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Lamoth F, Prakash K, Beigelman-Aubry C, Baddley JW. Lung and sinus fungal infection imaging in immunocompromised patients. Clin Microbiol Infect 2024; 30:296-305. [PMID: 37604274 DOI: 10.1016/j.cmi.2023.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 08/06/2023] [Accepted: 08/13/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Imaging is a key diagnostic modality for suspected invasive pulmonary or sinus fungal disease and may help to direct testing and treatment. Fungal diagnostic guidelines have been developed and emphasize the role of imaging in this setting. We review and summarize evidence regarding imaging for fungal pulmonary and sinus disease (in particular invasive aspergillosis, mucormycosis and pneumocystosis) in immunocompromised patients. OBJECTIVES We reviewed data on imaging modalities and findings used for diagnosis of invasive fungal pulmonary and sinus disease. SOURCES References for this review were identified by searches of PubMed, Google Scholar, Embase and Web of Science through 1 April 1 2023. CONTENT Computed tomography imaging is the method of choice for the evaluation of suspected lung or sinus fungal disease. Although no computed tomography radiologic pattern is pathognomonic of pulmonary invasive fungal disease (IFD) the halo sign firstly suggests an angio-invasive pulmonary aspergillosis while the Reversed Halo Sign is more suggestive of pulmonary mucormycosis in an appropriate clinical setting. The air crescent sign is uncommon, occurring in the later stages of invasive aspergillosis in neutropenic patients. In contrast, new cavitary lesions should suggest IFD in moderately immunocompromised patients. Regarding sinus site, bony erosion, peri-antral fat or septal ulceration are reasonably predictive of IFD. IMPLICATIONS Imaging assessment of the lung and sinuses is an important component of the diagnostic work-up and management of IFD in immunocompromised patients. However, radiological features signs have sensitivity and specificity that often vary according to underlying disease states. Periodic review of imaging studies and diagnostic guidelines characterizing imaging findings may help clinicians to consider fungal infections in clinical care thereby leading to an earlier confirmation and treatment of IFD.
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Affiliation(s)
- Frederic Lamoth
- Service of Infectious Diseases, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; Institute of Microbiology, Department of Laboratory Medicine and Microbiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Katya Prakash
- Division of Infectious Diseases, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Catherine Beigelman-Aubry
- Radiodiagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - John W Baddley
- Division of Infectious Diseases, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA.
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2
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Heylen J, Vanbiervliet Y, Maertens J, Rijnders B, Wauters J. Acute Invasive Pulmonary Aspergillosis: Clinical Presentation and Treatment. Semin Respir Crit Care Med 2024; 45:69-87. [PMID: 38211628 DOI: 10.1055/s-0043-1777769] [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: 01/13/2024]
Abstract
Among all clinical manifestations of pulmonary aspergillosis, invasive pulmonary aspergillosis (IPA) is the most acute presentation. IPA is caused by Aspergillus hyphae invading the pulmonary tissue, causing either tracheobronchitis and/or bronchopneumonia. The degree of fungal invasion into the respiratory tissue can be seen as a spectrum, going from colonization to deep tissue penetration with angio-invasion, and largely depends on the host's immune status. Patients with prolonged, severe neutropenia and patients with graft-versus-host disease are at particularly high risk. However, IPA also occurs in other groups of immunocompromised and nonimmunocompromised patients, like solid organ transplant recipients or critically ill patients with severe viral disease. While a diagnosis of proven IPA is challenging and often warranted by safety and feasibility, physicians must rely on a combination of clinical, radiological, and mycological features to assess the likelihood for the presence of IPA. Triazoles are the first-choice regimen, and the choice of the drug should be made on an individual basis. Adjunctive therapy such as immunomodulatory treatment should also be taken into account. Despite an improving and evolving diagnostic and therapeutic armamentarium, the burden and mortality of IPA still remains high. This review aims to give a comprehensive and didactic overview of the current knowledge and best practices regarding the epidemiology, clinical presentation, diagnosis, and treatment of acute IPA.
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Affiliation(s)
- Jannes Heylen
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Yuri Vanbiervliet
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Haematology, University Hospitals Leuven, Leuven, Belgium
| | - Johan Maertens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Haematology, University Hospitals Leuven, Leuven, Belgium
| | - Bart Rijnders
- Department of Internal Medicine and Infectious Diseases, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Joost Wauters
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
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3
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Ankrah AO, Lawal IO, Dierckx RAJO, Sathekge MM, Glaudemans AWJM. Imaging of Invasive Fungal Infections- The Role of PET/CT. Semin Nucl Med 2023; 53:57-69. [PMID: 35933165 DOI: 10.1053/j.semnuclmed.2022.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/06/2022] [Accepted: 07/07/2022] [Indexed: 01/28/2023]
Abstract
Over the last decades, the population at risk for invasive fungal disease (IFD) has increased because of medical therapy advances and diseases compromising patients' immune systems. The high morbidity and mortality associated with invasive fungal disease in the immunocompromised present the challenge of early diagnosis of the IFD and the need to closely monitor the infection during treatment. The definitive diagnosis of invasive fungal disease based on culture or histopathological methods often has reduced diagnostic accuracy in the immunocompromised and may be very invasive. Less invasive and indirect evidence of the fungal infection by serology and imaging has been used for the early diagnosis of fungal infection before definitive results are available or when the definitive methods of diagnosis are suboptimal. Imaging in invasive fungal disease is a non-invasive biomarker that helps in the early diagnosis of invasive fungal disease but helps follow-up the infection during treatment. Different imaging modalities are used in the workup to evaluate fungal disease. The different imaging modalities have advantages and disadvantages at different sites in the body and may complement each other in the management of IFD. Positron emission tomography integrated with computed tomography with [18F]Fluorodeoxyglucose (FDG PET/CT) has helped manage IFD. The combined functional data from PET and anatomical data from the CT from almost the whole body allows noninvasive evaluation of IFD and provides a semiquantitative means of assessing therapy. FDG PET/CT adds value to anatomic-based only imaging modalities. The nonspecificity of FDG uptake has led to the evaluation of other tracers in the assessment of IFD. However, these are mainly still at the preclinical level and are yet to be translated to humans. FDG PET/CT remains the most widely evaluated radionuclide-based imaging modality in IFD management. The limitations of FDG PET/CT must be well understood, and more extensive prospective studies in uniform populations are needed to validate its role in the management of IFD that can be international guidelines.
