Pulmonary aspergillosis following post-influenzal bronchopneumonia treated with antibiotics

Influenza-associated and COVID-19-associated pulmonary aspergillosis in critically ill patients

Influenza-associated pulmonary aspergillosis (IAPA) and COVID-19-associated pulmonary aspergillosis (CAPA) are increasingly recognised as important complications in patients requiring intensive care for severe viral pneumonia. The diagnosis can typically be made in 10-20% of patients with severe influenza or COVID-19, but only when appropriate diagnostic tools are used. Bronchoalveolar lavage sampling for culture, galactomannan testing, and PCR forms the cornerstone of diagnosis, whereas visual examination of the tracheobronchial tract during bronchoscopy is required to detect invasive Aspergillus tracheobronchitis. Azoles are the first-choice antifungal drugs, with liposomal amphotericin B as an alternative in settings where azole resistance is prevalent. Despite antifungal therapy, IAPA and CAPA are associated with poor outcomes, with fatality rates often exceeding 50%. In this Review, we discuss the mechanistic and clinical aspects of IAPA and CAPA. Moreover, we identify crucial knowledge gaps and formulate directions for future research.

The influenza A virus promotes fungal growth of Aspergillus fumigatus via direct interaction in vitro

Seasonal influenza A virus (IAV) infections still pose a major burden for public health worldwide. Severe disease progression or even death is often related to superinfections of the virus and a secondary bacterial pathogen. However, fungi, especially Aspergillus fumigatus, are also frequently diagnosed during IAV infection. Although, clinical studies have reported the severity of influenza-associated pulmonary aspergillosis, the molecular mechanisms underlying this type of disease are poorly understood. Here, a new in vitro model is introduced that allows the investigation of complex pathogen-host and pathogen-pathogen interactions during coinfection of lung epithelial cells with IAV and A. fumigatus. Our data reveal a reduced IAV load and IAV-induced cytokine and chemokine expression in the presence of A. fumigatus. At the same time, IAV infection promotes the growth of A. fumigatus. Even in the absence of the human host cell, purified IAV particles are able to induce hyphal growth, due to a direct interaction of the virus particles with the fungal surface. Thus, our study gives first insights into the complex interplay between IAV, A. fumigatus and the host cell as well as the two pathogens alone.

Higher risk for influenza-associated pulmonary aspergillosis (IAPA) in asthmatic patients: A Swiss multicenter cohort study on IAPA in critically ill influenza patients

BACKGROUND

Influenza-associated pulmonary aspergillosis (IAPA) is an important complication of severe influenza with high morbidity and mortality.

METHODS

We conducted a retrospective multicenter study in tertiary hospitals in Switzerland during 2017/2018 and 2019/2020 influenza seasons. All adults with PCR-confirmed influenza infection and treatment on intensive-care unit (ICU) for >24 h were included. IAPA was diagnosed according to previously published clinical, radiological, and microbiological criteria. We assessed risk factors for IAPA and predictors for poor outcome, which was a composite of in-hospital mortality, ICU length of stay ≥7 days, mechanical ventilation ≥7 days, or extracorporeal membrane oxygenation.

RESULTS

One hundred fifty-eight patients (median age 64 years, 45% females) with influenza were included, of which 17 (10.8%) had IAPA. Asthma was more common in IAPA patients (17% vs. 4% in non-IAPA, P = 0.05). Asthma (OR 12.0 [95% CI 2.1-67.2]) and days of mechanical ventilation (OR 1.1 [1.1-1.2]) were associated with IAPA. IAPA patients frequently required organ supportive therapies including mechanical ventilation (88% in IAPA vs. 53% in non-IAPA, P = 0.001) and vasoactive support (75% vs. 45%, P = 0.03) and had more complications including ARDS (53% vs. 26%, P = 0.04), respiratory bacterial infections (65% vs. 37%, P = 0.04), and higher ICU-mortality (35% vs. 16.4%, P = 0.05). IAPA (OR 28.8 [3.3-253.4]), influenza A (OR 3.3 [1.4-7.8]), and higher SAPS II score (OR 1.07 [1.05-1.10]) were independent predictors of poor outcome.

