Clinical features of invasive bronchial-pulmonary aspergillosis in critically ill patients with chronic obstructive respiratory diseases: a prospective study

Combined NGS and lung biopsy for refractory respiratory failure: a case of HRV and secondary bacterial pneumonia mimicking organizing pneumonia

BACKGROUND

Some studies of community-acquired pneumonia (CAP) have reported that human rhinovirus (HRV) is the most common virus in viral pneumonia in immunocompetent adults. Secondary bacterial and fungal infections are increasingly recognized complications of HRV infection that have substantial morbidity and mortality. We report a novel case of a co-infection of Streptococcus pneumoniae (S. pneumoniae) associated with HRV pneumonia that had successful diagnosis with combined target next generation sequencing (NGS) and percutaneous lung puncture biopsy (PLPB).

CASE PRESENTATION

A 62-year-old female was admitted with productive cough, dyspnea and respiratory failure. She was initially diagnosed with severe pneumonia caused by HRV infection by targeted NGS from bronchial-alveolar lavage fluid. After initial clinical improvement treated by high flow nasal cannula (HFNC) and antibiotics, the patient's condition worsened again after her discharge, with persistent dyspnea and refractory hypoxemia. Chest computed tomography showed areas of consolidation and ground glass opacification. Despite empirical antibiotics for a suspected secondary co-infection, her condition showed no significant improvement. A PLPB was performed, and targeted NGS for the lung tissue was positive only for S. pneumoniae. Targeted NGS of her sputum was positive for S. pneumoniae, Aspergillus fumigatus and type A HRV. The patient was treated with linezolid, voriconazole and methylprednisolone. HFNC was weaned on day 57, and she was discharged with good lung recovery.

CONCLUSIONS

Our case demonstrates the diagnostic utility of combined targeted NGS and CT-guided PLPB in resolving refractory pneumonia with overlapping viral and bacterial etiologies. Co-infection with these two pathogens should be considered in the differential diagnosis of patients with consolidation, wheezing and respiratory failure following severe HRV infection. The combination of targeted NGS and CT-guided PLPB should be reserved for diagnostically challenging cases refractory to conventional methods.

A score for predicting invasive pulmonary aspergillosis in immunocompetent critically ill patients

BACKGROUND

Delayed treatment leads to increased mortality in critically ill patients with invasive pulmonary aspergillosis (IPA). We aimed to develop and validate a prediction score based on novel biomarkers and clinical risk factors to identify IPA in immunocompetent patients in the intensive care unit (ICU).

METHODS

A retrospective study was conducted to collect medical information and novel biomarkers upon ICU admission. Risk factors adopted for the final prediction score were identified using multivariate logistic regression analysis.

RESULTS

We retrospectively collected 1841 critical ill patients between January 2018 and August 2022. Patients with IPA had higher C-reactive protein-to-albumin ratio (CAR), neutrophil-to-lymphocyte ratio, systemic immune-inflammation index and lower prognostic nutritional index (PNI). Chronic obstructive pulmonary disease (COPD), continuous renal replacement therapy (CRRT), high dose of corticosteroids, broad-spectrum antibiotics, blood galactomannan (GM) positivity and high CAR were independent risk factors for IPA and were entered into the final prediction score. The score had good discrimination, with the area under receiver operating characteristic curve of 0.816 and 0.780 for the training and validation cohorts, respectively, and good calibration.

CONCLUSION

A score based on six clinical and novel immunological biomarkers showed promising predictive value for antifungal treatment in immunocompetent ICU patients.

Clinical features and prognostic analysis of patients with Aspergillus isolation during acute exacerbation of chronic obstructive pulmonary disease

Background

Lower respiratory tract (LRT) specimen culture is widely performed for the identification of Aspergillus. We investigated the clinical features and prognosis of patients with Aspergillus isolation from LRT specimens during acute exacerbation of chronic obstructive pulmonary disease (AECOPD).

Methods

This is a 6-year single-center, real-world study. 75 cases out of 1131 hospitalized AECOPD patients were positive for Aspergillus. These patients were carefully evaluated and finally diagnosed of pulmonary aspergillosis (PA, 60 cases, 80%) or colonization (15 cases, 20%). Comparisons of clinical data were performed between these two groups. A cox regression model was used to confirm prognostic factors of Aspergillus infection.

Results

The PA group had worse lung function and higher rates of systemic corticosteroid use and broad-spectrum antibiotic use before admission than the colonization group. The PA group had significantly higher in-hospital mortality and 180-day mortality than the colonization group (45% (27/60) vs. 0% (0/15), p = 0.001, and 52.5% (31/59) vs. 6.7% (1/15), p < 0.001, respectively). By multivariable analysis among Aspergillus infection patients, antifungal therapy (HR 0.383, 95% CI 0.163–0.899, p = 0.027) was associated with improved survival, whereas accumulated dose of systemic steroids > 700 mg (HR 2.452, 95% CI 1.134–5.300, p = 0.023) and respiratory failure at admission (HR 5.983, 95% CI 2.487–14.397, p < 0.001) were independently associated with increased mortality. Significant survival differential was observed among PA patients without antifungals and antifungals initiated before and after Aspergillus positive culture (p = 0.001).

