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Neuböck MJ, Günther G, Barac A, Davidsen JR, Laursen CB, Agarwal R, Sehgal IS, Lange C, Salzer HJF. Chronic Pulmonary Aspergillosis as a Considerable Complication in Post-Tuberculosis Lung Disease. Semin Respir Crit Care Med 2024; 45:102-113. [PMID: 38196060 DOI: 10.1055/s-0043-1776913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
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.
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Affiliation(s)
- Matthias J Neuböck
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine 4 - Pneumology, Kepler University Hospital, Linz, Austria
- Medical Faculty, Johannes Kepler University Linz, Linz, Austria
| | - Gunar Günther
- Department of Pulmonology and Allergology, Inselspital, Bern University Hospital, Bern, Switzerland
- Department of Medical Sciences, Faculty of Health Sciences, University of Namibia, Windhoek, Namibia
| | - Aleksandra Barac
- Clinic for Infectious and Tropical Diseases, University Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Jesper R Davidsen
- Department of Respiratory Medicine, Pulmonary Aspergillosis Centre Denmark, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Odense Respiratory Research Unit, University of Southern Denmark, Odense, Denmark
| | - Christian B Laursen
- Department of Respiratory Medicine, Pulmonary Aspergillosis Centre Denmark, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Odense Respiratory Research Unit, University of Southern Denmark, Odense, Denmark
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Inderpaul S Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Christoph Lange
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
- German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Hamburg, Germany
- Respiratory Medicine and International Health, University of Lübeck, Lübeck, Germany
- Baylor College of Medicine and Texas Children's Hospital, Global Tuberculosis Program, Houston, Texas
| | - Helmut J F Salzer
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine 4 - Pneumology, Kepler University Hospital, Linz, Austria
- Medical Faculty, Johannes Kepler University Linz, Linz, Austria
- Ignaz-Semmelweis-Institute, Interuniversity Institute for Infection Research, Vienna, Austria
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Bongomin F, Kwizera R, Namusobya M, van Rhijn N, Andia-Biraro I, Kirenga BJ, Meya DB, Denning DW. Re-estimation of the burden of serious fungal diseases in Uganda. Ther Adv Infect Dis 2024; 11:20499361241228345. [PMID: 38328511 PMCID: PMC10848809 DOI: 10.1177/20499361241228345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 01/09/2024] [Indexed: 02/09/2024] Open
Abstract
Background It is of utmost importance to monitor any change in the epidemiology of fungal diseases that may arise from a change in the number of the at-risk population or the availability of local data. Objective We sought to update the 2015 publication on the incidence and prevalence of serious fungal diseases in Uganda. Methods Using the Leading International Fungal Education methodology, we reviewed published data on fungal diseases and drivers of fungal diseases in Uganda. Regional or global data were used where there were no Ugandan data. Results With a population of ~45 million, we estimate the annual burden of serious fungal diseases at 4,099,357 cases (about 9%). We estimated the burden of candidiasis as follows: recurrent Candida vaginitis (656,340 cases), oral candidiasis (29,057 cases), and esophageal candidiasis (74,686 cases) in HIV-infected people. Cryptococcal meningitis annual incidence is estimated at 5553 cases, Pneumocystis pneumonia at 4604 cases in adults and 2100 cases in children. For aspergillosis syndromes, invasive aspergillosis annual incidence (3607 cases), chronic pulmonary aspergillosis (26,765 annual cases and 63,574 5-year-period prevalent cases), and prevalence of allergic bronchopulmonary aspergillosis at 75,931 cases, and severe asthma with fungal sensitization at 100,228 cases. Tinea capitis is common with 3,047,989 prevalent cases. For other mycoses, we estimate the annual incidence of histoplasmosis to be 646 cases and mucormycosis at 9 cases. Conclusion Serious fungal diseases affect nearly 9% of Ugandans every year. Tuberculosis and HIV remain the most important predisposition to acute fungal infection necessitating accelerated preventive, diagnostic, and therapeutic interventions for the management of these diseases.
