Serological evidence of chronic pulmonary Aspergillosis in tuberculosis patients in Kenya

Characteristics and risk factors of pulmonary fungal infection in patients with pulmonary tuberculosis

OBJECTIVE

To investigate the characteristics of and the risk factors for pulmonary fungal infection in patients with pulmonary tuberculosis (PT).

METHODS

A retrospective analysis was conducted on the clinical data of 218 PT patients treated at Beijing Luhe Hospital Affiliated with Capital Medical University from May 2022 to May 2024. Based on the presence or absence of fungal infection, these 218 patients were assigned to an infection group (n=87) or a non-infection group (n=131). Clinical baseline data, pulmonary fungal infection status ten days after admission, clinical symptoms on the first day of admission, and serum protein and hemoglobin levels were compared between the two groups. Logistic regression analysis was conducted to identify independent risk factors for pulmonary fungal infection in PT patients. A receiver operating characteristic (ROC) curve was generated to evaluate the predictive performance of these independent risk factors.

RESULTS

Among the 218 PT patients included, 87 (39.91%) had fungal infections. A total of 210 fungal strains were isolated and cultured from the infection group, with Candida albicans accounting for the highest proportion (42.65%), followed by candida tropicalis (20.59%) and Candida glabrata (17.65%). The infection group exhibited significantly higher rates of cough, fever, anemia, and pulmonary rales compared to the non-infection group (all P<0.05). The infection group showed significantly lower levels of serum protein and hemoglobin than the non-infection group (P<0.0001). Multivariate analysis identified history of smoking, disease course, duration of corticosteroid use, invasive procedure, serum protein level, and hemoglobin level as independent factors for fungal infection in PT patients. ROC curve analysis indicated that serum protein levels had the highest accuracy and area under the curve (AUC) value, while smoking history and hemoglobin levels performed less well in the model.

CONCLUSION

This study found a high rate of pulmonary fungal infections among PT patients, with Candida albicans being the most prevalent, followed by candida tropicalis and Candida glabrata. A history of smoking, a prolonged disease course, invasive procedures, extended corticosteroid use, and low serum protein and hemoglobin levels are independent factors for fungal infection in PT patients.

A retrospective study exploring chronic pulmonary aspergillosis in post-tuberculosis lung disease patients

Background

Chronic pulmonary aspergillosis (CPA) complicates post-tuberculosis lung disease (PTLD), causing significant morbidity and mortality. Predictors for Aspergillus seropositivity and CPA in a PTLD population remain unclear. The objective of this study was to identify the clinical, radiological, physiological, and biochemical characteristics of patients presenting to an adult PTLD clinical service, who met full criteria for CPA, and to compare them to those who did not, as well as compare those with positive Aspergillus serology to those without.

Methods

This retrospective cross-sectional study, performed in a tertiary adult PTLD clinical service in South Africa, investigated the clinical, radiological, physiological and biochemical characteristics of patients who had Aspergillus serology performed and compared those with positive and negative serology, as well as those meeting CPA diagnostic criteria with those who did not.

Results

Over a 2-year period, 238 patients were seen in the PTLD clinic, of which 79 had registered Aspergillus immunoglobulin G (IgG) serology testing and computed tomography (CT) chest imaging performed. Twenty-six (32.9%) patients had positive Aspergillus serology and 20 (25.3%) met criteria for CPA. Current radiological definitions for CPA when applied in a blinded fashion, had a sensitivity of 80.8% and a specificity of 58.5% for Aspergillus seropositivity, with a positive predictive value of 48.8%. Having ≥4 episodes of previous pulmonary tuberculosis (PTB) was significantly associated with both Aspergillus seropositivity [odds ratio (OR) =10.9; 95% confidence interval (CI): 2.1-84.9] and CPA diagnosis (OR =15.5; 95% CI: 2.8-125.6). Haemoptysis was significantly more common in those with positive Aspergillus serology (OR =2.7; 95% CI: 1.4-5.2) and in those with CPA (OR =2.7; 95% CI: 1.4-5.4). Total immunoglobulin E (IgE) levels were significantly higher in those with Aspergillus seropositivity (P value =0.006) and in those with CPA (P value =0.03). Other symptoms, spirometric and laboratory findings were similar between groups.

Conclusions

Current radiological criteria are not sufficiently specific for the diagnosis of CPA in PTLD populations, necessitating wider use of Aspergillus serology. The significant overlap in clinical syndromes highlights a complicated yet poorly understood relationship between CPA and PTLD, with increased frequency of haemoptysis requiring further research.