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Affiliation(s)
- Alfred O Ankrah
- National Centre for Radiotherapy Oncology and Nuclear Medicine, Korle Bu Teaching Hospital, Accra GA, Ghana; Department of Nuclear Medicine, University of Pretoria, Steve Biko Academic Hospital, Pretoria, South Africa; Medical Imaging Center, University Medical Center Groningen, University of Groningen, RB Groningen, The Netherlands.
| | - Ismaheel O Lawal
- Department of Nuclear Medicine, University of Pretoria, Steve Biko Academic Hospital, Pretoria, South Africa; Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA
| | - Rudi A J O Dierckx
- Medical Imaging Center, University Medical Center Groningen, University of Groningen, RB Groningen, The Netherlands
| | - Mike M Sathekge
- Department of Nuclear Medicine, University of Pretoria, Steve Biko Academic Hospital, Pretoria, South Africa
| | - Andor W J M Glaudemans
- Medical Imaging Center, University Medical Center Groningen, University of Groningen, RB Groningen, The Netherlands
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4
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Enger K, Tonnar X, Kotter E, Bertz H. Sequential low-dose CT thorax scans to determine invasive pulmonary fungal infection incidence after allogeneic hematopoietic cell transplantation. Ann Hematol 2023; 102:413-420. [PMID: 36460795 PMCID: PMC9889523 DOI: 10.1007/s00277-022-05062-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 11/18/2022] [Indexed: 12/05/2022]
Abstract
Invasive fungal disease (IFD) during neutropenia goes along with a high mortality for patients after allogeneic hematopoietic cell transplantation (alloHCT). Low-dose computed tomography (CT) thorax shows good sensitivity for the diagnosis of IFD with low radiation exposure. The aim of our study was to evaluate sequential CT thorax scans at two time points as a new reliable method to detect IFD during neutropenia after alloHCT. We performed a retrospective single-center observational study in 265/354 screened patients admitted for alloHCT from June 2015 to August 2019. All were examined by a low-dose CT thorax scan at admission (CT t0) and after stable neutrophil recovery (CT t1) to determine the incidences of IFD. Furthermore, antifungal prophylaxis medications were recorded and cohorts were analyzed for statistical differences in IFD incidence using the sequential CT scans. In addition, IFD cases were classified according to EORTC 2008. At CT t0 in 9.6% of the patients, an IFD was detected and antifungal therapy initiated. The cumulative incidence of IFD in CT t1 in our department was 14%. The use of Aspergillus-effective prophylaxis through voriconazole or posaconazole decreased CT thorax t1 suggesting IFD is statistically significant compared to prophylaxis with fluconazole (5.6% asp-azol group vs 16.3% fluconazole group, p = 0.048). In 86%, CT t1 was negative for IFD. Low-dose sequential CT thorax scans are a valuable tool to detect pulmonary IFDs and guide antifungal prophylaxis and therapies. Furthermore, a negative CT t1 scan shows a benefit by allowing discontinuation of antifungal medication sparing patients from drug interactions and side effects.
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Affiliation(s)
- K. Enger
- Department of Hematology, Oncology and Stem Cell Transplantation, Faculty of Medicine, Freiburg University Medical Center, Freiburg, Germany
| | - X. Tonnar
- Department of Hematology, Oncology and Stem Cell Transplantation, Faculty of Medicine, Freiburg University Medical Center, Freiburg, Germany
| | - E. Kotter
- Department of Diagnostic and Interventional Radiology, Freiburg University Medical Center, Freiburg, Germany
| | - H. Bertz
- Department of Hematology, Oncology and Stem Cell Transplantation, Faculty of Medicine, Freiburg University Medical Center, Freiburg, Germany
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5
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Shroff GS, Wu CC, Ocazionez D, Carter BW, Shivaprasad A, Chai T, Supsupin EP, Truong MT, Shroff S. It's Not All in Your Head: Thoracic Manifestations of Neurologic Diseases and Disorders. Acad Radiol 2022; 29:736-747. [PMID: 32622741 PMCID: PMC7329291 DOI: 10.1016/j.acra.2020.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/11/2020] [Accepted: 06/12/2020] [Indexed: 12/15/2022]
Abstract
Myriad conditions may affect both the neurologic system and the thorax, while other diseases primarily affecting the thorax may manifest with neurologic abnormalities. Correlation of signs, symptoms, and imaging findings in the neurological system with those in the thorax can help diagnose certain conditions and/or guide further diagnostic work-up and treatment. We will review and illustrate the imaging appearance of several systemic/neurological diseases with thoracic manifestations as well as discuss conditions in the thorax that can lead to neurologic symptoms.
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Affiliation(s)
- Girish S Shroff
- MD Anderson Cancer Center, 1515 Holcombe Blvd. Unit 1478, Houston, TX.
| | - Carol C Wu
- MD Anderson Cancer Center, 1515 Holcombe Blvd. Unit 1478, Houston, TX
| | | | - Brett W Carter
- MD Anderson Cancer Center, 1515 Holcombe Blvd. Unit 1478, Houston, TX
| | | | - Thomas Chai
- MD Anderson Cancer Center, 1515 Holcombe Blvd. Unit 1478, Houston, TX
| | | | - Mylene T Truong
- MD Anderson Cancer Center, 1515 Holcombe Blvd. Unit 1478, Houston, TX
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6
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Kunihiro Y, Tanaka N, Kawano R, Yujiri T, Ueda K, Gondo T, Kobayashi T, Matsumoto T, Ito K. High-resolution CT findings of pulmonary infections in patients with hematologic malignancy: comparison between patients with or without hematopoietic stem cell transplantation. Jpn J Radiol 2022; 40:791-799. [PMID: 35284995 PMCID: PMC9345826 DOI: 10.1007/s11604-022-01260-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 02/24/2022] [Indexed: 12/27/2022]
Abstract
Abstract
Purpose
To evaluate the high-resolution CT (HRCT) findings of pulmonary infections in patients with hematologic malignancy and compare them between patients with or without hematopoietic stem cell transplantation (HSCT).
Materials and methods
A total of 128 patients with hematologic malignancy and pulmonary infection were included in this study. The diagnoses of the patients consisted of bacterial pneumonia (37 non-HSCT cases and 14 HSCT cases), pneumocystis pneumonia (PCP) (29 non-HSCT cases and 11 HSCT cases), and fungal infection other than PCP (20 non-HSCT cases and 17 HSCT cases). Two chest radiologists retrospectively evaluated the HRCT criteria and compared them using chi-squared tests and a multiple logistic regression analysis.
Results
According to the multiple logistic regression analysis, nodules were an indicator in HSCT patients with PCP (p = 0.025; odds ratio, 5.8; 95% confidence interval, 1.2–26.6). The centrilobular distribution of nodules was the most frequent (n = 4, 36%) in HSCT patients with PCP. A mosaic pattern was an indicator of PCP in both HSCT and non-HSCT patients. There were no significant differences in other infections.
Conclusion
The mosaic pattern could be an indicator of PCP in both HSCT and non-HSCT patients. Nodules with centrilobular distribution might be relatively frequent HRCT findings of PCP in HSCT patients.