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Affiliation(s)
- Felix Bongomin
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
- Manchester Fungal Infection Group, Division of Evolution, Infection and Genomics, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Richard Kwizera
- Infectious Diseases Institute, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Martha Namusobya
- Department of Clinical Epidemiology and Biostatistics, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Norman van Rhijn
- Manchester Fungal Infection Group, Division of Evolution, Infection and Genomics, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | | | - Bruce J. Kirenga
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - David B. Meya
- Infectious Diseases Institute, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - David W. Denning
- Manchester Fungal Infection Group, CTF Building, The University of Manchester, Grafton Street, Manchester M13 9NT, UK
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Baker J, Denning DW. The SSS revolution in fungal diagnostics: speed, simplicity and sensitivity. Br Med Bull 2023; 147:62-78. [PMID: 37328942 PMCID: PMC10502448 DOI: 10.1093/bmb/ldad011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 04/24/2023] [Accepted: 05/29/2023] [Indexed: 06/18/2023]
Abstract
INTRODUCTION Fungal disease has historically presented a diagnostic challenge due to its often non-specific clinical presentations, relative infrequency and reliance on insensitive and time-intensive fungal culture. SOURCES OF DATA We present the recent developments in fungal diagnostics in the fields of serological and molecular diagnosis for the most clinically relevant pathogens; developments that have the potential to revolutionize fungal diagnosis through improvements in speed, simplicity and sensitivity. We have drawn on a body of evidence including recent studies and reviews demonstrating the effectiveness of antigen and antibody detection and polymerase chain reaction (PCR) in patients with and without concurrent human immunodeficiency virus infection. AREAS OF AGREEMENT This includes recently developed fungal lateral flow assays, which have a low cost and operator skill requirement that give them great applicability to low-resource settings. Antigen detection for Cryptococcus, Histoplasma and Aspergillus spp. are much more sensitive than culture. PCR for Candida spp., Aspergillus spp., Mucorales and Pneumocystis jirovecii is more sensitive than culture and usually faster. AREAS OF CONTROVERSY Effort must be made to utilize recent developments in fungal diagnostics in clinical settings outside of specialist centres and integrate their use into standard medical practice. Given the clinical similarities of the conditions and frequent co-infection, further study is required into the use of serological and molecular fungal tests, particularly in patients being treated for tuberculosis. GROWING POINTS Further study is needed to clarify the utility of these tests in low-resource settings confounded by a high prevalence of tuberculosis. AREAS TIMELY FOR DEVELOPING RESEARCH The diagnostic utility of these tests may require revision of laboratory work flows, care pathways and clinical and lab coordination, especially for any facility caring for the immunosuppressed, critically ill or those with chronic chest conditions, in whom fungal disease is common and underappreciated.
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Affiliation(s)
- Jacob Baker
- Department of Medicine, Shrewsbury and Telford Hospitals Trust, Mytton Oak Rd, Shrewsbury SY3 8XQ, UK
| | - David W Denning
- Manchester Fungal Infection Group, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Global Action For Fungal Infections (GAFFI), Rue Le Corbusier 1208 Geneva, Switzerland
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Chakrabarti A, Patel AK, Soman R, Todi S. Overcoming clinical challenges in the management of invasive fungal infections in low- and middle-income countries (LMIC). Expert Rev Anti Infect Ther 2023; 21:1057-1070. [PMID: 37698201 DOI: 10.1080/14787210.2023.2257895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 09/07/2023] [Indexed: 09/13/2023]
Abstract
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.
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Affiliation(s)
- Arunaloke Chakrabarti
- Department of Infectious Disease and Microbiology, Doodhadhari Burfani Hospital & Research Institute, Haridwar, India
| | - Atul K Patel
- Infectious Diseases Department, Sterling Hospital, Ahmedabad, India
| | - Rajeev Soman
- Infectious Diseases Physician, Jupiter Hospital and Deenanath Mangeskar Hospital, Pune, India
| | - Subhash Todi
- Critical Care and Emergency Medicine, AMRI Hospitals, Kolkata, India
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Rozaliyani A, Antariksa B, Nurwidya F, Zaini J, Setianingrum F, Hasan F, Nugrahapraja H, Yusva H, Wibowo H, Bowolaksono A, Kosmidis C. The Fungal and Bacterial Interface in the Respiratory Mycobiome with a Focus on Aspergillus spp. Life (Basel) 2023; 13:life13041017. [PMID: 37109545 PMCID: PMC10142979 DOI: 10.3390/life13041017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/08/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023] Open
Abstract
The heterogeneity of the lung microbiome and its alteration are prevalently seen among chronic lung diseases patients. However, studies to date have primarily focused on the bacterial microbiome in the lung rather than fungal composition, which might play an essential role in the mechanisms of several chronic lung diseases. It is now well established that Aspergillus spp. colonies may induce various unfavorable inflammatory responses. Furthermore, bacterial microbiomes such as Pseudomonas aeruginosa provide several mechanisms that inhibit or stimulate Aspergillus spp. life cycles. In this review, we highlighted fungal and bacterial microbiome interactions in the respiratory tract, with a focus on Aspergillus spp.