Conclusions

Aspergillus isolation in hospitalized AECOPD patients largely indicated PA. AECOPD patients with PA had worse prognosis than those with Aspergillus colonization. Empirical antifungal therapy is warranted to improve the prognosis for Aspergillus infection.

Th17 cells are involved in mouse chronic obstructive pulmonary disease complicated with invasive pulmonary aspergillosis

BACKGROUND

The incidence of chronic obstructive pulmonary disease (COPD) complicated with invasive pulmonary aspergillosis (IPA) has increased in the last two decades. The mechanism underpinning susceptibility to and high mortality of COPD complicated with IPA is unclear, and the role of T helper cells 17 (Th17 cells) in the compound disease remains unknown. Therefore, this study aimed to assess the function of Th17 cells in COPD combined with IPA.

METHODS

COPD, IPA, and COPD+IPA mouse models were established in male wild type C57/BL6 mice. The amounts of Th17 cells and retinoic acid-related orphan receptors γt (RORγt) were tested by flow cytometry. Then, serum interleukin (IL)-17 and IL-23 levels were detected by enzyme-linked immunosorbent assay (ELISA) in the control, COPD, IPA and COPD+IPA groups. In addition, COPD+IPA was induced in IL-17 knockout (KO) mice, for determining the role of Th17 cells in COPD+IPA.

RESULTS

Compared with the COPD group, the COPD+IPA group showed higher amounts of blood RORγt ([35.09 ± 16.12]% vs. [17.92 ± 4.91]%, P = 0.02) and serum IL-17 (17.96 ± 9.59 pg/mL vs. 8.05 ± 4.44 pg/mL, P = 0.02), but blood ([5.18 ± 1.09]% vs. [4.15 ± 0.87]%, P = 0.28) and lung levels of Th17 cells ([1.98 ± 0.83]% vs. [2.03 ± 0.98]%, P = 0.91), lung levels of RORγt ([9.58 ± 6.93]% vs. [9.63 ± 5.98]%, P = 0.49) and serum IL-23 (51.55 ± 27.82 pg/mL vs. 68.70 ± 15.20 pg/mL, P = 0.15) showed no significant differences. Compared with the IPA group, the COPD+IPA group displayed lower amounts of blood ([5.18 ± 1.09]% vs. [9.21 ± 3.56]%, P = 0.01) and lung Th17 cells ([1.98 ± 0.83]% vs. [6.29 ± 1.11]%, P = 0.01) and serum IL-23 (51.55 ± 27.82 pg/mL vs. 154.90 ± 64.60 pg/mL, P = 0.01) and IL-17 (17.96 ± 9.59 pg/mL vs. 39.81 ± 22.37 pg/mL, P = 0.02), while comparable blood ([35.09 ± 16.12]% vs. [29.86 ± 15.42]%, P = 0.25) and lung levels of RORγt ([9.58 ± 6.93]% vs. [15.10 ± 2.95]%, P = 0.18) were found in these two groups. Finally, Aspergillus load in IL-17 KO COPD+IPA mice was almost 2 times that of COPD+IPA mice (1,851,687.69 ± 944,480.43 vs. 892,958.10 ± 686,808.80, t = 2.32, P = 0.02).

CONCLUSION

These findings indicate that Th17 cells might be involved in the pathogenesis of COPD combined with IPA, with IL-17 likely playing an antifungal role.

Invasive Tracheobronchial Aspergillosis in Critically Ill Patients with Severe Influenza. A Clinical Trial

Rationale: Invasive tracheobronchial aspergillosis (ITBA) is an uncommon but severe clinical form of invasive pulmonary aspergillosis in which the fungal infection is entirely or predominantly confined to the tracheobronchial tree.Objectives: To analyze the diagnostic and prognostic differences between tracheobronchial aspergillosis and pulmonary aspergillosis without tracheobronchial lesions among patients admitted to the ICU with severe influenza.Methods: This retrospective, observational study included critically ill patients with influenza associated with pulmonary aspergillosis from three hospital ICUs between 2010 and 2019. Patient characteristics and clinical and mycologic data at admission and during ICU stay were collected in a database to evaluate variables in the two groups.Measurements and Main Results: Thirty-five patients admitted to the ICU with severe influenza and pulmonary aspergillosis were included. Ten patients were included in the group with ITBA (n = 10 of 35; 28.6%), and 25 patients were included in the group without ITBA. The group with ITBA comprised more patients with active smoking, diabetes mellitus, and higher severity scores (Simplified Acute Physiology Score II). Ninety-day mortality rates in the groups with and without ITBA were 90% and 44%, respectively (P = 0.02). Moreover, significantly higher serum 1,3-β-d-glucan and galactomannan and BAL fluid galactomannan concentrations were observed in the group with ITBA compared with the group without ITBA (P < 0.0001, P = 0.003, and P = 0.008, respectively).Conclusions: ITBA was associated with higher severity scores, mortality, and serum and BAL fluid galactomannan and 1,3-β-d-glucan concentrations than invasive pulmonary aspergillosis without tracheobronchial lesions. ITBA should be systematically researched by bronchoscopic examination in ICU patients with concomitant pulmonary aspergillosis and influenza.Clinical trial registered with www.clinicaltrials.gov (NCT04077697).