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Affiliation(s)
- Yoshie Kunihiro
- Department of Radiology, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi, 755-8505, Japan.
| | - Nobuyuki Tanaka
- Department of Radiology, National Hospital Organization Yamaguchi-Ube Medical Center, 685 Higashikiwa, Ube, Yamaguchi, 755-0241, Japan
| | - Reo Kawano
- Center for Integrated Medical Research, Hiroshima University Hospital, Kasumi 1-2-3 Minami-ku, Hiroshima, Hiroshima, 734-8551, Japan
| | - Toshiaki Yujiri
- Division of Endocrinology, Metabolism, Hematological Science and Therapeutics, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi, 755-8505, Japan
| | - Kazuhiro Ueda
- Department of General Thoracic Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1, Sakuragaoka, Kagoshima, Kagoshima, 890-8520, Japan
| | - Toshikazu Gondo
- Division of Pathology, Fujisawa City Hospital, 2-6-1 Fujisawa, Fujisawa, Kanagawa, 251-8550, Japan
| | - Taiga Kobayashi
- Department of Radiology, National Hospital Organization Yamaguchi-Ube Medical Center, 685 Higashikiwa, Ube, Yamaguchi, 755-0241, Japan
| | - Tsuneo Matsumoto
- Department of Radiology, National Hospital Organization Yamaguchi-Ube Medical Center, 685 Higashikiwa, Ube, Yamaguchi, 755-0241, Japan
| | - Katsuyoshi Ito
- Department of Radiology, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi, 755-8505, Japan
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7
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Douglas AP, Smibert OC, Bajel A, Halliday CL, Lavee O, McMullan B, Yong MK, Hal SJ, Chen SC. Consensus guidelines for the diagnosis and management of invasive aspergillosis, 2021. Intern Med J 2021; 51 Suppl 7:143-176. [DOI: 10.1111/imj.15591] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Abby P. Douglas
- Department of Infectious Diseases Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Sir Peter MacCallum Department of Oncology University of Melbourne Melbourne Victoria Australia
- National Centre for Infections in Cancer Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Department of Infectious Diseases Austin Health Melbourne Victoria Australia
| | - Olivia. C. Smibert
- Department of Infectious Diseases Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Sir Peter MacCallum Department of Oncology University of Melbourne Melbourne Victoria Australia
- National Centre for Infections in Cancer Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Department of Infectious Diseases Austin Health Melbourne Victoria Australia
| | - Ashish Bajel
- Sir Peter MacCallum Department of Oncology University of Melbourne Melbourne Victoria Australia
- Department of Clinical Haematology Peter MacCallum Cancer Centre and The Royal Melbourne Hospital Melbourne Victoria Australia
| | - Catriona L. Halliday
- Centre for Infectious Diseases and Microbiology Laboratory Services Institute of Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead Hospital Sydney New South Wales Australia
- Marie Bashir Institute for Infectious Diseases and Biosecurity The University of Sydney Sydney New South Wales Australia
| | - Orly Lavee
- Department of Haematology St Vincent's Hospital Sydney New South Wales Australia
| | - Brendan McMullan
- National Centre for Infections in Cancer Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Department of Immunology and Infectious Diseases Sydney Children's Hospital Sydney New South Wales Australia
- School of Women's and Children's Health University of New South Wales Sydney New South Wales Australia
| | - Michelle K. Yong
- Department of Infectious Diseases Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Sir Peter MacCallum Department of Oncology University of Melbourne Melbourne Victoria Australia
- National Centre for Infections in Cancer Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Victorian Infectious Diseases Service Royal Melbourne Hospital Melbourne Victoria Australia
| | - Sebastiaan J. Hal
- Sydney Medical School University of Sydney Sydney New South Wales Australia
- Department of Microbiology and Infectious Diseases Royal Prince Alfred Hospital Sydney New South Wales Australia
| | - Sharon C.‐A. Chen
- Centre for Infectious Diseases and Microbiology Laboratory Services Institute of Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead Hospital Sydney New South Wales Australia
- Marie Bashir Institute for Infectious Diseases and Biosecurity The University of Sydney Sydney New South Wales Australia
- Sydney Medical School University of Sydney Sydney New South Wales Australia
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8
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Hałaburda-Rola M, Dzieciątkowski T, Górka M, Rowiński O, Grabowska-Derlatka L. Clinical utility of the updated European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and the Mycoses Study Group Education and Research Consortium computed tomography criteria of invasive pulmonary aspergillosis in hematological malignancies. ACTA ACUST UNITED AC 2021; 26:398-407. [PMID: 34057050 DOI: 10.1080/16078454.2021.1931739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Invasive pulmonary aspergillosis is a life-threatening complication in the cases of patients with hematologic malignancies. In December 2019, the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and the Mycoses Study Group Education and Research Consortium published a revision and an update of the consensus definitions of invasive fungal disease. The aim of this study was to evaluate the signs and radiologic patterns of early-stage invasive pulmonary aspergillosis in computed tomography in patients with hematologic entities according to the latest criteria. This retrospective analysis of a baseline high-resolution computed tomography included neutropenic patients with hematological malignancies and probable invasive pulmonary aspergillosis. The data were collected between the years 2017 and 2019. Computed tomography was performed within 72 h from the beginning of clinical symptoms: fever, dyspnea or nonproductive cough. CT scans were analyzed by two independent radiologists according to the standardized protocol based on predefined criteria. All 35 evaluated patients had typical lesions for early-stage invasive aspergillosis. Wedge-shaped infiltrates were noted in 48.6% of patients. In this group, 40% of patients had coexisting atypical radiological findings. In 11.4% of patients, wedge-shape consolidations were noted as the only type of lesions. Employment of the latest EORTC/MSG criteria increased diagnostic value of the baseline high resolution computed tomography in our study group by 11.4%.
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Affiliation(s)
| | - Tomasz Dzieciątkowski
- Chair and Department of Medical Microbiology, Medical University of Warsaw, Warsaw, Poland.,Department of Microbiology, Central Clinical Hospital in Warsaw, Warsaw, Poland
| | - Michał Górka
- Department of Hematology, Oncology and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Olgierd Rowiński
- 2nd Department of Radiology, Medical University of Warsaw, Warsaw, Poland
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9
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Fernández-Cruz A, Lewis RE, Kontoyiannis DP. How Long Do We Need to Treat an Invasive Mold Disease in Hematology Patients? Factors Influencing Duration of Therapy and Future Questions. Clin Infect Dis 2021; 71:685-692. [PMID: 32170948 DOI: 10.1093/cid/ciz1195] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 03/11/2019] [Indexed: 12/18/2022] Open
Abstract
Treatment duration for invasive mold disease (IMD) in patients with hematological malignancy is not standardized and is a challenging subject in antifungal stewardship. Concerns for IMD relapse during subsequent reinduction or consolidation chemotherapy or graft versus host disease treatment in hematopoietic stem cell transplant recipients often results in prolonged or indefinite antifungal treatment. There are no validated criteria that predict when it is safe to stop antifungals. Decisions are individualized and depend on the offending fungus, site and extent of IMD, comorbidities, hematologic disease prognosis, and future plans for chemotherapy or transplantation. Recent studies suggest that FDG-PET/CT could help discriminate between active and residual fungal lesions to support decisions for safely stopping antifungals. Validation of noninvasive biomarkers for monitoring treatment response, tests for quantifying the "net state of immunosuppression," and genetic polymorphisms associated with poor fungal immunity could lead to a personalized assessment for the continued need for antifungal therapy.