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Affiliation(s)
- Anna Rozaliyani
- Department of Parasitology, Faculty of Medicine, Universitas Indonesia, Jakarta 10430, Indonesia
- Indonesia Pulmonary Mycoses Centre, Jakarta 10430, Indonesia
| | - Budhi Antariksa
- Department of Pulmonoloy and Respiratory Medicine, Faculty of Medicinie, Universitas Indonesia, Persahabatan National Respiratory Referral Hospital, Jakarta 13230, Indonesia
| | - Fariz Nurwidya
- Department of Pulmonoloy and Respiratory Medicine, Faculty of Medicinie, Universitas Indonesia, Persahabatan National Respiratory Referral Hospital, Jakarta 13230, Indonesia
| | - Jamal Zaini
- Department of Pulmonoloy and Respiratory Medicine, Faculty of Medicinie, Universitas Indonesia, Persahabatan National Respiratory Referral Hospital, Jakarta 13230, Indonesia
| | - Findra Setianingrum
- Department of Parasitology, Faculty of Medicine, Universitas Indonesia, Jakarta 10430, Indonesia
- Indonesia Pulmonary Mycoses Centre, Jakarta 10430, Indonesia
| | - Firman Hasan
- Indonesia Pulmonary Mycoses Centre, Jakarta 10430, Indonesia
| | - Husna Nugrahapraja
- Life Science and Biotechnology, Bandung Institute of Technology, Bandung 40312, Indonesia
| | - Humaira Yusva
- Magister Program of Biomedical Sciences, Faculty of Medicine, Universitas Indonesia, Jakarta 10430, Indonesia
| | - Heri Wibowo
- Department of Parasitology, Faculty of Medicine, Universitas Indonesia, Jakarta 10430, Indonesia
| | - Anom Bowolaksono
- Department of Biology, Faculty of Mathematics and Natural Sciences (FMIPA), Universitas Indonesia, Depok 16424, Indonesia
| | - Chris Kosmidis
- Manchester Academic Health Science Centre, Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M23 9LT, UK
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Denning DW, Cole DC, Ray A. New estimation of the prevalence of chronic pulmonary aspergillosis (CPA) related to pulmonary TB - a revised burden for India. IJID REGIONS 2022; 6:7-14. [PMID: 36568568 PMCID: PMC9772841 DOI: 10.1016/j.ijregi.2022.11.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 11/13/2022] [Indexed: 11/19/2022]
Abstract
Background Chronic pulmonary aspergillosis (CPA) may be confused with, or a coinfection of, pulmonary tuberculosis (PTB), or may manifest itself after completion of antituberculous therapy (ATT). Methods Literature searches were conducted on PubMed. The selected studies stated the timing of CPA diagnosis with respect to PTB. The key assumptions for estimating the annual incidence, annual deaths, and 5-year-period prevalence related to CPA were: of the clinically diagnosed PTB patients , 19% of those HIV-negative had CPA and 7% of HIV-positive patients had CPA; the percentage of patients presenting in the first year after PTB diagnosis or developing CPA as ATT finished was 10%; the annual rate of development of CPA from 2-5 years after PTB diagnosis was 1.5%; and the mortality of CPA was 20% in year 1 and 7.5% thereafter to year 5. Findings In India, the annual incidence of CPA arising in PTB patients in 2019 was estimated to be 363 601 cases (range 254 521 - 472 682) and 42 766 deaths (range 29 936-55 595) - 10.5% of total PTB deaths. The 5-year-period prevalence of CPA was estimated at 1 575 716 , with an additional 100 715 deaths' total range of deaths 100 436- 186 525) annually. Interpretation The revised estimation indicates a substantial unmet need for better diagnosis of CPA as part of a complex PTB-related respiratory morbidity burden.