INTERPRETATION

High clinical suspicion, early diagnostics, and therapy are indicated in IAPA because of high morbidity and mortality. Asthma is likely an underappreciated risk factor for IAPA.

Pathogenesis of Respiratory Viral and Fungal Coinfections

Individuals suffering from severe viral respiratory tract infections have recently emerged as "at risk" groups for developing invasive fungal infections. Influenza virus is one of the most common causes of acute lower respiratory tract infections worldwide. Fungal infections complicating influenza pneumonia are associated with increased disease severity and mortality, with invasive pulmonary aspergillosis being the most common manifestation. Strikingly, similar observations have been made during the current coronavirus disease 2019 (COVID-19) pandemic. The copathogenesis of respiratory viral and fungal coinfections is complex and involves a dynamic interplay between the host immune defenses and the virulence of the microbes involved that often results in failure to return to homeostasis. In this review, we discuss the main mechanisms underlying susceptibility to invasive fungal disease following respiratory viral infections. A comprehensive understanding of these interactions will aid the development of therapeutic modalities against newly identified targets to prevent and treat these emerging coinfections.

Risk Factors Associated with Invasive Pulmonary Mycosis Among Severe Influenza Patients in Beijing City, China

Objective

Influenza co-infection with fungal infection increases the risk of death. Our study was to estimate risk factors associated with invasive pulmonary mycosis (IPM) among severe influenza patients at a single center in Beijing, China.

Methods

A retrospective chart review was carried out of all patients with severe influenza admitted to respiratory the department including the respiratory intensive care unit (RICU) during the 2014 to 2019 influenza seasons in Beijing Chao-yang hospital, China. We compared the differences of characteristics and examination outcomes between IPM patients and non-IPM patients, and explored the predictors of IPM by a multivariate logistic regression.

Results

Influenza associated IPM was found in 65 of 131 (49.62%) patients. The average age of IPM patients was 57.28±14.56 years and 70.77% were male. The mortality rate was much higher in the IPM group than the non-IPM group (34.85% versus 18.46%, P=0.026). Older age, hypoimmunity, liver disease, hypertension, positive serum GM test, steroids using, gasping, gastrointestinal symptoms, high APECHEII, low oxygenation index, other viruses co-infection, bacterial co-infection, low lymphocyte counts, low CD4+ T-cell counts, low CD8+ T-cell counts, low RBC, low hemoglobin, low platelets, high N%, low total protein, high CRP, low albumin, low fibrinogen, high BUN, positive serum GM test, more mechanical ventilation requirement, and more renal replacement requirement were risk factors of influenza IPM co-infection.

Conclusion

IPM is a severe complication of influenza hospitalizations. It is associated with increasing mortality, longer hospital stays, and higher hospital charges compared with non-IPM patients. Clinicians caring for patients with severe influenza should consider IPM.

COVID-19-Associated Pulmonary Aspergillosis (CAPA)