[Invasive aspergillosis in critically ill patients]

Critically ill patients without severe immunosuppression make up a population in which invasive aspergillosis (IA) has been identified as an emergent pathology. Chronic treatment with corticosteroids, chronic obstructive pulmonary disease, and liver cirrhosis are repeatedly identified risk factors. However, due to the non-specificity of the symptoms and signs in the critical patient, and the relative low diagnostic capacity of the complementary tests, the diagnosis of the IA is a challenge for the specialist in critical care medicine. The application of diagnostic algorithms adapted to critical patients, in whom activation will depend on the isolation of Aspergillus in a respiratory specimen, is the most efficient diagnostic methodology in this population. Among the diagnostic approaches, the determination of galactomannan in bronchoalveolar fluid is the most useful diagnostic test. Once the suspicion is established, treatment should be started as soon as possible. Voriconazole, amphotericin B, and isavuconazole are the most effective treatments. Although voriconazole and amphotericin B are the drugs with the most scientific evidence, they are related with adverse effects and pharmacokinetic difficulties. Therefore, isavuconazole, which has shown high efficacy and safety in other populations, is a potential alternative of great interest for critically ill patients.

Invasive aspergillosis in critically ill patients: An autopsy study

Autopsy studies show that IA is among the most commonly missed diagnoses in critically ill patients. And, because of lack of unequivocal diagnostic criteria, a timely diagnosis remains challenging. We investigate the epidemiology of and the clinical risk factors for IA in critically ill patients. We conducted a retrospective, observational study of all consecutive ICU patients with evidence of IA in the postmortem examination. During the period of the study (25 years), 893 postmortem examinations were performed in the ICU. Twenty-five patients (2.8%) were diagnosed with IA in autopsy. Only ten (40%) were classified as IA ante-mortem, based on the initiation of antifungal treatment. The most common comorbid conditions were corticosteroid treatment (n = 14, 56%), chronic obstructive pulmonary disease (COPD) (n = 11, 44%), immunosuppression (n = 6, 24%) and haematological malignancy (n = 5, 20%). Twenty-three patients (92%) had three or more risk factors for IA. Critically ill patients with pulmonary infiltrates, treated with high doses intravenous corticosteroids (even for a short period of time), particularly COPD patients who developed worsening respiratory insufficiency despite appropriate treatment were at the highest risk of IA.

Intensive Care of Pulmonary Complications Following Liver Transplantation

Chronic liver disease has been associated with pulmonary dysfunction both before and after liver transplantation. Post-liver transplantation pulmonary complications can affect both morbidity and mortality often necessitating intensive care during the immediate postoperative period. The major pulmonary complications include pneumonia, pleural effusions, pulmonary edema, and atelectasis. Poor clinical outcomes have been known to be associated with age, severity of liver dysfunction, and preexisting lung disease as well as perioperative events related to fluid balance, particularly transfusion and fluid volumes. Delineating each and every one of these pulmonary complications and their associated risk factors becomes paramount in guiding specific therapeutic strategies.

Diagnosis and management of Aspergillus diseases: executive summary of the 2017 ESCMID-ECMM-ERS guideline

The European Society for Clinical Microbiology and Infectious Diseases, the European Confederation of Medical Mycology and the European Respiratory Society Joint Clinical Guidelines focus on diagnosis and management of aspergillosis. Of the numerous recommendations, a few are summarized here. Chest computed tomography as well as bronchoscopy with bronchoalveolar lavage (BAL) in patients with suspicion of pulmonary invasive aspergillosis (IA) are strongly recommended. For diagnosis, direct microscopy, preferably using optical brighteners, histopathology and culture are strongly recommended. Serum and BAL galactomannan measures are recommended as markers for the diagnosis of IA. PCR should be considered in conjunction with other diagnostic tests. Pathogen identification to species complex level is strongly recommended for all clinically relevant Aspergillus isolates; antifungal susceptibility testing should be performed in patients with invasive disease in regions with resistance found in contemporary surveillance programmes. Isavuconazole and voriconazole are the preferred agents for first-line treatment of pulmonary IA, whereas liposomal amphotericin B is moderately supported. Combinations of antifungals as primary treatment options are not recommended. Therapeutic drug monitoring is strongly recommended for patients receiving posaconazole suspension or any form of voriconazole for IA treatment, and in refractory disease, where a personalized approach considering reversal of predisposing factors, switching drug class and surgical intervention is also strongly recommended. Primary prophylaxis with posaconazole is strongly recommended in patients with acute myelogenous leukaemia or myelodysplastic syndrome receiving induction chemotherapy. Secondary prophylaxis is strongly recommended in high-risk patients. We strongly recommend treatment duration based on clinical improvement, degree of immunosuppression and response on imaging.