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Affiliation(s)
- Ana Fernández-Cruz
- Infectious Diseases Unit, Internal Medicine Department, Hospital Universitario Puerta de Hierro-Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Madrid, Spain
| | - Russell E Lewis
- Clinic of Infectious Diseases, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases, Infection Control and Employee Health, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
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10
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Alexander BD, Lamoth F, Heussel CP, Prokop CS, Desai SR, Morrissey CO, Baddley JW. Guidance on Imaging for Invasive Pulmonary Aspergillosis and Mucormycosis: From the Imaging Working Group for the Revision and Update of the Consensus Definitions of Fungal Disease from the EORTC/MSGERC. Clin Infect Dis 2021; 72:S79-S88. [PMID: 33709131 DOI: 10.1093/cid/ciaa1855] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Clinical imaging in suspected invasive fungal disease (IFD) has a significant role in early detection of disease and helps direct further testing and treatment. Revised definitions of IFD from the EORTC/MSGERC were recently published and provide clarity on the role of imaging for the definition of IFD. Here, we provide evidence to support these revised diagnostic guidelines. METHODS We reviewed data on imaging modalities and techniques used to characterize IFDs. RESULTS Volumetric high-resolution computed tomography (CT) is the method of choice for lung imaging. Although no CT radiologic pattern is pathognomonic of IFD, the halo sign, in the appropriate clinical setting, is highly suggestive of invasive pulmonary aspergillosis (IPA) and associated with specific stages of the disease. The ACS is not specific for IFD and occurs in the later stages of infection. By contrast, the reversed halo sign and the hypodense sign are typical of pulmonary mucormycosis but occur less frequently. In noncancer populations, both invasive pulmonary aspergillosis and mucormycosis are associated with "atypical" nonnodular presentations, including consolidation and ground-glass opacities. CONCLUSIONS A uniform definition of IFD could improve the quality of clinical studies and aid in differentiating IFD from other pathology in clinical practice. Radiologic assessment of the lung is an important component of the diagnostic work-up and management of IFD. Periodic review of imaging studies that characterize findings in patients with IFD will inform future diagnostic guidelines.
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Affiliation(s)
- Barbara D Alexander
- Department of Medicine, Division of Infectious Diseases, Duke University, Durham, North Carolina, USA
| | - Frédéric Lamoth
- Service of Infectious Diseases, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Institute of Microbiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Claus Peter Heussel
- Department of Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik gGmbH, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg, Member of the German Centre for Lung Research.,Diagnostic and Interventional Radiology, Ruprecht-Karls-University, Heidelberg, Germany
| | | | - Sujal R Desai
- Department of Radiology, Royal Brompton and Harefield National Health Service Foundation Trust, London and National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - C Orla Morrissey
- Department of Infectious Diseases, Alfred Health and Monash University, Melbourne, Australia
| | - John W Baddley
- Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, Maryland, USA
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11
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Suwatanapongched T, Visoottiviseth Y, Watcharananan SP, Kanoksil W, Muntham D, Pornsuriyasak P. Clinical characteristics and CT manifestations of invasive pulmonary aspergillosis in hospitalised patients with systemic lupus erythematosus. Clin Radiol 2021; 76:548.e13-548.e23. [PMID: 33610288 DOI: 10.1016/j.crad.2021.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 01/13/2021] [Indexed: 11/17/2022]
Abstract
AIM To investigate clinical and computed tomography (CT) findings of invasive pulmonary aspergillosis (IPA) in patients with systemic lupus erythematosus (SLE) and to explore the relationships of CT findings with clinical characteristics and outcomes. MATERIALS AND METHODS Clinical and CT findings of 14 SLE patients with proven (n=4) and probable (n=10) IPA between January 2006 and April 2013 were reviewed retrospectively and related to patients' outcomes. RESULTS All patients (mean age, 42.3 ± 15.1 years; 11 women, three men) had active SLE, prior corticosteroid, and/or immunosuppressive therapy. Dominant CT findings performed within 10 days of the clinical onset consisted of nodules/masses (100%, 14/14), consolidations (92.9%, 13/14), and ground-glass opacity (85.7%, 12/14). Bilateral, multilobar, and upper-lobe involvement was common. Regardless of dominant patterns, the halo, reversed halo, air-crescent, hypodense, and feeding vessel signs were found in 12 (85.7%), one (7.1%), three (21.3%), seven (50%), and seven (50%) patients, respectively. There was no significant difference in CT findings between the IPA alone (n=5) and co-infection (n=9) groups and between survived (n=4) and non-survived (n=10) patients. The IPA-alone group more frequently had alcohol consumption (p=0.018), haemoptysis (p=0.023), and disseminated aspergillosis (p=0.027) than did the co-infection group. Non-survived patients tended to be older and have a history of recent hospitalisation. CONCLUSIONS IPA is a rare, life-threatening disease affecting SLE patients in the early course of disease with high disease activity requiring corticosteroid and/or immunosuppressive therapy. Dominant CT findings are characteristics of angio-invasive form with a high frequency of the halo sign and bilateral, multilobar, and upper-lobe involvement.