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Affiliation(s)
- David W. Denning
- Manchester Fungal Infection Group, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK,Global Action for Fungal Infections, Geneva, Switzerland,Correspondence: David W. Denning, Professor of Infectious Diseases in Global Health, Manchester Fungal Infection Group, CTF building, Grafton Street, Manchester M13 9NT, UK
| | - Donald C. Cole
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Animesh Ray
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
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Mohamed A, Obanda BA, Njeri HK, Loroyokie SN, Mashedi OM, Ouko TT, Gatumwa EM, Korir RK, Yaguchi T, Bii CC. Serological evidence of chronic pulmonary Aspergillosis in tuberculosis patients in Kenya. BMC Infect Dis 2022; 22:798. [PMID: 36284285 PMCID: PMC9594872 DOI: 10.1186/s12879-022-07782-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 09/17/2022] [Accepted: 10/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pulmonary tuberculosis (PTB) is a significant risk factor for fungal infection. The cavitary lesions post PTB serves as a good reservoir for fungal colonization and subsequent infection. Furthermore, the severe immunosuppression associated with HIV and TB co-infection is another predisposition. The inadequate capacity to investigate and manage fungal infection in PTB patients increases their morbidity and mortality. The study aimed to provide serological evidence of chronic pulmonary aspergillosis (CPA) among PTB patients in Kenya. Towards this, we analysed 234 serum samples from patients presenting with persistent clinical features of PTB infections despite TB treatment in four referral hospitals. METHODS This was a cross sectional laboratory based study and patients were recruited following an informed consent. Serological detection of Aspergillus fumigatus IgG was done using enzyme-linked immunosorbent assay (Bordier Affinity Products SA). Sputum samples were subjected to microscopy and standard fungal culture. The isolated fungi were subjected to macro and micro morphological identifications and confirmed by sequence analysis of calmadulin, betatubilin and ITS genes. RESULTS Serological evidence of CPA or fungal sensitization was 46(19.7%) and equivocal or borderline was 14(6.0%). Mycological investigations of sputum resulted in 88(38%) positive for fungal culture. Aspergillus spp. accounted for 25(28%) of which A. fumigatus was 13(14.8%), A. niger 8(9.1%), A. terreus, A. flavus, A. candidus and A. clavatus 1 (1.1%) each. This was followed by Penicillium spp. 10 (11.4%), Scedosporium spp. 5 (5.7%) and Rhizopus spp. 3 (3.4%). Among the yeasts; Candida albicans accounted for 18(20.5%) followed by C. glabrata 5(5.7%). Cryptococcus spp. was isolated from 3(3.4%) of the samples while 13(14.8%) were other yeasts. CONCLUSION Chronic pulmonary aspergillosis is a significant co-morbidity in PTB patients in Kenya that could be misdiagnosed as relapse or treatment failures in the absence of reliable diagnostic and clinical management algorithm. It could be the cause of persistent clinical symptoms despite TB treatment often misdiagnosed as TB smear/GeneXpert MTB/RIF® negative or relapse. We recommend that all patients with persistent clinical symptoms despite TB treatment should be subjected to fungal investigations before retreatment.
