Invasive pulmonary aspergillosis in an insulin-dependent diabetic

Association between early diagnosis of and inpatient mortality from invasive pulmonary aspergillosis among patients without immunocompromised host factors: a nationwide observational study

OBJECTIVES

The incidence of invasive pulmonary aspergillosis (IPA) among patients without immunocompromised host factors (ICHF) has been described extensively. However, its diagnosis remains challenging. To date, no study has statistically confirmed the efficacy of early IPA diagnosis in patients without ICHF.

METHODS

We conducted a cross-sectional study on mortality from IPA among patients without ICHF, using the Japanese Diagnosis Procedure Combination National Inpatient Database (April 2014-March 2018). The early diagnosis group was defined according to antifungal therapy initiation within 7 days of hospital admission. The delayed diagnosis group was defined according to antifungal therapy initiation between 8 and 28 days of the hospitalization. Associations were estimated using multivariate logistic regression.

RESULTS

A total of 423 patients were registered (early diagnosis group, n = 262, 62%). The early diagnosis group had a lower mortality rate (30%) than the delayed diagnosis group (42%). The early diagnosis group that was treated with voriconazole was associated with lower odds of mortality (odds ratio 0.55, 95% confidence interval 0.31-0.99, P = 0.047). An age of ≥65 years and mechanical ventilation were associated with a higher mortality rate.

CONCLUSION

Early diagnosis along with optimal antifungal treatment are crucial for achieving favorable outcomes among patients with IPA without ICHF.

Characteristics of the Computed Tomography Imaging Findings in 72 Patients with Airway-Invasive Pulmonary Aspergillosis

BACKGROUND This multiple-center retrospective study aimed to investigate computed tomography (CT) imaging findings in 72 patients with airway-invasive pulmonary aspergillosis. MATERIAL AND METHODS Seventy-two patients with airway-invasive pulmonary aspergillosis confirmed by pathology results were divided into 3 types according to image characteristics. Type I involved the trachea or the main bronchus. Type II involved the lobular and segmental bronchi, which manifested early as bronchial wall thickening, and later development was divided into types IIa and IIb. Type IIa manifested as bronchiectasis, and type IIb manifested as consolidation around the bronchus. Type III involved the bronchioles and pulmonary parenchyma, with tree-in-bud sign and acinar nodules around. CT signs of the various types and their differentiation were investigated. RESULTS The main clinical manifestations of the 72 patients with airway-invasive pulmonary aspergillosis were shortness of breath (55/72, 76.4%), cough (40/72, 55.6%), expectoration (35/72, 48.6%), dyspnea (8/72, 11.1%), weight loss (2/72, 2.8%), and fever (30/72, 41.7%). CT typing identified 3 types: 2 patients (2.8%) had type I, presenting as thickening of trachea or main bronchial walls; 3 patients (4.2%) had early type II, manifesting as thickening of lobular or segmental bronchial walls; 27 patients (37.5%) developed type IIa, manifesting as bronchiectasis; 22 patients (30.6%) had type IIb, manifesting as consolidation around the bronchus; and 18 patients (25.0%) had type III, presenting as nodules and patchy shadows with small cavities in the periphery of the lung. CONCLUSIONS Airway pulmonary aspergillosis has characteristic imaging findings, which can help early clinical diagnosis through classification according to CT imaging characteristics.

Invasive pulmonary aspergillosis and influenza co-infection in immunocompetent hosts: case reports and review of the literature

Invasive pulmonary aspergillosis (IPA) is classically considered an illness of severely immunocompromised patients with limited host defenses. However, IPA has been reported in immunocompetent but critically ill patients. This report describes two fatal cases of pathologically confirmed IPA in patients with influenza in the intensive care unit. One patient had influenza B infection, whereas the other had influenza A H1N1. Both patients died despite broad-spectrum antimicrobials, mechanical ventilation, and vasopressor support. Microscopic and histologic postmortem examination confirmed IPA. Review of the English language and foreign literature indicates that galactomannan antigen testing and classic radiologic findings for IPA may not be reliable in immunocompetent patients. Respiratory cultures which grow Aspergillus species in critically ill patients, particularly those with underlying influenza infection, should not necessarily be disregarded as contaminants or colonizers. Further research is needed to better understand the immunological relationship between influenza and IPA for improved prevention and treatment of influenza and Aspergillus co-infections.

Clinical manifestations and outcomes of pulmonary aspergillosis: experience from Pakistan

Introduction

Pulmonary aspergillosis has variable course of illness, severity and outcomes depending on underlying conditions. There is limited data available on the clinical manifestations and outcome of pulmonary aspergillosis from Pakistan.

Methods

To determine the clinical manifestations and outcome of pulmonary aspergillosis in a tertiary care hospital a retrospective study was conducted from 2004 to 2014 in patients admitted with pulmonary aspergillosis at the Aga Khan University Hospital Karachi, Pakistan.