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Affiliation(s)
- T Suwatanapongched
- Division of Diagnostic Radiology, Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
| | - Y Visoottiviseth
- Division of Diagnostic Radiology, Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - S P Watcharananan
- Division of Infectious Disease, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - W Kanoksil
- Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - D Muntham
- Section for Mathematics, Faculty of Science and Technology, Rajamangala University of Technology, Phranakhon Si Ayutthaya Province, Thailand
| | - P Pornsuriyasak
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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12
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Zhang H, Zhu A. Emerging Invasive Fungal Infections: Clinical Features and Controversies in Diagnosis and Treatment Processes. Infect Drug Resist 2020; 13:607-615. [PMID: 32110071 PMCID: PMC7039084 DOI: 10.2147/idr.s237815] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 01/30/2020] [Indexed: 12/15/2022] Open
Abstract
Background The diagnosis and treatment of invasive fungal infection (IFI) are still challenging due to its complexity and non-specificity. This study was aimed to investigate the clinical features, diagnosis process, and outcomes of patients with emerging IFIs. Methods A retrospective review of emerging IFIs in adult patients at a university hospital in China was conducted; diagnoses were based on the criteria of EORTC/MSG 2008. Results 145 IFI patients (pulmonary, intestinal and urinary) were enrolled in this study, including 80 proven (55.2%), 59 probable (40.7%), or 6 possible IFIs (4.1%). Among the 126 pulmonary IFIs, the positivity rate for sputum microscopy, sputum culture, and 1.3-ß-D-glucan (BG) test was 54.0%, 44.4%, and 37.3%, respectively. Among the 19 intestinal and urinary IFIs, routine examination of stool or urine and their culture were the main methods of detection. Positive results of 75 detected fungal strains from the samples showed that 30 cases were complicated with one or more bacterial infections. The average length of hospital stay of IFI patients was 14.0 (10.0, 20.0) days. The time from admission to antifungal therapy initiation (P<0.001), liver cirrhosis (P<0.001), hematological tumor (P<0.001), coinfection (P=0.019) and immune diseases (P=0.025) were independent predictors of prolonged hospitalization. Conclusion Delayed time was the primary predictor of prolonged hospitalization. This prediction is suggested to improve IFI diagnostic and therapeutic process of IFI to promote prognosis.
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Affiliation(s)
- Hongliang Zhang
- Emergency Department, The Second Xiangya Hospital of Central South University, Changsha, Hunan 410011, People's Republic of China
| | - Aiqun Zhu
- Emergency Department, The Second Xiangya Hospital of Central South University, Changsha, Hunan 410011, People's Republic of China.,Department of Nursing, The Second Xiangya Hospital of Central South University, Changsha, Hunan 410011, People's Republic of China
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13
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CT Halo sign: A systematic review. Eur J Radiol 2020; 124:108843. [PMID: 32007819 DOI: 10.1016/j.ejrad.2020.108843] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 01/12/2020] [Accepted: 01/14/2020] [Indexed: 12/18/2022]
Abstract
PURPOSE The CT Halo sign or Halo sign (HS) refers to ground-glass opacity surrounding a nodule or mass in the lung parenchyma. We conducted a systematic review to find the etiological associations of HS. We also evaluated the diagnostic performances of HS for invasive fungal infections (IFI) in immunosuppressed patients. METHOD The systematic review was conducted as per PRISMA guidelines. We searched the PubMed and EMBASE database till June 2018 without any restrictions. Only case reports, case series and original articles published in English language were included. A database created from the electronic searches was compiled and subsequent analysis was done. [PROSPERO registration: CRD42018094739] RESULTS: 168 studies were eligible, which included 51 case reports, 15 prospective studies, 102 retrospective studies. A total of 1977 patients (out of 6371) with HS were identified with age range between <1year-94years. The most common diagnosis in the immunosuppressed, mixed, immunocompetent and not specified groups were IFI (86.9 %, n = 1194), Cryptococcosis (51.6 %, n = 124), Cryptococcosis (40 %, n = 20) and lung neoplasms (81.8 %, n = 36) respectively. 14 studies (11 retrospective, 3 prospective) were included in quantitative analysis. The pooled sensitivity(sn), specificity(sp) and odd's ratio (OR) of HS for diagnosing IFI were 50.4 %, 91 % and 6.61 respectively. Also, HS could not reliably differentiate IPA from mucormycosis in the pooled analysis. CONCLUSIONS HS can be seen in a large number of diverse conditions both in immunosuppressed and immunocompetent population. In immunosuppressed patients HS is specific for IFI but cannot rule it out. Additionally, it cannot reliably distinguish between IPA and mucormycosis.
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Stanzani M, Sassi C, Battista G, Lewis RE. Beyond biomarkers: How enhanced CT imaging can improve the diagnostic-driven management of invasive mould disease. Med Mycol 2019; 57:S274-S286. [PMID: 31292659 DOI: 10.1093/mmy/myy125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 10/17/2018] [Accepted: 10/30/2018] [Indexed: 12/15/2022] Open
Abstract
CT imaging remains an essential diagnostic test for identification, staging and management of invasive mould infection (IMI) in patients with hematological malignancies. Yet the limited specificity of standard CT imaging can drive excessive antifungal use in patients, especially when more definitive diagnosis cannot be established through microbiology or invasive diagnostic procedures. CT pulmonary angiography (CTPA) is a complimentary, non-invasive approach to standard CT that allows for direct visualization of pulmonary arteries inside infiltrates for signs of angioinvasion, vessel destruction and vessel occlusion. Experience from several centers that are using CTPA as part of a standard diagnostic protocol for IMI suggests that a positive vessel occlusion sign (VOS) is the most sensitive and a specific sign of IMI in both neutropenic and non-neutropenic patients. CTPA is particularly useful in patients who develop suspected breakthrough IMI during antifungal prophylaxis because, unlike serum and/or BAL galactomannan and polymerase chain reaction (PCR) testing, the sensitivity is not reduced by antifungal therapy. A negative VOS may also largely rule-out the presence of IMI, supporting earlier discontinuation of empirical therapy. Future imaging protocols for IMI in patients with hematological malignancies will likely replace standard chest X-rays in favor of early low radiation dose CT exams for screening, with characterization of the lesions by CTPA and routine follow-up using functional/metabolic imaging such as 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (FDG-PET/CT) to assess treatment response. Hence, enhanced CT imaging techniques can improve the diagnostic-driven management of IMI management in high-risk patients with hematological malignancies.
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Affiliation(s)
- Marta Stanzani
- Institute of Hematology, "Lorenzo e Ariosto Seràgnoli" Department of Hematology and Clinical Oncology S'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Claudia Sassi
- Division of Radiology, Department of Experimental and Diagnostic Medicine, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Giuseppe Battista
- Division of Radiology, Department of Experimental and Diagnostic Medicine, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Russell E Lewis
- Clinic of Infectious Diseases, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
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15
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Welte T, Len O, Muñoz P, Romani L, Lewis R, Perrella A. Invasive mould infections in solid organ transplant patients: modifiers and indicators of disease and treatment response. Infection 2019; 47:919-927. [PMID: 31576498 DOI: 10.1007/s15010-019-01360-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 09/18/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE Invasive mould infections, in particular invasive aspergillosis (IA), are comparatively frequent complications of immunosuppression in patients undergoing solid organ transplantation (SOT). Guidelines provide recommendations as to the procedures to be carried out to diagnose and treat IA, but only limited advice for SOT recipients. METHODS Literature review and expert consensus summarising the existing evidence related to prophylaxis, diagnosis, treatment and assessment of response to IA and infections by Mucorales in SOT patients RESULTS: Response to therapy should be assessed early and at regular intervals. No indications of improvement should lead to a prompt change of the antifungal treatment, to account for possible infections by Mucorales or other moulds such as Scedosporium. Imaging techniques, especially CT scan and possibly angiography carried out at regular intervals during early and long-term follow-up and coupled with a careful clinical diagnostic workout, should be evaluated as diagnostic tools and outcome predictors, and standardised to improve therapy monitoring. The role of biomarkers such as the galactomannan test and PCR, as well as selected inflammation parameters, has not yet been definitively assessed in the SOT population and needs to be studied further. The therapeutic workup should consider a reduction of immunosuppressive therapy. CONCLUSIONS The role of immunosuppression and immune tolerance mechanisms in the response to invasive fungal infection treatment is an important factor in the SOT population and should not be underestimated. The choice of the antifungal should consider not only their toxicity but also their effects on the immune system, two features that are intertwined.