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Affiliation(s)
- Abdi Mohamed
- grid.33058.3d0000 0001 0155 5938Kenya Medical Research Institute, Centre for Microbiology Research, Mycology and Opportunistic Infections Laboratory, P.O.Box 54840-00200, Nairobi, Kenya
| | - Benear A. Obanda
- grid.33058.3d0000 0001 0155 5938Kenya Medical Research Institute, Centre for Microbiology Research, Mycology and Opportunistic Infections Laboratory, P.O.Box 54840-00200, Nairobi, Kenya
| | - Hannah K. Njeri
- grid.33058.3d0000 0001 0155 5938Kenya Medical Research Institute, Centre for Microbiology Research, Mycology and Opportunistic Infections Laboratory, P.O.Box 54840-00200, Nairobi, Kenya
| | - Sally N. Loroyokie
- grid.33058.3d0000 0001 0155 5938Kenya Medical Research Institute, Centre for Microbiology Research, Mycology and Opportunistic Infections Laboratory, P.O.Box 54840-00200, Nairobi, Kenya
| | - Olga M. Mashedi
- grid.33058.3d0000 0001 0155 5938Kenya Medical Research Institute, Centre for Respiratory Diseases Research, Tuberculosis Laboratory, P.O.Box 54840-00200, Nairobi, Kenya
| | - Tom T. Ouko
- grid.33058.3d0000 0001 0155 5938Kenya Medical Research Institute, Centre for Microbiology Research, Mycology and Opportunistic Infections Laboratory, P.O.Box 54840-00200, Nairobi, Kenya
| | - Evangeline M. Gatumwa
- grid.33058.3d0000 0001 0155 5938Kenya Medical Research Institute, Centre for Respiratory Diseases Research, Tuberculosis Laboratory, P.O.Box 54840-00200, Nairobi, Kenya
| | - Richard K. Korir
- grid.33058.3d0000 0001 0155 5938Kenya Medical Research Institute, Centre for Microbiology Research, Mycology and Opportunistic Infections Laboratory, P.O.Box 54840-00200, Nairobi, Kenya
| | - Takashi Yaguchi
- grid.136304.30000 0004 0370 1101Medical Mycology Research Centre (MMRC), Division of BioResources, Chiba University, 1-8- 1 Inohana, Chuo-ku, 260-8673 Chiba, Japan
| | - Christine C. Bii
- grid.33058.3d0000 0001 0155 5938Kenya Medical Research Institute, Centre for Microbiology Research, Mycology and Opportunistic Infections Laboratory, P.O.Box 54840-00200, Nairobi, Kenya
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Ocansey BK, Otoo B, Adjei A, Gbadamosi H, Kotey FCN, Kosmidis C, Afriyie-Mensah JS, Denning DW, Opintan JA. Chronic Pulmonary Aspergillosis is Common among Patients with Presumed Tuberculosis Relapse in Ghana. Med Mycol 2022; 60:6661426. [PMID: 35953428 PMCID: PMC9462665 DOI: 10.1093/mmy/myac063] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/31/2022] [Accepted: 08/09/2022] [Indexed: 11/13/2022] Open
Abstract
Chronic pulmonary aspergillosis (CPA) may mimic pulmonary tuberculosis (PTB). The two diseases are clinically indistinguishable and may result in CPA misdiagnosed as PTB or vice versa. Although PTB is largely recognised as a differential diagnosis of CPA and often ruled out prior to CPA diagnosis, the reverse is uncommon. The aim of this study was to determine the proportion of CPA cases among patients being assessed for PTB. A cross-sectional survey was conducted among consecutive patients referred for GeneXpert Mycobacterium tuberculosis test for the diagnosis of PTB at the Korle-Bu Teaching Hospital, Accra, Ghana. Patients’ demographics, clinical and socioeconomic details were obtained using a structured questionnaire. Blood was collected for Aspergillus and HIV serology, and sputum samples obtained for Aspergillus culture. Chest radiograph was obtained, and computed tomography scan was also done for patients with positive Aspergillus serology or cavitation. CPA was defined using an algorithm developed by the Global Action for Fungal Infections (GAFFI) international expert panel. A total of 154 patients were included in the analysis, of whom 134 (87%) did not have a prior PTB diagnosis. There were 41 (26.6%) GeneXpert positive cases. CPA prevalence was 9.7% overall, but 50% in patients with a prior history of PTB and 3.7% in those without previous PTB. Although CPA is rarely considered as a differential diagnosis of PTB in Ghana, our findings show that CPA may affect half of patients being assessed for PTB relapse. Efforts to diagnose CPA should be prioritised in this patient group.