[Pneumonia in immunocompromised patients]

Pneumonia occurs frequently in immunocompromised patients and often shows a complicated course of disease when compared to immunocompetent persons. The type of pathogen involved is directly associated with the type of immunosuppression and includes a wide variety of pathogens. Congenital and primary immunodeficiencies often appear during childhood. Acquired immunodeficiencies are most commonly caused by immunosuppressive medication. The concept of immunosuppression can be extended to patients with COPD or elderly patients because the variety of pathogens and specific features regarding frequency and course of the disease are similar to immunosuppressed patients. Computed tomography can provide an indication of the pathogen and is superior to the chest x‑ray in this respect. Blood cultures, antigen and PCR tests are non-invasive diagnostic tools for pathogen diagnostics. Invasive tests include fiberoptic bronchoscopy and complete the diagnostic methods of identifying the causative pathogen.

Analysis of the clinical features of invasive bronchopulmonary aspergillosis

INTRODUCTION

Early diagnosis of invasive bronchopulmonary aspergillosis (IBPA) is difficult, so the mortality rate is high.

OBJECTIVE

To discuss the clinical features of IBPA.

METHODS

We retrospectively analyzed the clinical features, imaging findings, laboratory test, diagnosis and treatment of 115 patients with IBPA diagnosed from October 2004 to June 2013 in Zhongshan Hospital, Fudan University.

RESULTS

The main clinical manifestations were cough in 58 patients (50.4%), expectoration in 37 patients (32.2%), fever in 18 patients (15.7%), shortness of breath in 26 patients (22.6%), hemoptysis in 26 patients (22.6%) and chest pain in 7 patients (6.0%). The main CT findings were nodules in 35 patients (30.4%), consolidation shadows or patchy shadows in 62 patients (53.9%) and cavity in 14 patients (12.2%). Percutaneous pulmonary biopsy was conducted in 25 patients (21.7%), TBLB in 58 patients (50.4%) and thoracoscopic surgery in 32 patients (27.8%). The positive rate of GM test was 73.5% (72/98). Thirty patients who received lobectomy were followed up for 1-3 years. Fifty-five patients who received monotherapy with antifungal agents were followed up for 1-3 years, and 12 patients were healed. The lesions for 23 patients were obviously absorbed, 10 patients had aggravation and two patients died.

CONCLUSIONS

The clinical manifestations of IBPA were unspecific. The main symptoms were cough and expectorate. Patients with different immunologic function had different imaging findings. The halo sign and new moon sign for diagnosis was not as common as reported. Interventional therapy under bronchoscope is very important for patients with ATB.

Candida and invasive mould diseases in non-neutropenic critically ill patients and patients with haematological cancer

Critically ill patients and patients with haematological cancer are HIV-negative populations at high risk of invasive fungal infections. In intensive-care units, candidaemia and intra-abdominal candidiasis predominate, but aspergillosis has emerged as a lethal, under-recognised cause of pneumonia. In patients with haematological malignancies or who have undergone stem-cell transplantations, pulmonary disease due to aspergillus and other mould diseases predominate. In this Series paper, we provide an update on risk assessment, new diagnostic strategies, and therapeutic approaches. New concepts have emerged for use of risk prediction rules and an evidence base now exists for inclusion of biomarkers (eg, galactomannan, 1,3-β-D-glucan, and PCR assays for Aspergillus spp) into early diagnostic and therapeutic strategies. Imaging techniques remain helpful for early diagnosis of pulmonary mould diseases, with PET techniques offering potential improvements in diagnostic specificity and evaluation of clinical response. Echinocandins and triazoles have been validated extensively for prophylaxis, empirical therapy, and targeted therapy, but an increase in intrinsically resistant fungi and emergence of secondary resistance as a result of drug-induced selection pressure are of major concern. Echinocandins remain a major component of treatment of invasive candidiasis and new triazoles are the best alternative for prophylaxis and therapy of invasive aspergillosis.

Multiple cavities with halo sign in a case of invasive pulmonary aspergillosis during therapy for drug-induced hypersensitivity syndrome

A 67-year-old female with rheumatoid arthritis and asthma-chronic obstructive pulmonary disease overlap syndrome was admitted for drug-induced hypersensitivity syndrome (DIHS) caused by salazosulfapyridine. Human herpes virus 6 (HHV-6) variant B was strongly positive on peripheral blood. Multiple cavities with ground grass opacities rapidly emerged predominantly in the upper and middle lobes. She was diagnosed with invasive pulmonary aspergillosis (IPA), and was treated successfully with antifungal agents. Therapeutic systemic corticosteroids, emphysematous change in the lungs, and the worsening of the patient's general condition due to DIHS were considered major contributing factor leading to IPA. HHV-6 reactivation could have an effect on clinical course of IPA. Cavities with halo sign would provide an early clue to IPA in non-neutropenic and immunosuppressive patients.

Immunity status of invasive pulmonary aspergillosis patients with structural lung diseases in Chinese adults

BACKGROUND

Invasive pulmonary aspergillosis (IPA) is a fungal infection frequently observed in patients with immune dysfunction, such as those suffering from structural lung diseases. Nevertheless, studies assessing IPA combined with other common respiratory diseases remain scarce, particularly those regarding the immune status of its patients. Different structural lung diseases are known to differently affect patient immune status; however, the mechanisms by which this is conferred have yet to be determined. Thus, our study aims to compare the immune status of IPA patients with the structural lung diseases chronic obstructive pulmonary diseases (COPD), interstitial lung disease (ILD) and non-cystic fibrosis bronchiectasis (NCFB).