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Affiliation(s)
- Tobias Welte
- Department of Respiratory Medicine, Hannover Medical School, Carl Neuberg Str 1, 30625, Hannover, Germany.
| | - Oscar Len
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Patricia Muñoz
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Medicine Department, Universidad Complutense de Madrid, CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain
| | - Luigina Romani
- Department of Experimental Medicine, School of Medicine, University of Perugia, 06132, Perugia, Italy
| | - Russell Lewis
- Infectious Diseases Hospital, S. Orsola-Malpighi, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Alessandro Perrella
- VII, Department of Infectious Disease and Immunology, Hospital D. Cotugno, Naples, Italy
- CLSE-Liver Transplant Unit, Hospital A. Cardarelli, Naples, Italy
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16
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Shroff GS, Marom EM, Godoy MC, Truong MT, Chiles C. CT Signs in the Lungs. Semin Ultrasound CT MR 2019; 40:265-274. [DOI: 10.1053/j.sult.2018.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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17
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Differential diagnosis of pulmonary infections in immunocompromised patients using high-resolution computed tomography. Eur Radiol 2019; 29:6089-6099. [DOI: 10.1007/s00330-019-06235-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 03/28/2019] [Accepted: 04/10/2019] [Indexed: 12/11/2022]
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18
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Heinz WJ, Vehreschild JJ, Buchheidt D. Diagnostic work up to assess early response indicators in invasive pulmonary aspergillosis in adult patients with haematologic malignancies. Mycoses 2019; 62:486-493. [PMID: 30329192 DOI: 10.1111/myc.12860] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 10/03/2018] [Accepted: 10/07/2018] [Indexed: 12/20/2022]
Abstract
In immunocompromised patients with acute leukaemia as well as in allogeneic hematopoietic stem cell transplant patients, pulmonary lesions are commonly seen. Existing guidelines provide useful algorithms for diagnostic procedures and treatment options, but they do not give recommendations on how to evaluate early success or failure and if or when it is best to change therapy. Here, we review the diagnostic techniques currently used in association with clinical findings and propose an approach using a combination of computer tomography, clinical and all available biomarkers and inflammation parameters, especially those positive at baseline, to assess early response in invasive pulmonary aspergillosis. Computed tomography scans should be carried out at regular intervals during early and long-term follow-up. Imaging on day seven, or even earlier in clinically unstable patients, combined with an additional testing of biomarkers and inflammatory markers in between, is needed for a reliable assessment at day 14. If no improvement is seen after 2 weeks of therapy or the clinical condition is deteriorating, a change of antifungal therapy should be considered. Alleged breakthrough infections or treatment failure should undergo early diagnostic workup, including tissue biopsies when possible, to retrieve fungal cultures for resistance testing.
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Affiliation(s)
- Werner J Heinz
- Klinikum Weiden, Weiden, Würzburg university medical center, Würzburg, Germany
| | - Jörg J Vehreschild
- Department for Internal Medicine, German Centre for Infection Research, University Hospital of Cologne, Partner Site Bonn-Cologne, University of Cologne, Köln, Germany
| | - Dieter Buchheidt
- Department of Internal Medicine-Hematology and Oncology, Mannheim University Hospital, Heidelberg University, Mannheim, Germany
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19
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Ruhnke M, Behre G, Buchheidt D, Christopeit M, Hamprecht A, Heinz W, Heussel CP, Horger M, Kurzai O, Karthaus M, Löffler J, Maschmeyer G, Penack O, Rieger C, Rickerts V, Ritter J, Schmidt-Hieber M, Schuelper N, Schwartz S, Ullmann A, Vehreschild JJ, von Lilienfeld-Toal M, Weber T, Wolf HH. Diagnosis of invasive fungal diseases in haematology and oncology: 2018 update of the recommendations of the infectious diseases working party of the German society for hematology and medical oncology (AGIHO). Mycoses 2018; 61:796-813. [PMID: 30098069 DOI: 10.1111/myc.12838] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 08/05/2018] [Indexed: 01/05/2023]
Abstract
Invasive fungal diseases (IFD) are a primary cause of morbidity and mortality in patients with haematological malignancies. These infections are mostly life-threatening and an early diagnosis and initiation of appropriate antifungal therapy are essential for the clinical outcome. Most commonly, Aspergillus and Candida species are involved. However, other Non-Aspergillus moulds are increasingly identified in case of documented IFD. For definite diagnosis of IFD, a combination of diagnostic tools have to be applied, including conventional mycological culture and non-conventional microbiological tests such as antibody/antigen and molecular tests, as well as histopathology and radiology. Although varying widely in cancer patients, the risk of invasive fungal infection is highest in those with allogeneic stem cell transplantation and those with acute leukaemia and markedly lower in patients with solid cancer. Since the last edition of Diagnosis of Invasive Fungal Diseases recommendations of the German Society for Hematology and Oncology in 2012, integrated care pathways have been proposed for the management and therapy of IFDs with either a diagnostic driven strategy as opposed to a clinical or empirical driven strategy. This update discusses the impact of this additional evidence and effective revisions.