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Affiliation(s)
- Bright K Ocansey
- Division of Evolution, Infection and Genomics, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | | | - Abraham Adjei
- Chest Diseases Unit, Department of Medicine and Therapeutics, Korle-Bu Teaching Hospital, Accra, Ghana
| | | | - Fleischer C N Kotey
- FleRhoLife Research Consult, Accra, Ghana.,Department of Medical Microbiology, University of Ghana Medical School, Accra, Ghana
| | - Chris Kosmidis
- Division of Evolution, Infection and Genomics, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,National Aspergillosis Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Jane S Afriyie-Mensah
- Chest Diseases Unit, Department of Medicine and Therapeutics, Korle-Bu Teaching Hospital, Accra, Ghana.,Department of Medicine and Therapeutics, University of Ghana Medical School, Accra, Ghana
| | - David W Denning
- Division of Evolution, Infection and Genomics, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Japheth A Opintan
- Department of Medical Microbiology, University of Ghana Medical School, Accra, Ghana
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Pulmonary and Extrapulmonary Manifestations of Fungal Infections Misdiagnosed as Tuberculosis: The Need for Prompt Diagnosis and Management. J Fungi (Basel) 2022; 8:jof8050460. [PMID: 35628715 PMCID: PMC9143176 DOI: 10.3390/jof8050460] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 01/15/2023] Open
Abstract
Fungal infections commonly present with myriad symptoms that mimic other clinical entities, notable amongst which is tuberculosis. Besides histoplasmosis and chronic pulmonary aspergillosis, which can mimic TB, this review has identified several other fungal infections which also do. A total of 80 individual cases misdiagnosed as TB are highlighted: aspergillosis (n = 18, 22.5%), histoplasmosis (n = 16, 20%), blastomycosis (n = 14, 17.5%), cryptococcosis (n = 11, 13.8%), talaromycosis (n = 7, 8.8%), coccidioidomycosis (n = 5, 6.3%), mucormycosis (n = 4, 5%), sporotrichosis (n = 3, 3.8%), phaeohyphomycosis (n = 1, 1.3%) and chromoblastomycosis (n = 1, 1.3%). Case series from India and Pakistan reported over 100 cases of chronic and allergic bronchopulmonary aspergillosis had received anti-TB therapy before the correct diagnosis was made. Forty-five cases (56.3%) had favorable outcomes, and 25 (33.8%) died, outcome was unclear in the remainder. Seventeen (21.3%) cases were infected with human immunodeficiency virus (HIV). Diagnostic modalities were histopathology (n = 46, 57.5%), culture (n = 42, 52.5%), serology (n = 18, 22.5%), cytology (n = 2, 2.5%), gene sequencing (n = 5, 6.3%) and microscopy (n = 10, 12.5%) including Gram stain, India ink preparation, bone marrow smear and KOH mount. We conclude that the above fungal infections should always be considered or ruled out whenever a patient presents with symptoms suggestive of tuberculosis which is unconfirmed thereby reducing prolonged hospital stay and mortalities associated with a delayed or incorrect diagnosis of fungal infections.
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10
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Namusobya M, Bongomin F, Mukisa J, Olwit WK, Batte C, Mukashyaka C, Mande E, Kwizera R, Denning DW, Rhein J, Prasad S, Sekaggya-Wiltshire C. Chronic pulmonary aspergillosis in patients with active pulmonary tuberculosis with persisting symptoms in Uganda. Mycoses 2022; 65:625-634. [PMID: 35419885 PMCID: PMC9156563 DOI: 10.1111/myc.13444] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 03/31/2022] [Accepted: 04/07/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND The occurrence of chronic pulmonary aspergillosis (CPA) among drug sensitive pulmonary tuberculosis (PTB) patients on optimal therapy with persistent symptoms was investigated. METHODS We consecutively enrolled participants with PTB with persistent pulmonary symptoms after 2 months of anti-TB treatment at Mulago Hospital, Kampala, Uganda between July 2020, and June 2021. CPA was defined as a positive Aspergillus-specific IgG/IgM immunochromatographic test (ICT), a cavity with or without a fungal ball on chest x-ray (CXR), and compatible symptoms >3 months. RESULTS We enrolled 162 participants (median age 30 years; IQR: 25 - 40), 97 (59.9%) were male, 48 (29.6%) were HIV-infected, and 15 (9.3%) had prior PTB. Thirty-eight (23.4%) sputum samples grew A. niger and 13 (8.0%) A. fumigatus species complexes. Six (3.7%) participants had intra-cavitary fungal balls, and 52 (32.1%) had cavities. Overall, 32 (19.8%) participants had CPA. CPA was associated with prior PTB (adjusted odds ratio (aOR): 6.61, 95% CI: 1.85 - 23.9, p=0.004), and far advanced CXR changes (aOR: 4.26, 95%CI: 1.72 - 10.52, p=0.002). The Aspergillus IgG/IgM ICT was positive in 10 (31.3%) participants with CPA. CONCLUSIONS CPA may cause persistent respiratory symptoms in up to one-fifth of patients after intensive treatment for PTB. The Aspergillus IgG/IgM ICT positivity rate was very low and may not be used alone for the diagnosis of CPA in Uganda.