Invasive Pulmonary Aspergillosis (IPA) has been recognized as a possible secondary infection complicating Coronavirus disease 2019 (COVID-19) and increasing mortality. The aim of this review was to report and summarize the available data in the literature concerning the incidence, pathophysiology, diagnosis, and treatment of COVID-19-Associated Pulmonary Aspergillosis (CAPA). Currently, the incidence of CAPA is unclear due to different definitions and diagnostic criteria used among the studies. It was estimated that approximately 8.6% (206/2383) of mechanically ventilated patients were diagnosed with either proven, probable, or putative CAPA. Classical host factors of invasive aspergillosis are rarely recognized in patients with CAPA, who are mainly immuno-competent presenting with comorbidities, while the role of steroids warrants further investigation. Direct epithelial injury and diffuse pulmonary micro thrombi in combination with immune dysregulation, hyper inflammatory response, and immunosuppressive treatment may be implicated. Discrimination between two forms of CAPA (e.g., tracheobronchial and parenchymal) is required, whereas radiological signs of aspergillosis are not typically evident in patients with severe COVID-19 pneumonia. In previous studies, the European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) criteria, a clinical algorithm to diagnose Invasive Pulmonary Aspergillosis in intensive care unit patients (AspICU algorithm), and influenza-associated pulmonary aspergillosis (IAPA) criteria were used for the diagnosis of proven/probable and putative CAPA, as well as the differentiation from colonization, which can be challenging. Aspergillus fumigatus is the most commonly isolated pathogen in respiratory cultures. Bronchoalveolar lavage (BAL) and serum galactomannan (GM), β-d-glucan (with limited specificity), polymerase chain reaction (PCR), and Aspergillus-specific lateral-flow device test can be included in the diagnostic work-up; however, these approaches are characterized by low sensitivity. Early treatment of CAPA is necessary, and 71.4% (135/189) of patients received antifungal therapy, mainly with voriconazole, isavuconazole, and liposomal amphotericin B . Given the high mortality rate among patients with Aspergillus infection, the administration of prophylactic treatment is debated. In conclusion, different diagnostic strategies are necessary to differentiate colonization from bronchial or parenchymal infection in intubated COVID-19 patients with Aspergillus spp. in their respiratory specimens vs. those not infected with severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2). Following confirmation, voriconazole or isavuconazole should be used for the treatment of CAPA.

Candida spp. co-infection in COVID-19 patients with severe pneumonia: Prevalence study and associated risk factors

Background

Invasive fungal infections (IFI) are increasing in prevalence in recent years. In the last few months, the rise of COVID-19 patients has generated a new escalation in patients presenting opportunistic mycoses, mainly by Aspergillus. Candida infections are not being reported yet.

Objectives

We aimed to determine the prevalence of systemic candidiasis in patients admitted to ICUs due to severe pneumonia secondary to SARS-CoV-2 infection and the existence of possible associated risk factors that led these patients to develop candidiasis.

Patients/methods

We designed a study including patients with a confirmed diagnosis of COVID-19.

Results

The prevalence of systemic candidiasis was 14.4%, and the main isolated species were C. albicans and C. parapsilosis. All patients that were tested positive for Candida spp. stayed longer in the ICU in comparison to patients who tested negative. Patients with candidiasis had higher MuLBSTA score and mortality rates and a worse radiological involvement. In our study, Candida spp. isolates were found in patients that were submitted to: tocilizumab, tocilizumab plus systemic steroids, interferon type 1β and Lopinavir-Ritonavir.

Conclusions

Results suggested a high prevalence of systemic candidiasis in severe COVID-19-associated pneumonia patients. Patients with Candidiasis had the worst clinical outcomes. Treatment with tocilizumab could potentialize the risk to develop systemic candidiasis.

Isavuconazole Is as Effective as and Better Tolerated Than Voriconazole for Antifungal Prophylaxis in Lung Transplant Recipients

BACKGROUND

Invasive fungal infections (IFIs) are common following lung transplantation. Isavuconazole is unstudied as prophylaxis in organ transplant recipients. We compared effectiveness and tolerability of isavuconazole and voriconazole prophylaxis in lung transplant recipients.

METHODS

A single-center, retrospective study of patients who received isavuconazole (September 2015-February 2018) or voriconazole (September 2013-September 2015) for antifungal prophylaxis. IFIs were defined by EORTC/MSG criteria.