Chronic pulmonary aspergillosis in tea population of Assam

BACKGROUND

Chronic pulmonary aspergillosis (CPA) is a disease commonly caused by Aspergillus fumigatus and other Aspergillus species characterized by cavitary lung lesions. Tea garden population is an agrarian population of Assam, mostly associated with tea plantations. Assam is a major tea-producing state with 803 tea gardens producing approximately 50% of the total tea in India, of which 177 are present in the Dibrugarh district alone. Tuberculosis is common in tea garden workers. This community-based cross-sectional study in the tea garden community of Dibrugarh was done to find the prevalence of Aspergillus IgG antibodies and CPA cases in individuals with chronic respiratory symptoms.

METHODOLOGY AND PRINCIPAL FINDINGS

Patients visiting 3 tea garden hospitals and 2 referral hospitals with chronic cough and/or haemoptysis, weight loss/fatigue, and other respiratory symptoms for a duration of 3 months or more were included in this one-year study. Serum samples were tested by Immunocap Phadia 200 for Aspergillus fumigatus-specific IgG antibodies. CPA cases were diagnosed based on clinical, radiological, and serological criteria. Out of 128 samples, seropositivity was seen in 41 (32.0%) patients (cutoff value: 27 mgA/l). Male preponderance (1.6:1) with a mean age of 41.9 (±15.69) was observed. Haemoptysis and fatigue were significant symptoms seen (p-values: 0.0086 and 0.0098, respectively). Aspergillus fumigatus-specific IgG antibody was found to be significantly high in 29 out of 76 patients (38.1%) with a history of tuberculosis. Amongst them, seropositivity with active TB was 5 out of 27 patients (18.5%), and seropositivity with post-TB was 24 out of 49 patients (48.9%). Chronic cavitary pulmonary aspergillosis was the predominant type (38.1%). Proven CPA (clinically, radiologically, and serologically positive) were 22 (17.1%, 95% CI 10.7%-26.0%), and possible CPA (clinically and serologically positive but without radiological data) were 19 (14.8%, 95% CI 8.9%-23.1%).

CONCLUSION

A high prevalence of CPA (60 per 100 000) was detected. High Aspergillus seropositivity of 48.9% was seen in the post-TB population. Aspergillus-specific IgG antibody testing is the only confirmatory method for diagnosing CPA, which is available in limited centres in India. Aspergillus seropositivity should be detected in post-TB patients presenting with chronic respiratory symptoms.

Clinical Features, Treatment Outcome and Potential risk Factors for Recurrence Among Patients with Chronic Pulmonary Aspergillosis in a Resource-limited Setting: A Retrospective Observational Study

OBJECTIVE

To evaluate the clinical characteristics and treatment outcomes of patients with chronic pulmonary aspergillosis (CPA) and to determine risk factors for disease recurrence.

METHODS

A total of 43 patients with CPA (mean ± SD age: 61.4 ± 10.5 years, 83.7% were males) were included in this retrospective study. Data on demographic, clinical and disease-related characteristics, galactomannan (GM) test positivity in bronchoalveolar lavage (BAL) samples, histopathological diagnosis, imaging (CT) findings and CPA forms, antifungal therapy, recurrence rate and time to recurrence were recorded.

RESULTS

Chronic obstructive pulmonary disease (COPD;76.7%) was the leading predisposing factor, and the aspergillus nodule (37.2%) was the most prevalent CPA form.GM test positivity was noted in 89.7% (35/39) of BAL samples. Median duration of voriconazole treatment was 180 days. CPA recurrence was noted in 14.0% of patients, while the comorbid tuberculosis sequela (66.7% vs. 16.2%, p = 0.02) and mild immunosuppressive disorder (100.0% vs. 51.4%, p = 0.032) were significantly more common in patients with recurrence vs. those without recurrence. Recurrence rate was 50.0% (3 of 6 patients) in patients with simple aspergilloma, and ranged from 0.0% to 25.0% in those with other CPA forms. Treatment duration and time to recurrence ranged 70-270 days and 1.1-37 months, respectively in simple aspergilloma, while they were ranged 150-180 days and 30-43.3 months, respectively in other CPA forms.

CONCLUSIONS

Our findings indicate the importance of considering CPA in differential diagnosis in patients with predisposing conditions, and emphasize the tuberculosis sequela, immunosuppressive disorder and the certain CPA forms managed with shorter duration of antifungal therapy (i.e., simple aspergilloma) as the potential risk factors of CPA recurrence.

Chronic Pulmonary Aspergillosis as a Considerable Complication in Post-Tuberculosis Lung Disease

Post-tuberculosis lung disease (PTLD) has only recently been put in the spotlight as a medical entity. Recent data suggest that up to 50% of tuberculosis (TB) patients are left with PTLD-related impairment after completion of TB treatment. The presence of residual cavities in the lung is the largest risk factor for the development of chronic pulmonary aspergillosis (CPA) globally. Diagnosis of CPA is based on four criteria including a typical radiological pattern, evidence of Aspergillus species, exclusion of alternative diagnosis, and a chronic course of disease. In this manuscript, we provide a narrative review on CPA as a serious complication for patients with PTLD.