METHODS

This study was performed retrospectively with data collected over the years 2004 to 2013 at Shanghai Pulmonary Hospital, Tongji University, and included 77 patients whose lower respiratory tract (LRT) samples tested positive for. Our analysis considered blood examinations of CD3+, CD4+, CD8+, CD4+/CD8+, IgG, IgA and IgM levels.

RESULTS

CD4+/CD8+ double positive cells, representing cell-mediated immunity, were less abundant in IPA patients with COPD than those with ILD and NCFB (0.81±0.09 vs. 1.39±0.25 and 0.81±0.09 vs. 1.57±0.06, respectively, P<0.001). In agreement with this result, corticosteroid and broad-spectrum antibiotic use were most common in individuals with COPD (57%). IgA levels, which indicate humoral immunity, were lower in IPA patients with NCFB than those with COPD or ILD (0.95±0.28 vs. 1.64±0.40 g/L and 0.95±0.28 vs. 3.16±0.83 g/L, respectively, P<0.001).

CONCLUSIONS

Immunity status differs between IPA patients with different structural lung diseases. Among IPA patients with COPD, ILD and NCFB, those with COPD have the lowest cell-mediated immunity, while those with NCFB have the lowest humoral immunity.

Invasive fungal tracheobronchitis in mechanically ventilated critically ill patients: underlying conditions, diagnosis, and outcomes

Background

Invasive fungal tracheobronchitis (IFT) is a severe form of pulmonary fungal infection that is not limited to immunocompromised patients. Although respiratory failure is a crucial predictor of death, information regarding IFT in critically ill patients is limited.

Methods

In this retrospective, multicenter, observational study, we enrolled adults diagnosed as having IFT who had been admitted to the intensive care unit between January 2007 and December 2015. Their demographics, clinical imaging data, bronchoscopic and histopathological findings, and outcomes were recorded.

Results

This study included 31 patients who had been diagnosed as having IFT, comprising 24 men and 7 women with a mean age of 64.7 ± 13.7 years. All patients developed respiratory failure and received mechanical ventilation before diagnosis. Eighteen (58.1%) patients had diabetes mellitus, and 12 (38.7%) had chronic lung disease. Four (12.9%) patients had hematologic disease, and none of the patients had neutropenia. Twenty-five (80.6%) patients were diagnosed as having proven IFT, and the remaining patients had probable IFT. Aspergillus spp. (61.3%) were the most common pathogenic species, followed by Mucorales (25.8%) and Candida spp. (6.5%). The diagnoses in six (19.4%) patients were confirmed only through bronchial biopsy and histopathological examination, whereas their cultures of bronchoalveolar lavage fluid were negative for fungi. The overall in-hospital mortality rate was 93.5%.

Conclusions

IFT in critically ill patients results in a high mortality rate. Diabetes mellitus is the most prevalent underlying disease, followed by chronic lung disease. In addition to Aspergillus spp., Mucorales is another crucial pathogenic species. Bronchial lesion biopsy is the key diagnostic strategy.

Application of a parametric model in the mortality risk analysis of ICU patients with severe COPD

OBJECTIVE

To evaluate the mortality risk factors of patients with severe chronic obstructive pulmonary disease (COPD) in the intensive care unit (ICU) by utilizing parametric model of survival analysis, and to estimate patients' prognoses based on the risk and survival functions in the model.

METHODS

The clinical data and outcomes of COPD patients admitted to a respiratory intensive care unit (RICU) at Beijing Chao-Yang Hospital from January 2009 to June 2014 were prospectively collected. Based on the clinical outcomes, these patients were divided into a survival group and a death group. A univariate analysis was conducted to identify statistically significant variables. According to the distribution characteristics of these data, residual plots were prepared for an exponential model, a Weibull model and a Gamma model. The Gamma model was determined to be the best fitted for these data and was used as the analytical tool. Therefore, the variables with differences obtained from the univariate analysis were put into the Gamma model to determine the patients' mortality risk factors. The risk and survival functions were also generated according to the model formula.

RESULTS

A total of 160 patients (111 survival, 49 death) were enrolled. The univariate analysis showed that, compared with the survival group, patients in the death group had higher Charlson Comorbidity Index score (CCI), higher body temperature, higher white blood cell counts, higher proportions of neutrophils, higher serum creatinine levels and higher pH levels; lower resting carbon dioxide pressure (PCO₂ ); and more cases complicated with invasive pulmonary aspergillosis (IPA). A further analysis with the Gamma model revealed that concurrent or non-concurrent IPA, white blood cell count, pH level and PCO₂ were associated with the patients' mortality risk and that the predicted value (PV) of the patients' mortality risk = 2.8655 + 0.4070 × IPA + 0.0048 × WBC + 0.0049 × pH - 0.0097 × PCO₂ . Moreover, the survival function formula was obtained according to the Gamma model: S(x) = 1 - I (0.7507 x, -3.3773), where I is an incomplete gamma function.