RESULTS

Patients received isavuconazole (n = 144) or voriconazole (n = 156) for median 3.4 and 3.1 months, respectively. Adjunctive inhaled amphotericin B (iAmB) was administered to 100% and 41% of patients in the respective groups. At 1 year, 8% of patients receiving isavuconazole or voriconazole developed IFIs. For both groups, 70% and 30% of IFIs were caused by molds and yeasts, respectively, and breakthrough IFI (bIFI) rate was 3%. Outcomes did not significantly differ for patients receiving or not receiving iAmB. Independent risk factors for bIFI and breakthrough invasive mold infection (bIMI) were mold-positive respiratory culture and red blood cell transfusion >7 units at transplant. Bronchial necrosis >2 cm from anastomosis and basiliximab induction were also independent risk factors for bIMI. Isavuconazole and voriconazole were discontinued prematurely due to adverse events in 11% and 36% of patients, respectively (P = .0001). Most common causes of voriconazole and isavuconazole discontinuation were hepatotoxicity and lack of oral intake, respectively. Patients receiving ≥90 days prophylaxis had fewer IFIs at 1 year (3% vs 9%, P = .02). IFIs were associated with increased mortality (P = .0001) and longer hospitalizations (P = .0005).

CONCLUSIONS

Isavuconazole was effective and well tolerated as antifungal prophylaxis following lung transplantation.

Navigating the uncertainties of COVID-19 associated aspergillosis (CAPA): A comparison with influenza associated aspergillosis (IAPA)

Invasive pulmonary aspergillosis (IPA) is increasingly recognized as a life-threatening superinfection of severe respiratory viral infections, such as influenza. The pandemic of Coronavirus Disease 2019 (COVID-19) due to emerging SARS-CoV-2 rose concern about the eventuality of IPA complicating COVID-19 in intensive care unit mechanically-ventilated patients. While the association between severe influenza and IPA has been demonstrated, it remains unclear whether SARS-CoV-2 infection represents a specific risk factor for IPA. A variable incidence of such complication has been previously reported, which can be partly attributed to differences in diagnostic strategy and IPA definitions, and possibly local environmental/epidemiological factors. In this article, we discuss the similarities and differences between influenza-associated pulmonary aspergillosis (IAPA) and COVID-19-associated pulmonary aspergillosis (CAPA). Compared to IAPA, the majority of CAPA cases have been classified as putative rather than proven/probable IPA, in the absence of positive serum galactomannan or histopathologic evidence of angio-invasion. Discrimination between Aspergillus airways colonization and CAPA is difficult. Distinct physiopathology and cytokine profiles of influenza and COVID-19 may explain these discrepancies. Whether CAPA represents a distinct entity is still debatable and many questions remain unanswered, such as its actual incidence, the predisposing role of corticosteroids or immunomodulatory drugs, and the indications for antifungal therapy.

Invasive pulmonary aspergillosis in critically ill patients with severe COVID-19 pneumonia: Results from the prospective AspCOVID-19 study

Background

Superinfections, including invasive pulmonary aspergillosis (IPA), are well-known complications of critically ill patients with severe viral pneumonia. Aim of this study was to evaluate the incidence, risk factors and outcome of IPA in critically ill patients with severe COVID-19 pneumonia.

Methods

We prospectively screened 32 critically ill patients with severe COVID-19 pneumonia for a time period of 28 days using a standardized study protocol for oberservation of developement of COVID-19 associated invasive pulmonary aspergillosis (CAPA). We collected laboratory, microbiological, virological and clinical parameters at defined timepoints in combination with galactomannan-antigen-detection from nondirected bronchial lavage (NBL). We used logistic regression analyses to assess if COVID-19 was independently associated with IPA and compared it with matched controls.

Findings

CAPA was diagnosed at a median of 4 days after ICU admission in 11/32 (34%) of critically ill patients with severe COVID-19 pneumonia as compared to 8% in the control cohort. In the COVID-19 cohort, mean age, APACHE II score and ICU mortality were higher in patients with CAPA than in patients without CAPA (36% versus 9.5%; p<0.001). ICU stay (21 versus 17 days; p = 0.340) and days of mechanical ventilation (20 versus 15 days; p = 0.570) were not different between both groups. In regression analysis COVID-19 and APACHE II score were independently associated with IPA.