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Affiliation(s)
- Martha Namusobya
- Makerere Lung Institute, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Felix Bongomin
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
| | - John Mukisa
- Department of Immunology and Molecular Biology, School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - William Kane Olwit
- Department of Radiology, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Charles Batte
- Makerere Lung Institute, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Claudine Mukashyaka
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Emmanuel Mande
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Richard Kwizera
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - David W Denning
- Manchester Fungal Infection Group, University of Manchester, Manchester, United Kingdom
| | - Joshua Rhein
- Centre for Global Health and Social Responsibility, University of Minnesota, Minneapolis, Minnesota, USA
| | - Shailendra Prasad
- Centre for Global Health and Social Responsibility, University of Minnesota, Minneapolis, Minnesota, USA
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Zarif A, Thomas A, Vayro A. Chronic Pulmonary Aspergillosis: A Brief Review. THE YALE JOURNAL OF BIOLOGY AND MEDICINE 2021; 94:673-679. [PMID: 34970105 PMCID: PMC8686779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Chronic Pulmonary Aspergillosis (CPA) is a destructive pulmonary disease caused by a fungal infection, affecting mainly individuals with prior or concurrent pulmonary conditions. It has a global prevalence of 42 per 100,000 population, but in the US and Europe, prevalence is less than 1 per 100,000. The clinical definition of CPA is based on various factors accounting for comorbidities, clinical presentation, and duration. It may be categorized into five subtypes that the disease may evolve between over time. Based on global consensus covering the spectrum of low-resource to high-resource settings, diagnosis is a multi-factorial process that involves a combination of clinical presentation persisting over 3 months, radiological findings, positive culture growth, and serological tests. CPA remains underdiagnosed due to a lack of awareness and is often misdiagnosed due to the comorbidities present. Treatment options are limited due to a lack of research. Furthermore, associated comorbidities and drug interactions further complicate treatment plans. Follow-up throughout treatment should be based on understanding the predictors of mortality. Identification of potential relapse or resistance to antifungal therapy is crucial to limit the low long-term survival rate. Awareness surrounding this devastating disease needs to be raised further to enable earlier identification, improve understanding of patient factors associated with prognosis, and the future potential for targeted therapies. This review aims to raise awareness of this rare condition among practitioners, by providing an overview of common risk factors influencing the prevalence and incidence of the disease. We further discuss current approaches and recent advancements in CPA diagnosis and treatment.
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Affiliation(s)
- Azmaeen Zarif
- Cambridge Judge Business School, University of
Cambridge, Cambridge, UK
- School of Biological Sciences, University of Cambridge,
Cambridge, UK
- Gonville & Caius College, University of Cambridge,
Cambridge, UK
| | - Adith Thomas
- Cambridge Judge Business School, University of
Cambridge, Cambridge, UK
- School of Biological Sciences, University of Cambridge,
Cambridge, UK
- Queens’ College, University of Cambridge, Cambridge,
UK
| | - Alex Vayro
- Cambridge Judge Business School, University of
Cambridge, Cambridge, UK
- School of Biological Sciences, University of Cambridge,
Cambridge, UK
- Emmanuel College, University of Cambridge, Cambridge,
UK
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12
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Olum R, Osaigbovo II, Baluku JB, Stemler J, Kwizera R, Bongomin F. Mapping of Chronic Pulmonary Aspergillosis in Africa. J Fungi (Basel) 2021; 7:jof7100790. [PMID: 34682212 PMCID: PMC8541146 DOI: 10.3390/jof7100790] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 09/17/2021] [Accepted: 09/21/2021] [Indexed: 01/09/2023] Open
Abstract
Africa has a high burden of tuberculosis, which is the most important risk factor for chronic pulmonary aspergillosis (CPA). Our goal was to systematically evaluate the burden of CPA in Africa and map it by country. We conducted an extensive literature search for publications on CPA in Africa using the online databases. We reviewed a total of 41 studies published between 1976 and 2021, including a total of 1247 CPA cases from 14 African countries. Most of the cases came from Morocco (n = 764, 62.3%), followed by South Africa (n = 122, 9.9%) and Senegal (n = 99, 8.1%). Seventeen (41.5%) studies were retrospective, 12 (29.3%) were case reports, 5 case series (12.2%), 5 prospective cohorts, and 2 cross-sectional studies. The majority of the cases (67.1%, n = 645) were diagnosed in men, with a median age of 41 years (interquartile range: 36–45). Active/previously treated pulmonary tuberculosis (n = 764, 61.3%), human immunodeficiency virus infection (n = 29, 2.3%), diabetes mellitus (n = 19, 1.5%), and chronic obstructive pulmonary disease (n = 10, 0.8%) were the common co-morbidities. Haemoptysis was the most frequent presenting symptom, reported in up to 717 (57%) cases. Smoking (n = 69, 5.5%), recurrent lung infections (n = 41, 3%) and bronchorrhea (n = 33, 3%) were noted. This study confirms that CPA is common in Africa, with pulmonary tuberculosis being the most important risk factor.