CONCLUSION

Formula generated from parametric model may help to predict the prognosis of patients with severe COPD in ICU, and this method need to be evaluated in further studies. According to our formula, IPA is an important risk factor of mortality for patients with severe COPD in the ICU.

Galactomannan in bronchoalveolar lavage fluid for diagnosis of invasive aspergillosis in non-hematological patients

BACKGROUND

The role of galactomannan (GM) in serum or bronchoalveolar lavage fluid (BALF) for the diagnosis of invasive pulmonary aspergillosis (IPA) has been extensively evaluated in hematological patients, however its performance in non-hematological patients is not well established.

METHODS

We performed a multicenter retrospective study in 3 university hospitals in Madrid, Spain between 2010 and 2014. The study population comprised patients with chronic obstructive pulmonary disease (COPD) and patients with immunosuppressive conditions in whom IPA was suspected and for whom BALF GM was available. Patients with hematological disorders were excluded.

RESULTS

A total of 188 patients (35 with COPD and 153 with immunosuppressive conditions) were analyzed, and 31 cases of IPA (proven or probable) were identified. The global sensitivity of BALF GM (optical density index [ODI] ≥ 1.0) was 77.4%; sensitivity was higher in patients with immunosuppressive conditions than in patients with COPD (81.8% vs 66.7%; p: 0.38). In COPD patients, the best performance was obtained for BALF GM (ODI ≥ 0.5), although sensitivity (88.9%) was similar to that of BALF fungal culture (88.9%). The sensitivity of GM in serum was very poor in both populations (36.4% and 11.6%, respectively).

CONCLUSIONS

In the present series, the diagnostic performance of BALF GM was good for IPA in non-hematological patients, especially in patients with immunosuppressive conditions.

Putative invasive pulmonary aspergillosis in critically ill patients with chronic obstructive pulmonary disease: a matched cohort study

Introduction

Patients with advanced chronic obstructive pulmonary disease (COPD) are at risk for developing invasive pulmonary aspergillosis. A clinical algorithm has been validated to discriminate colonization from putative invasive pulmonary aspergillosis (PIPA) in Aspergillus-positive respiratory tract cultures of critically ill patients. We focused on critically ill patients with COPD who met the criteria for PIPA.

Methods

This matched cohort study included critically ill patients with COPD from two university hospital intensive care units (ICUs). We studied the risk factors for PIPA as well as the impact of PIPA on short- and long-term outcomes. Whether PIPA was associated with a pattern of bacterial colonization and/or infection 6 months before and/or during ICU stay was assessed. In addition, antifungal strategies were reviewed.

Results

Fifty cases of PIPA in critically ill patients with COPD in the ICU were matched with one hundred control patients with COPD. The ICU short- and the long-term (at 1 year) mortality were significantly increased in the PIPA group (p < 0.001 for all variables). PIPA was a strong independent risk factor for mortality in the ICU (odds ratio 7.44, 95 % confidence interval 2.93–18.93, p < 0.001) before vasopressor therapy, renal replacement therapy, and duration of mechanical ventilation. Before ICU admission, the use of corticosteroids and antibiotics significantly increased the risk of PIPA (p = 0.004 and p < 0.001, respectively). No significant difference in bacterial etiologic agents responsible for colonization and/or infection was found between the groups. Antifungal treatment was started in 64 % of PIPA cases, with a poor impact on the overall outcome.

Conclusions

PIPA was a strong death predictor in critically ill patients with COPD. The use of corticosteroids and antibiotics before ICU admission was a risk factor for PIPA. PIPA was not associated with a specific bacterial pattern of colonization or infection. Prompting antifungal treatment in critically ill patients with COPD who have PIPA may not be the only factor involved in prognosis reversal.

Republished: The clinical spectrum of pulmonary aspergillosis

The clinical presentation of Aspergillus lung disease is determined by the interaction between fungus and host. Invasive aspergillosis develops in severely immunocompromised patients, including those with neutropenia, and increasingly in the non-neutropenic host, including lung transplant recipients, the critically ill patients and patients on steroids. A high index of suspicion is required in patients without the classical risk factors as early presentation is usually silent and non-specific, pyrexia uncommon and timely treatment is crucial for survival. Invasive aspergillosis has also been diagnosed in normal hosts after massive exposure to fungal spores. Chronic pulmonary aspergillosis affects patients without obvious immune compromise, but with an underlying lung condition such as COPD or sarcoidosis, prior or concurrent TB or non-tuberculous mycobacterial disease. Aspergillus bronchitis may be responsible for persistent respiratory symptoms in patients with Aspergillus detected repeatedly in sputum without evidence of parenchymal Aspergillus disease, especially in patients with bronchiectasis and cystic fibrosis. Allergic bronchopulmonary aspergillosis affects patients with asthma and cystic fibrosis, and is important to recognise as permanent lung or airways damage may accrue if untreated. Changes in the classification of Aspergillus allergic lung disease have been proposed recently. Cases of extrinsic allergic alveolitis and chronic pulmonary aspergillosis have been observed after Aspergillus exposure. Asymptomatic colonisation of the respiratory tract needs close monitoring as it can lead to clinical disease especially with ongoing immunosuppression. The various syndromes should be viewed as a semicontinuous spectrum of disease and one form may evolve into another depending on the degree of ongoing immunosuppression.