Interpretation

CAPA is highly prevalent and associated with a high mortality rate. COVID-19 is independently associated with invasive pulmonary aspergillosis. A standardized screening and diagnostic approach as presented in our study can help to identify affected patients at an early stage.

Aspergillosis Complicating Severe Coronavirus Disease

Aspergillosis complicating severe influenza infection has been increasingly detected worldwide. Recently, coronavirus disease-associated pulmonary aspergillosis (CAPA) has been detected through rapid reports, primarily from centers in Europe. We provide a case series of CAPA, adding 20 cases to the literature, with review of pathophysiology, diagnosis, and outcomes. The syndromes of pulmonary aspergillosis complicating severe viral infections are distinct from classic invasive aspergillosis, which is recognized most frequently in persons with neutropenia and in other immunocompromised persons. Combined with severe viral infection, aspergillosis comprises a constellation of airway-invasive and angio-invasive disease and results in risks associated with poor airway fungus clearance and killing, including virus- or inflammation-associated epithelial damage, systemic immunosuppression, and underlying lung disease. Radiologic abnormalities can vary, reflecting different pathologies. Prospective studies reporting poor outcomes in CAPA patients underscore the urgent need for strategies to improve diagnosis, prevention, and therapy.

Influenza-associated aspergillosis in critically-ill patients-a retrospective bicentric cohort study

Influenza was recently reported as a risk factor for invasive aspergillosis (IA). We aimed to describe prognostic factors for influenza-associated IA (IAA) and poor outcome and mortality in critically ill patients in Switzerland. All adults with confirmed influenza admitted to the ICU at two Swiss tertiary care centres during the 2017/2018 influenza season were retrospectively evaluated. IAA was defined by clinical, mycological and radiological criteria: a positive galactomannan in bronchoalveolar lavage or histopathological or cultural evidence in respiratory specimens of Aspergillus spp., any radiological infiltrate and a compatible clinical presentation. Poor outcome was defined as a composite of in-hospital mortality, ICU length of stay (LOS), invasive ventilation for > 7 days or extracorporeal membrane oxygenation. Of 81 patients with influenza in the ICU, 9 (11%) were diagnosed with IAA. All patients with IAA had poor outcome compared to 26 (36%) patients without IAA (p < 0.001). Median ICU-LOS and mortality were 17 vs. 3 days (p < 0.01) and 3/9 (33%) vs. 13/72 (18%; p = 0.37) in patients with vs. without IAA, respectively. Patients with IAA had significantly longer durations of antibiotic therapy, vasoactive support and mechanical ventilation. Aspergillus was the most common respiratory co-pathogen (9/40, 22%) followed by classical bacterial co-pathogens. IAA was not associated with classical risk factors. Aspergillus is a common superinfection in critically ill influenza patients associated with poor outcome and longer duration of organ supportive therapies. Given the absence of classical risk factors for aspergillosis, greater awareness is necessary, particularly in those requiring organ supportive therapies.

Invasive pulmonary aspergillosis complicating severe influenza: epidemiology, diagnosis and treatment

PURPOSE OF REVIEW

Bacterial super-infection of critically ill influenza patients is well known, but in recent years, more and more reports describe invasive aspergillosis as a frequent complication as well. This review summarizes the available literature on the association of invasive pulmonary aspergillosis (IPA) with severe influenza [influenza-associated aspergillosis (IAA)], including epidemiology, diagnostic approaches and treatment options.

RECENT FINDINGS

Though IPA typically develops in immunodeficient patients, non-classically immunocompromised patients such as critically ill influenza patients are at high-risk for IPA as well. The morbidity and mortality of IPA in these patients is high, and in the majority of them, the onset occurs early after ICU admission. At present, standard of care (SOC) consists of close follow-up of these critically ill influenza patients with high diagnostic awareness for IPA. As soon as there is clinical, mycological or radiological suspicion for IAA, antifungal azole-based therapy (e.g. voriconazole) is initiated, in combination with therapeutic drug monitoring (TDM). Antifungal treatment regimens should reflect local epidemiology of azole-resistant Aspergillus species and should be adjusted to clinical evolution. TDM is necessary as azoles like voriconazole are characterized by nonlinear pharmacokinetics, especially in critically ill patients.