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Affiliation(s)
- Ronald Olum
- School of Medicine, College of Health Sciences, Makerere University, Kampala P.O. Box 7072, Uganda;
| | - Iriagbonse Iyabo Osaigbovo
- Department of Medical Microbiology, School of Medicine, College of Medical Sciences, University of Benin, Benin City PMB 1154, Nigeria;
| | - Joseph Baruch Baluku
- Division of Pulmonology, Mulago National Referral Hospital, Kampala P.O Box 7272, Uganda;
- Makerere University Lung Institute, Kampala P.O. Box 7749, Uganda
| | - Jannik Stemler
- Excellence Center for Medical Mycology (ECMM), Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50973 Cologne, Germany;
- Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Faculty of Medicine and University Hospital Cologne, University of Cologne, Herderstr. 52, 50931 Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Herderstr. 52, 50931 Cologne, Germany
| | - Richard Kwizera
- Translational Research Laboratory, Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala P.O. Box 22418, Uganda;
| | - Felix Bongomin
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu P.O. Box 166, Uganda
- Correspondence:
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13
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Bongomin F, Olum R, Kwizera R, Baluku JB. Surgical management of chronic pulmonary aspergillosis in Africa: A systematic review of 891 cases. Mycoses 2021; 64:1151-1158. [PMID: 34363630 DOI: 10.1111/myc.13359] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 08/03/2021] [Accepted: 08/05/2021] [Indexed: 12/29/2022]
Abstract
Chronic pulmonary aspergillosis (CPA) is an emerging fungal infectious disease of public health importance. We conducted a systematic review of studies reporting the outcomes of patients with CPA managed surgically in Africa. A search of Medline, Embase, Web of Science, Google Scholar and African Journals Online was conducted to identify studies indexed from inception to June 2021 that examined surgical management of CPA in Africa. All articles that presented primary data, including case reports and case series, were included. We excluded review articles. A total of 891 cases (557 males (62.5%), mean age 39.3 years) extracted from 27 eligible studies published between 1976 and 2020 from 11 African countries were included. Morocco (524, 59%) and Senegal (99, 11%) contributed the majority of cases. Active or previous pulmonary tuberculosis was reported in 677 (76.0%) cases. Haemoptysis was reported in 682 (76.5%) cases. Lobectomy (either unilateral or bilateral, n = 493, 55.3%), pneumonectomy (n = 154, 17.3%) and segmentectomy (n = 117, 13.1%) were the most frequently performed surgical procedures. Thirty (4.9%) cases from South Africa received bronchial artery embolisation. Empyema (n = 59, 27.4%), significant haemorrhage (n = 38, 173.7%), incomplete lung expansion (n = 26, 12.1%) and prolonged air leak (n = 24, 11.2%) were the most frequent complications. Overall, 45 (5.1%) patients died. The causes of death included respiratory failure (n = 14), bacterial superinfection/sepsis (n = 10), severe haemorrhage (n = 5), cardiopulmonary arrest (n = 3) and complications of chronic obstructive pulmonary disease (n = 3). The cause of death was either unknown or unspecified in 9 cases. We conclude that surgical treatment had very low mortality rates and maybe considered as first-line management option in centres with experience and expertise in Africa.
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Affiliation(s)
- Felix Bongomin
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
| | - Ronald Olum
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Richard Kwizera
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Joseph Baruch Baluku
- Division of Pulmonology, Kiruddu National Referral Hospital, Kampala, Uganda.,Makerere Lung Institute, Kampala, Uganda
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