[Invasive pulmonary aspergillosis in patients with chronic obstructive pulmonary disease]

Invasive pulmonary aspergillosis (IPA) is a common infection in immunocompromised patients with hematological malignancies or allogenic stem cell transplantation, and is less frequent in the context of chronic obstructive pulmonary disease (COPD). Mucociliary activity impairment, immunosuppression due to the inhibition of alveolar macrophages and neutrophils by steroids, and receiving broad-spectrum antibiotics, play a role in the development of IPA in COPD patients. Colonized patients or those with IPA are older, with severe CODP stage (GOLD≥III), and have a higher number of comorbidities. The mortality rate is high due to the fact that having a definitive diagnosis of IPA in COPD patients is often difficult. The main clinical and radiological signs of IPA in these types of patients are non-specific, and tissue samples for definitive diagnosis are often difficult to obtain. The poor prognosis of IPA in COPD patients could perhaps be improved by faster diagnosis and prompt initiation of antifungal treatment. Some tools, such as scales and algorithms based on risk factors of IPA, may be useful for its early diagnosis in these patients.

Aspergillus tracheobronchitis, bronchopleural fistula and empyema after lobectomy for aspergilloma

Aspergillus tracheobronchitis and Aspergillus empyema are two rare manifestations of Aspergillus infection. This case report presents a patient with chronic obstructive pulmonary disease who developed a pseudomembranous Aspergillus tracheobronchitis, bronchopleural fistula and empyema 16 months after lobectomy for an aspergilloma. Bronchoscopy proved to be important for assessment of severity. Combined systemic anti-fungal treatment (voriconazole) and open window thoracostomy were used to successfully treat the patient.

Aspergillus tracheobronchitis in critically ill patients with chronic obstructive pulmonary diseases

Aspergillus tracheobronchitis (ATB) is considered as an unusual form of invasive aspergillosis and has a fatal outcome. There is little current information on several aspects of chronic obstructive pulmonary diseases (COPD) complicated by ATB, the frequency of which is expected to increase in the coming years. In a prospective study of invasive bronchial-pulmonary aspergillosis (IBPA) in a critically ill COPD population, three proven cases of ATB were identified. The three new cases, combined with eight previously reported cases of COPD with ATB over a 30-year period (1983-2013), were analysed. Among 153 critically ill COPD patients admitted to the ICU, eight cases were complicated by ATB [23.5% of IBPA (8 of 34); and 5.2% of COPD (8 of 153)], and three cases were finally diagnosed as proven ATB by histopathological findings. Among the three new cases reported and the eight published cases, the overall mortality rate was 72.7% (8 of 11 cases), with a median of 11.5 days (range, 7-27 days) between admission to death. The mortality rate was significantly higher in patients with invasive pulmonary aspergillosis (IPA) [100% (8 of 8 patients)] than in patients without parenchyma invasion [0% (0 of 3 patient), P = 0.006]. Seven patients (77.8%) received systemic corticosteroid therapy and three patients (33.3%) inhaled corticosteroids before diagnosis with ATB. Dyspnoea resistant to corticosteroids (77.8%) was the most frequent symptom. The radiological manifestations progressed rapidly in three patients (75%) who had normal chest X-rays (CXRs) at admission. Pseudomembranous lesions were the most frequent form (54.5%) observed by bronchoscopy. Aspergillus fumigatus was the most frequently isolated pathogen (40%). ATB is an uncommon cause of exacerbation in approximately 5% of critically ill COPD patients admitted to the ICU, and may progress rapidly to IPA with a high mortality rate. Dyspnoea resistant to corticosteroids and appropriate antibiotics with a negative CXR should raise the suspicion of ATB. Early diagnosis of ATB is based on bronchoscopic examination and proven diagnosis maybe safely established with a bronchial mucous biopsy.

Arg279 is the key regulator of coenzyme selectivity in the flavin-dependent ornithine monooxygenase SidA

Siderophore A (SidA) is a flavin-dependent monooxygenase that catalyzes the NAD(P)H- and oxygen-dependent hydroxylation of ornithine in the biosynthesis of siderophores in Aspergillus fumigatus and is essential for virulence. SidA can utilize both NADPH or NADH for activity; however, the enzyme is selective for NADPH. Structural analysis shows that R279 interacts with the 2'-phosphate of NADPH. To probe the role of electrostatic interactions in coenzyme selectivity, R279 was mutated to both an alanine and a glutamate. The mutant proteins were active but highly uncoupled, oxidizing NADPH and producing hydrogen peroxide instead of hydroxylated ornithine. For wtSidA, the catalytic efficiency was 6-fold higher with NADPH as compared to NADH. For the R279A mutant the catalytic efficiency was the same with both coenyzmes, while for the R279E mutant the catalytic efficiency was 5-fold higher with NADH. The effects are mainly due to an increase in the KD values, as no major changes on the kcat or flavin reduction values were observed. Thus, the absence of a positive charge leads to no coenzyme selectivity while introduction of a negative charge leads to preference for NADH. Flavin fluorescence studies suggest altered interaction between the flavin and NADP⁺ in the mutant enzymes. The effects are caused by different binding modes of the coenzyme upon removal of the positive charge at position 279, as no major conformational changes were observed in the structure for R279A. The results indicate that the positive charge at position 279 is critical for tight binding of NADPH and efficient hydroxylation.