SUMMARY

In light of the frequency, morbidity and mortality associated with influenza-associated aspergillosis in the ICU, a high awareness of the diagnosis and prompt initiation of antifungal therapy is required. Further studies are needed to evaluate the incidence of IAA in a prospective multicentric manner, to elucidate contributing host-derived factors to the pathogenesis of this super-infection, to further delineate the population at risk, and to identify the preferred diagnostic and management strategy, and also the role of prophylaxis.

Post-influenzal triazole-resistant aspergillosis following allogeneic stem cell transplantation

Influenza virus infection is now recognised as a risk factor for invasive pulmonary aspergillosis (IPA). Delays in diagnosis contribute to delayed commencement of antifungal therapy. In addition, the emergence of resistance to first-line triazole antifungal agents puts emphasis on early detection to prevent adverse outcomes. We present 2 allogeneic stem cell transplant patients who developed IPA due to triazole-resistant Aspergillus fumigatus following influenza infection. We underline the challenges faced in the management of these cases, the importance of early diagnosis and need for surveillance given the emergence of triazole resistance.

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.

Invasive pulmonary aspergillosis is a frequent complication of critically ill H1N1 patients: a retrospective study

PURPOSE

Despite their controversial role, corticosteroids (CS) are frequently administered to patients with H1N1 virus infection with severe respiratory failure secondary to viral pneumonia. We hypothesized that invasive pulmonary aspergillosis (IPA) is a frequent complication in critically ill patients with H1N1 virus infection and that CS may contribute to this complication.

METHODS

We retrospectively selected all adult patients with confirmed H1N1 virus infection admitted to the intensive care unit (ICU) of two tertiary care hospitals from September 2009 to March 2011. Differences in baseline factors, risk factors, and outcome parameters were studied between patients with and without IPA.

RESULTS

Of 40 critically ill patients with confirmed H1N1, 9 (23 %) developed IPA 3 days after ICU admission. Five patients had proven and four had probable IPA. Significantly more IPA patients received CS within 7 days before ICU admission (78 versus 23 %, p = 0.002). IPA patients also received significantly higher doses of CS before ICU admission [hydrocortisone equivalent 800 (360-2,635) versus 0 (0-0) mg, p = 0.005]. On multivariate analysis, use of CS before ICU admission was independently associated with IPA [odds ratio (OR) 14.4 (2.0-101.6), p = 0.007].

CONCLUSIONS

IPA was diagnosed in 23 % of critically ill patients with H1N1 virus infection after a median of 3 days after ICU admission. Our data suggest that use of CS 7 days before ICU admission is an independent risk factor for fungal superinfection. These findings may have consequences for clinical practice as they point out the need for increased awareness of IPA, especially in those critically ill H1N1 patients already receiving CS.

Isolation of Aspergillus in three 2009 H1N1 influenza patients

Please cite this paper as: Adalja et al. (2011) Isolation of Aspergillus in three 2009 H1N1 influenza patients. Influenza and Other Respiratory Viruses 5(4), 225–229

Objectives:  To describe the association of Aspergillus with influenza.

Design/Setting/Sample  Three case reports of ICU patients with influenza complicated by the isolation of Aspergillus species are described and a review of the literature on the topic was performed.

Conclusions:  Severe influenza cases can be complicated by Aspergillus infection.