Prevalence and predictors of Aspergillus seropositivity and chronic pulmonary aspergillosis in an urban tertiary hospital in Sierra Leone: A cross-sectional study

BACKGROUND

In the World Health Organization Global Tuberculosis (TB) Report 2022, 37% of pulmonary TB patients were clinically diagnosed and thus many people were treated for TB without evidence of the disease. Probably the most common TB misdiagnosis is chronic pulmonary aspergillosis (CPA). In this study, we aimed to assess the prevalence and predictors of Aspergillus seropositivity and CPA in patients with chronic respiratory symptoms in an urban tertiary hospital in Sierra Leone.

METHODOLOGY/PRINCIPAL FINDINGS

We used a cross-sectional study design to recruit adults (≥18 years) from the Chest Clinic of Connaught Hospital, Freetown between November 2021 and July 2022. Aspergillus antibody was detected using LDBio Aspergillus IgM/IgG. Logistic regression was performed to assess the independent predictors of Aspergillus seropositivity and CPA. Of the 197 patients with chronic respiratory symptoms, 147 (74.6%) were male. Mean age was 47.1 ± 16.4 years. More than half (104, 52.8%) had been diagnosed with TB in the past, while 53 (26.9%) were on TB treatment at the time of recruitment. Fifty-two (26.4%) patients were HIV positive, 41 (20.8%) were seropositive for Aspergillus and 23 (11.6%) had CPA, 2 (3.8%) with current TB and 18 (17.3%) with past TB. Common radiologic abnormalities reported were localized fibrotic changes 62 (31.5%), consolidation 54 (27.4%), infiltrates 46 (23.4%), hilar adenopathy 40 (20.3%) and pleural effusion 35 (17.85) and thickening 23 (11.7%). Common symptoms were weight loss 144 (73.1%), cough 135 (68.5%), fever 117 (59.4%) and dyspnea 90 (45.7%). Current or past TB infection {aOR 3.52, 95% CI (1.46, 8.97); p = 0.005} was an independent predictor of Aspergillus seropositivity and CPA.

CONCLUSIONS/SIGNIFICANCE

We report a high prevalence of Aspergillus antibody seropositivity and CPA, underscoring the need to integrate the prevention and management of pulmonary fungal infections with TB services and asthma care in order to reduce unnecessary morbidity and mortality.

Overcoming clinical challenges in the management of invasive fungal infections in low- and middle-income countries (LMIC)

INTRODUCTION

The management of invasive fungal infections (IFIs) in low- and middle-income countries (LMIC) is a serious challenge due to limited epidemiology studies, sub-optimal laboratory facilities, gap in antifungal management training and resources. Limited studies highlighted distinctive epidemiology of IFIs in those countries, and difficulty in distinguishing from closely related infections. To overcome the gaps for appropriate management of IFIs, innovative approaches are required.

AREAS COVERED

Extensive literature search and discussion with experts have helped us to summarize the epidemiology, diagnostic and management difficulties in managing IFIs in LMIC, and recommend certain solutions to overcome the challenges.

EXPERT OPINION

The strategies to overcome the challenges in diagnosis may include local epidemiology study, training of healthcare workers, association of fungal infections with already existing budgeted national programs, development and incorporation of point-of-care test (POCT) for prompt diagnosis, simplifying clinical diagnostic criteria suitable for LMIC, judicious use of available expertise, and diagnostic stewardship. For management strategies judicious use of antifungal, partnering with industry for inexpensive antifungal agents, development of LMIC specific guidelines for cost-effective management of IFIs and fungal outbreaks, improvement of infection control practices, advocacy for implementation of WHO recommended antifungal use, and integration of IFIs with public health.

Burden of fungal infections in Kenya

The burden of fungal infections has been on the rise globally and remains a significant public health concern in Kenya. We estimated the incidence and prevalence of fungal infections using all mycology publications in Kenya up to January 2023, and from neighbouring countries where data lacked. We used deterministic modelling using populations at risk to calculate the disease burden. The total burden of serious fungal infections is estimated to affect 6,328,294 persons which translates to 11.57% of the Kenyan population. Those suffering from chronic infections such as chronic pulmonary aspergillosis are estimated to be 100,570 people (0.2% of the population) and probably nearly 200,000 with fungal asthma, all treatable with oral antifungal therapy. Serious acute fungal infections secondary to HIV (cryptococcal meningitis, disseminated histoplasmosis, pneumocystis pneumonia, and mucosal candidiasis) affect 196,543 adults and children (0.4% of the total population), while cancer-related invasive fungal infection cases probably exceed 2,299 and those in intensive care about 1,230 incident cases, including Candida auris bloodstream infection. The burden of fungal infections in Kenya is high; however, limited diagnostic test availability, low clinician awareness and inadequate laboratory capacity constrain the country's health system in responding to the syndemic of fungal disease in Kenya.