Results

Of the 280 cases with provisional diagnosis of aspergillosis 69 met the inclusion criteria. The mean age was 45±15.7 years, 48 (69.6%) were men and 21 (30.4%) had diabetes mellitus (DM). The average length of hospital stay (LOS) was 10.61±9.08 days. Aspergillus fumigatus was the most common (42.0%), followed by Aspergillus flavus (28.9%). More than one-third of patients previously had tuberculosis (TB) (39.13%). The commonest pulmonary manifestation was chronic pulmonary aspergillosis (CPA) 47 (68.1%) followed by invasive pulmonary aspergillosis (IPA) 12 (17.4%) and subacute invasive aspergillosis (SAIA) 8 (11.6%). Surgical excision was performed in 28 patients (40.57%). Intensive care unit admission was required for 18 patients (26.08%). Case fatality rate was 14/69 (20.3%). DM, mean LOS and hypoxic respiratory failure were identified as independent risk factors of mortality on multivariate analysis.

Conclusion

A. fumigatus was the most frequent species found especially in patients with prior TB. CPA was the commonest pulmonary manifestation seen as post TB sequel. Diabetes, hypoxic respiratory failure and increased LOS were independent predictors of poor outcomes. Overall patients had good outcome with CPA compared with SAIA and IPA.

Successfully treated invasive pulmonary aspergillosis in a patient with diabetic ketoacidosis

We report herein a case of diabetic ketoacidosis associated with invasive aspergillosis that was successfully treated with liposomal amphotericin-B (L-AMB). Early intervention after confirming the diagnosis of invasive pulmonary aspergillosis is very important, and initiating early treatment with L-AMB can lead to a full recovery.

A Case of Acute Cerebral Aspergillosis Complicating Influenza A/H1N1pdm 2009

Invasive aspergillosis is a rare complication in patients with influenza infection. Several cases of invasive pulmonary aspergillosis accompanying influenza infections were reported during the influenza A/H1N1pdm 2009. We encountered a case of acute cerebral aspergillosis in a patient with influenza A/H1N1pdm 2009 infection. A 24-year-old man with uncontrolled diabetes was diagnosed with influenza A/H1N1pdm 2009 infection. Initial evaluation indicated methicillin-sensitive Staphylococcus aureus pneumonia and diabetic ketoacidosis along with influenza. During his hospital course, multiple new rim-enhancing mass lesions not evident in the initial evaluation developed in the fronto-parietal cortical and subcortical white matter and right cerebellum. Pathology and culture results confirmed the presence of Aspergillus fumigatus. Surgical drainage combined with a total of 18 weeks of antifungal therapy resulted in complete resolution of the infection. This case demonstrates that cerebral aspergillosis can present alongside influenza in patients with diabetes or those under intensive care. Clinical suspicion of invasive aspergillosis is required for a definite diagnosis and better prognosis in such cases.

Transient hyperglycaemia - an underestimated problem of paediatric oncohaematology

INTRODUCTION

The majority of hyperglycaemic incidents in oncohaematological patients treated with glucocorticosteroids remain undiagnosed. The aim of our study was to work out a detailed protocol for the control of carbohydrate metabolism and to evaluate whether such a protocol can help in diagnosis of carbohydrate metabolism disturbances in oncohaematological paediatric patients.

MATERIAL AND METHODS

A one hundred and twenty-eight children treated for proliferative diseases of the haematopoietic system and severe aplastic anaemia with therapeutic protocols including glucocorticosteroids were divided into two groups. Group I consisted of 70 children, whose blood glucose was evaluated on random occasions (retrospective analysis). Group II consisted of 58 children included in the programme of intensive carbohydrate metabolism control (prospective analysis). We compared the incidence of hyperglycaemia in both groups as well as the number of hyperglycaemic incidents per individual therapeutic protocol.

RESULTS

A significantly higher incidence of transient hyperglycaemia was noted in oncohaematological patients in the programme of early carbohydrate metabolism disturbances diagnosis than in the other group (22.4% vs. 5.7% respectively; p = 0.008), especially in patients treated with the ALL IC-BFM 2002 protocol for the high risk group (arm A and B), the ALL-REZ BFM 2002 protocol, and in a heterogenous group of children (protocols ALCL 99, Euro-LB02, Interfant-06, WPSAA) (p = 0.042, 0.021 and 0.002, respectively).

CONCLUSIONS

The improvement of transient hyperglycaemia detection may constitute the first step towards the reduction of unfavourable consequences of hyperglycaemia. Prospective studies are required to demonstrate the influence of normal carbohydrate metabolism on the frequency of infectious complications in this group.

[Pulmonary mucormycosis: difficulties in diagnosis and treatment]

INTRODUCTION

Mucormycosis is a rare opportunistic fungal infection due to filamentous fungi of the order Mucorales in the class Zygomycetes. Rhino-cerebral and pulmonary manifestations predominate on account of the airborn spread of the spores. Gastro-intestinal, cutaneous and disseminated disease is less common. The principal risk factors are immuno-suppression and diabetic keto-acidosis.

CASE REPORTS

One case of fatal pulmonary mucormycosis and two cases of colonisation illustrate both the extreme severity of this disease and the diagnostic difficulties facing the physician. The ubiquitous nature of the organism leads to frequent colonisation and, moreover, the symptomatology readily mimics that of invasive pulmonary aspergillosis. The diagnosis of mucormycosis can only be confirmed by pathological and mycological examination of biopsy specimens. These requirements conflict with the need for urgent treatment with surgical debridement, amphotericin B and control of the underlying pathology. Sadly the mortality remains very high, between 50 and 80% in published series.

CONCLUSION

Currently there is hope of new therapeutic approaches with posaconozole but the ineffectiveness of voriconozole and the echinocandines, used more and more against aspergillus, raises the possibility of an increase in mucormycosis by selection.