Invasive pulmonary aspergillosis in patients with chronic obstructive pulmonary disease

Background

Invasive pulmonary aspergillosis (IPA) is an infection often occurring in neutropenic patients and has high mortality rates. In recent years, it has been reported that the incidence of IPA has also increased in patients with chronic obstructive pulmonary disease (COPD). The purpose of this study is to investigate the clinical and demographic characteristics and treatment responses of IPA in patients with COPD.

Methods

Seventy-one patients with a positive culture of Aspergillus from lower respiratory tract samples were examined retrospectively. Eleven (15.4%) of these patients, affected with grade 3 or 4 COPD, had IPA.

Results

Aspergillus hyphae were detected in lung biopsy in three (27.3%) out of 11 patients and defined as proven IPA; a pathological sample was not taken in the other eight (72.7%) patients, and these were defined as probable IPA. Aspergillus isolates were identified as six cases of Aspergillusfumigatus and three of Aspergillusniger in nine patients, while two isolates were not identified at species level. While five patients required intensive care unit admission, four of them received mechanical ventilation. The most common finding on chest X-ray and computed tomography (CT) (respectively 63.6%, 72.7%) was infiltration. Amphotericin B was the initial drug of choice in all patients and five patients were discharged with oral voriconazole after amphotericin B therapy. Six patients (54.5%) died before treatment was completed.

Conclusions

IPA should be taken into account in the differential diagnosis particularly in patients with severe and very severe COPD presenting with dyspnea exacerbation, poor clinical status, and a new pulmonary infiltrate under treatment with broad-spectrum antibiotics and steroids.

Role of galactomannan determinations in bronchoalveolar lavage fluid samples from critically ill patients with chronic obstructive pulmonary disease for the diagnosis of invasive pulmonary aspergillosis: a prospective study

INTRODUCTION

Critically ill chronic obstructive pulmonary disease (COPD) patients are at particular risk of invasive pulmonary aspergillosis (IPA). Our aims were to determine whether bronchoalveolar lavage fluid (BALF) galactomannan (GM) has a higher sensitivity and specificity than serum GM or lower respiratory tract (LRT) sample culture. Furthermore, we aimed to investigate what the optimal cut-off value would be for BALF GM.

METHODS

In this prospective single-center study, BALF and serum samples were collected from critically ill COPD patients on the first day of their intensive care unit admission.

RESULTS

Of 50 critically ill COPD patients admitted, BALF and serum samples were collected in 34 patients. According to the receiver operating characteristics (ROC) curve, an optical density (OD) ratio of 0.8 was chosen as the cut-off value for GM in BALF. Compared to serum GM and LRT Aspergillus isolation, BALF GM yield a better sensitivity, specificity, positive and negative predictive values of 88.9%, 100%, 100% and 94.4%, respectively. Areas under the ROC curve were 0.912 (95%CI, 0.733 to 0.985) for BALF GM, and 0.879 (95%CI, 0.691 to 0.972) for serum GM results from the first day of ICU admission. Pairwise comparison of ROC curves showed P = 0.738. The OD ratio of BALF GM in IPA patients were significantly higher than those of non-IPA patients (2.88 ± 2.09 versus 0.49 ± 0.19, P = 0.009), and the OD ratio of BALF GM was significantly higher than serum GM in IPA patients (2.88 ± 2.09 versus 0.87 ± 0.47, P = 0.023). Positive BALF GM was seen earlier than LRT secretion culture (1 day versus 3.8 days).

CONCLUSIONS

Compared to serum GM and LRT Aspergillus isolation, BALF GM seems to have a better sensitivity in the diagnosis of IPA in critically ill COPD patients. The ROC curve suggests a possible cut-off value of 0.8 for GM from BALF specimens in critically ill COPD patients.

Year in review 2010: Critical Care--Infection

Infections remain among the most important concerns in critically ill patients. Early and reliable diagnosis of infection still poses difficulties in this setting but also represents a crucial step toward appropriate antimicrobial therapy. Increasing antimicrobial resistance challenges established approaches to the optimal management of infections in the intensive care unit. Rapid infection diagnosis, antibiotic dosing and optimization through pharmacologic indices, progress in the implementation of effective antimicrobial stewardship and infection control programs, and management of fungal infections are some of the most relevant issues in this special patient population. During the last 18 months, Critical Care and other journals have provided a wide array of descriptive and interventional clinical studies and scientific reports helping clinical investigators and critical care physicians to improve diagnosis, management, and therapy of infections in critically ill patients.