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Affiliation(s)
- Markus Ruhnke
- Department of Haematology & Oncology, Paracelsus-Klinik, Osnabrück, Germany
| | - Gerhard Behre
- Department of Haematology & Oncology, Universitätsklinik Leipzig, Leipzig, Germany
| | - Dieter Buchheidt
- Department of Internal Medicine III, Mannheim University Hospital, University of Heidelberg, Mannheim, Germany
| | - Maximilian Christopeit
- Department for Stem Cell Transplantation, University Medical Center Eppendorf, Hamburg, Germany
| | - Axel Hamprecht
- Institute for Medical Microbiology, Immunology and Hygiene, University Hospital of Cologne, Cologne, Germany
| | - Werner Heinz
- Department of Internal Medicine II, Julius Maximilians University, Würzburg, Germany
| | - Claus-Peter Heussel
- Department of Interventional & Diagnostic Radiology, Thorax Centre, University Hospital of Heidelberg, Heidelberg, Germany
| | - Marius Horger
- Department of Diagnostic and Interventional Radiology, Eberhard Karls University, Tübingen, Germany
| | - Oliver Kurzai
- National Reference Center for Invasive Fungal Infections NRZMyk, Leibniz Institute for Natural Product Research and Infection Biology - Hans-Knoell-Institute, Jena and Institute for Hygiene and Microbiology, University of Würzburg, Würzburg, Germany
| | - Meinolf Karthaus
- Deparment of Haematology & Oncology, Municipal Hospital Neuperlach, Munich, Germany
| | - Jürgen Löffler
- Department of Internal Medicine II, Julius Maximilians University, Würzburg, Germany
| | - Georg Maschmeyer
- Department of Haematology, Oncology and Palliative Care, Klinikum Ernst von Bergmann, Municipal Hospital, Potsdam, Germany
| | - Olaf Penack
- Division of Haematology & Oncology, Department of Internal Medicine, Charité University Medicine, Berlin, Germany
| | | | - Volker Rickerts
- Konsiliarlabor Für Kryptokokkose und Seltene Systemmykosen, Robert-Koch-Institut Berlin, Berlin, Germany
| | - Jörg Ritter
- Division of Haematology & Oncology, Department of Paediatrics, University Hospital of Münster, Münster, Germany
| | - Martin Schmidt-Hieber
- Division of Haematology & Oncology, Department of Internal Medicine, Charité University Medicine, Berlin, Germany
| | - Nikolai Schuelper
- Department of Haematology and Medical Oncology, Göttingen University Medical Centre, Göttingen, Germany
| | - Stefan Schwartz
- Division of Haematology & Oncology, Department of Internal Medicine, Charité University Medicine, Berlin, Germany
| | - Andrew Ullmann
- Department of Internal Medicine II, Julius Maximilians University, Würzburg, Germany
| | - Jörg Janne Vehreschild
- Department of Internal Medicine I, German Centre for Infection Research, partner-site Bonn-Cologne, University Hospital of Cologne, Cologne, Germany
| | - Marie von Lilienfeld-Toal
- Department of Internal Medicine II, National Reference Center for Invasive Fungal Infections NRZMyk, Leibniz Institute for Natural Product Research and Infection Biology - Hans-Knoell-Institute, Universitätsklinik Jena, Jena, Germany
| | - Thomas Weber
- Department of Internal Medicine IV, Universitätsklinik Halle, Halle, Germany
| | - Hans H Wolf
- Department of Internal Medicine IV, Universitätsklinik Halle, Halle, Germany
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20
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Shroff GS, Marom EM, Wu CC, Truong MT, Godoy MCB. Imaging of Pneumonias and Other Thoracic Complications After Hematopoietic Stem Cell Transplantation. Curr Probl Diagn Radiol 2018; 48:393-401. [PMID: 30122314 DOI: 10.1067/j.cpradiol.2018.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Revised: 07/15/2018] [Accepted: 07/17/2018] [Indexed: 01/15/2023]
Abstract
Hematopoietic stem cell transplantation (HSCT) is used in the treatment of various oncologic and hematologic diseases. After HSCT, patients are immunocompromised and are at risk for a wide variety of infectious and noninfectious complications. CT is routinely used when pulmonary complications are suspected after HSCT. In this article, we review the CT appearance of pulmonary complications that occur in the post-transplantation period with special emphasis on opportunistic infections, many of which are life-threatening.
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Affiliation(s)
- Girish S Shroff
- The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Edith M Marom
- Department of Diagnostic Imaging, The Chaim Sheba Medical Center, Tel Aviv University, Tel Hashomer, Israel.
| | - Carol C Wu
- The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Mylene T Truong
- The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Myrna C B Godoy
- The University of Texas MD Anderson Cancer Center, Houston, TX.
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21
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Blau IW, Heinz WJ, Schwartz S, Lipp HP, Schafhausen P, Maschmeyer G. [Pulmonary infiltrates in haematological patients]. MMW Fortschr Med 2018; 160:12-17. [PMID: 29974434 DOI: 10.1007/s15006-018-0727-2] [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: 08/11/2017] [Accepted: 01/30/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND Pulmonary complications are frequent in haematologic patients. METHOD This review article summarizes the outcome of a discussion that took place during an expert meeting on the subject of pulmonary infiltrates. RESULTS AND CONCLUSIONS The most common causes of pulmonary infiltrates in haematologic patients are bacterial infections. Viral infections are subject to relevant seasonal variations, but they may also cause an important proportion of pulmonary infiltrates. Microbiological examination of respiratory tract material (if possible, bronchoalveolar lavage, BAL) is the most important diagnostic procedure. Particularly in the case of prolonged (> 7 days) neutropenia, the likelihood of infiltrates being caused by fungal infections increases. For a differential diagnosis, however, also non-infectious causes, e.g. drug-induced infiltrates, have to be taken into consideration. The diagnostic workup, however, should not delay a timely start of an adequate antimicrobial therapy.
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Affiliation(s)
- Igor-Wolfgang Blau
- Medizinische Klinik für Hämatologie, Onkologie und Tumorimmunologie, Leitender Oberarzt Knochenmarktransplantation, Campus Virchow Klinikum der Charité - Universitätsmedizin Berlin, Berlin, Deutschland.
- Klinik für Hämatologie, Onkologie und Tumorimmunologie, Campus Virchow Klinikum der Charité - Universitätsmedizin Berlin, Augustenburgerplatz 1, D-13353, Berlin, Deutschland.
| | - Werner J Heinz
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Stefan Schwartz
- Medizinische Klinik für Hämatologie, Onkologie und Tumorimmunologie, Campus Benjamin Franklin der Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | | | - Philippe Schafhausen
- Zentrum für Onkologie, II. Medizinische Klinik und Poliklinik, UKE Hamburg, Hamburg, Deutschland
| | - Georg Maschmeyer
- Klinik für Hämatologie, Onkologie und Palliativmedizin, Klinikum Ernst von Bergmann gemeinnützige GmbH, Potsdam, Deutschland
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22
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Thornton CR. Molecular Imaging of Invasive Pulmonary Aspergillosis Using ImmunoPET/MRI: The Future Looks Bright. Front Microbiol 2018; 9:691. [PMID: 29686661 PMCID: PMC5900000 DOI: 10.3389/fmicb.2018.00691] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 03/23/2018] [Indexed: 12/19/2022] Open
Abstract
Invasive pulmonary aspergillosis (IPA) is a life-threatening lung disease of immuno-compromised humans caused by the ubiquitous environmental mold Aspergillus. Biomarker tests for the disease lack sensitivity and specificity, and culture of the fungus from invasive lung biopsy is slow, insensitive, and undesirable in critically ill patients. A computed tomogram (CT) of the chest offers a simple non-intrusive diagnostic procedure for rapid decision making, and so is used in many hematology units to drive antifungal treatment. However, radiological indicators that raise the suspicion of IPA are either transient signs in the early stages of the disease or not specific for Aspergillus infection, with other angio-invasive molds or bacterial pathogens producing comparable radiological manifestations in a chest CT. Improvements to the specificity of radiographic imaging of IPA have been attempted by coupling CT and positron emission tomography (PET) with [18F]fluorodeoxyglucose ([18F]FDG), a marker of metabolic activity well suited to cancer imaging, but with limited use in invasive fungal disease diagnostics due to its inability to differentiate between infectious etiologies, cancer, and inflammation. Bioluminescence imaging using single genetically modified strains of Aspergillus fumigatus has enabled in vivo monitoring of IPA in animal models of disease. For in vivo detection of Aspergillus lung infections in humans, radiolabeled Aspergillus-specific monoclonal antibodies, and iron siderophores, hold enormous potential for clinical diagnosis. This review examines the different experimental technologies used to image IPA, and recent advances in state-of-the-art molecular imaging of IPA using antibody-guided PET/magnetic resonance imaging (immunoPET/MRI).
