a mold
- Positive BAL culture or PCR
- Serum galactomannan >0.5 or serum LFA >0.5
- BAL galactomannan ≥1 or BAL LFA ≥1
- Probable pulmonary forms excluding tracheobronchitis
- Pulmonary infiltrate, preferably documented by CT chest, or cavitating infiltrate, not attributed to another cause
- At least one of the following:
- Microscopic detection of fungal elements in BAL, indicating a mold
- Positive BAL culture
- Serum galactomannan >0.5 or serum LFA >0.5
- BAL galactomannan ≥1 or BAL LFA ≥1
- Two or more positive Aspergillus PCR tests in plasma, serum, or whole blood
- A single positive Aspergillus PCR on BAL <36 cycles
- A single positive Aspergillus PCR in plasma, serum, or whole blood, plus a single positive PCR in BAL
- Possible pulmonary forms excluding tracheobronchitis
- Pulmonary infiltrate, preferably documented by CT chest, or cavitating infiltrate, not attributed to another cause
- At least one of the following:
- Microscopic detection of fungal elements in non-bronchoscopic lavage indicating a mould; positive non-bronchoscopic lavage culture
- Single non-BAL galactomannan index >4.5
- Non-BAL galactomannan index >1.2 twice or more
- Non-BAL galactomannan index >1.2 plus another non-BAL mycology test positive (non-BAL PCR or LFA)
References
- ^ Philipp Koehler, Matteo Bassetti, Arunaloke Chakrabarti, Sharon C A Chen, Arnaldo Lopes Colombo, Martin Hoenigl, Nikolay Klimko, Cornelia Lass-Flörl, Rita O Oladele, Donald C Vinh, Li-Ping Zhu, Boris Böll, Roger Brüggemann, Jean-Pierre Gangneux, John R Perfect, Thomas F Patterson, Thorsten Persigehl, Jacques F Meis, Luis Ostrosky-Zeichner, P Lewis White, Paul E Verweij, Oliver A Cornely. Defining and managing COVID-19-associated pulmonary aspergillosis: the 2020 ECMM/ISHAM consensus criteria for research and clinical guidance. The Lancet Infectious Diseases. 2021;21(6):e149-e162. doi:10.1016/s1473-3099(20)30847-1.