Specialization and medical mycology in the US, Britain and Japan

This paper attempts to bring new insights to a long-standing historical debate over medical specialization by analyzing the formation of medical mycology, a somewhat marginal biomedical discipline that emerged in the mid-twentieth century around studies of fungal disease in humans. The study of fungi predates that of bacteria and viruses, but from the 1880s it became eclipsed by bacteriology. However, in the postwar period, there were moves to establish medical mycology as an independent speciality. I trace the processes that led to the launch of professional societies in the United States, Britain and Japan, three major players in medical mycology, and more broadly in biomedicine. The analysis of the three different national contexts illustrates how geographical, medico-technological, epidemiological, political and social conditions gave the specialty a distinctive character in each country; this was further complicated by the different and changing medical fields in which fungal diseases were studied and treated. The three case studies show medical specialization as a process that is not simply cumulative but responds to specific historical events and developments.

Invasive pulmonary aspergillosis associated with influenza B

Invasive pulmonary aspergillosis (IPA) usually occurs in immunocompromised patients. However, rarely, this infection can occur in normal hosts. This review of the literature identified 13 cases of IPA associated with influenza, of which 12 had influenza A and the type of influenza was not mentioned in the other case. Reported here is a case of IPA, which was associated with influenza B, in a 63-year-old immunocompetent woman. Her lungs showed gross invasion and she was treated with itraconazole and amphotericin B. She required mechanical ventilation for about 5 months but recovered completely. This is the first reported case of IPA associated with influenza B.

Invasive cavitary pulmonary aspergillosis in patients with cancer: a clinicopathologic study

We studied the histopathology and clinicopathologic correlates of invasive cavitary pulmonary aspergillosis in 11 immunosuppressed patients with disseminated malignancy. In most patients cavities were produced by separation of necrotic from viable lung, resulting in an intracavitary sequestrum ("lung ball"). Central dissolution of large necrotic areas and suppurative granulomatous aspergillary pneumonia were additional causes of cavities in three patients. In four patients with chronic cavities sequestra had been replaced by intracavitary mycetomas ("fungus balls"). Neutrophils usually were numerous at the interface of the sequestrum and adjacent lung, but were minimally present in three patients with prolonged severe neutropenia. The lack of neutrophils in some patients suggests that factors other than neutrophil-derived proteases may be important in cavity formation. A prominent giant cell reaction was seen in three patients with chronic cavities. Hemoptysis occurred in five patients and massive hemoptysis due to a bronchoarterial fistula caused the death of one patient. The "air-crescent" sign was not observed radiographically in any patient and is therefore considered to be an insensitive marker for lung cavitation in invasive aspergillosis. Persistent intracavitary fungal growth may serve as a reservoir for recurrent fungal invasion in patients with prolonged or repeated episodes of severe neutropenia.

Invasive pulmonary aspergillosis complicating influenza A pneumonia in a previously healthy patient

A rare occurrence of invasive pulmonary aspergillosis complicates influenza pneumonia in a previously healthy adult. Five other similar cases are reported in the literature. Both transient depression of cell-mediated immunity and loss of ciliary function in the tracheobronchial tree occurs during acute influenzal illness and may predispose to fungal superinfection. Early diagnosis and treatment of opportunistic Aspergillus infection complicating influenza is mandatory in view of the high mortality associated with this complication.

Successful treatment of invasive pulmonary aspergillosis complicating influenza A

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Cerebral aspergilloma in a patient with allergic bronchopulmonary aspergillosis

The case is described of a woman of 21 who had suffered since childhood from asthma and allergic bronchopulmonary aspergillosis. During her recovery from a period of severe status asthmaticus she developed widespread patchy lung shadowing, signs of an intracerebral space-occupying lesion and high titres of serum precipitins to Aspergillus fumigatus. Post-mortem examination revealed Aspergillus bronchopneumonia and an intracerebral aspergilloma.

Necrotising aspergillosis complicating fulminating viral pneumonia

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Pulmonary aspergillosis; report of a case

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Primary pulmonary aspergillosis: report of an unusual case successfully treated by lobectomy

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Cavitation in the massive fibrosis of coal-workers' pneumoconiosis

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Broncho-pulmonary aspergillosis; a review and a report of eight new cases

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