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Affiliation(s)
- Christopher R Thornton
- Department of Biosciences, College of Life and Environmental Sciences, University of Exeter, Exeter, United Kingdom.,ISCA Diagnostics Ltd., Exeter, United Kingdom
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23
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Katragkou A, Fisher BT, Groll AH, Roilides E, Walsh TJ. Diagnostic Imaging and Invasive Fungal Diseases in Children. J Pediatric Infect Dis Soc 2017; 6:S22-S31. [PMID: 28927203 DOI: 10.1093/jpids/pix055] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Invasive fungal disease (IFD) is a life-threatening condition, especially in immunocompromised children. The role of diagnostic imaging in children at risk for an IFD is multifactorial, including initially detecting it, evaluating for dissemination of infection beyond the primary site of disease, monitoring the response to antifungal therapy, and assessing for potential relapse. The objective of this review was to synthesize the published literature relevant to the use of various imaging modalities for the diagnosis and management of IFD in children.
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Affiliation(s)
- Aspasia Katragkou
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Nationwide Children's Hospital and Ohio State University, Columbus
| | - Brian T Fisher
- Division of Infectious Diseases and Center for Pediatric Clinical Effectiveness Research, Children's Hospital of Philadelphia, Pennsylvania.,Departments of Pediatrics and Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Andreas H Groll
- Infectious Disease Research Program, Department of Pediatric Hematology and Oncology and Center for Bone Marrow Transplantation, University Children's Hospital Muenster, Germany
| | - Emmanuel Roilides
- Infectious Diseases Section, 3rd Department of Pediatrics, Faculty of Medicine, Aristotle University School of Health Sciences, Thessaloniki, Greece
| | - Thomas J Walsh
- Transplantation-Oncology Infectious Diseases Program and Departments of Medicine, Pediatrics, Microbiology and Immunology, Weill Cornell Medicine of Cornell University and New York Presbyterian Hospital
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Nam BD, Kim TJ, Lee KS, Kim TS, Han J, Chung MJ. Pulmonary mucormycosis: serial morphologic changes on computed tomography correlate with clinical and pathologic findings. Eur Radiol 2017; 28:788-795. [DOI: 10.1007/s00330-017-5007-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 05/18/2017] [Accepted: 07/26/2017] [Indexed: 01/14/2023]
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25
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Colombo AL, de Almeida Júnior JN, Slavin MA, Chen SCA, Sorrell TC. Candida and invasive mould diseases in non-neutropenic critically ill patients and patients with haematological cancer. THE LANCET. INFECTIOUS DISEASES 2017; 17:e344-e356. [PMID: 28774702 DOI: 10.1016/s1473-3099(17)30304-3] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 01/06/2017] [Accepted: 03/07/2017] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- A L Colombo
- Department of Medicine, Division of Infectious Diseases, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil.
| | - J N de Almeida Júnior
- Central Laboratory Division (LIM03) and Laboratory of Medical Mycology (LIM53), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Center, Melbourne, VIC, Australia; Victorian Infectious Diseases Service, Royal Melbourne Hospital at the Peter Doherty Institute, Melbourne, VIC, Australia
| | - Sharon C-A Chen
- The Center for Infectious Diseases and Microbiology Laboratory Services, ICPMR Pathology West, New South Wales Health Pathology, Westmead and Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Westmead, NSW, Australia
| | - Tania C Sorrell
- Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney and Westmead Institute for Medical Research, Westmead, NSW, Australia
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Lamoth F, Calandra T. Early diagnosis of invasive mould infections and disease. J Antimicrob Chemother 2017; 72:i19-i28. [PMID: 28355464 DOI: 10.1093/jac/dkx030] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Invasive mould infections (IMIs), such as invasive aspergillosis or mucormycosis, are a major cause of death in patients with haematological cancer and in patients receiving long-term immunosuppressive therapy. Early diagnosis and prompt initiation of antifungal therapy are crucial steps in the management of patients with IMI. The diagnosis of IMI remains a major challenge, with an increased spectrum of fungal pathogens and a diversity of clinical and radiological presentations within the expanding spectrum of immunocompromised hosts. Diagnosis is difficult to establish and is expressed on a scale of probability (proven, probable and possible). Imaging (CT scan), microbiological tools (direct examination, culture, PCR, fungal biomarkers) and histopathology are the pillars of the diagnostic work-up of IMI. None of the currently available diagnostic tests provides sufficient sensitivity and specificity alone, so the optimal approach relies on a combination of multiple diagnostic strategies, including imaging, fungal biomarkers (galactomannan and 1,3-β-d-glucan) and molecular tools. In recent years, the development of PCR for filamentous fungi (primarily Aspergillus or Mucorales) and the progress made in the standardization of fungal PCR technology, may lead to future advances in the field. The appropriate diagnostic approach for IMI should be individualized to each centre, taking into account the local epidemiology of IMI and the availability of diagnostic tests.
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Affiliation(s)
- Frédéric Lamoth
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland.,Institute of Microbiology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Thierry Calandra
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
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Ikari T, Nagai K, Ohe M, Harada T, Akiyama Y. Multiple cavities with halo sign in a case of invasive pulmonary aspergillosis during therapy for drug-induced hypersensitivity syndrome. Respir Med Case Rep 2017; 21:124-128. [PMID: 28480161 PMCID: PMC5407638 DOI: 10.1016/j.rmcr.2017.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 04/10/2017] [Accepted: 04/18/2017] [Indexed: 11/02/2022] Open
Abstract
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.
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Key Words
- BAL, bronchoalveolar lavage
- BG, 1,3-β-glucan
- CMV, cytomegalovirus
- COPD, chronic obstructive pulmonary disease
- CT, computed tomography
- Chronic obstructive pulmonary disease (COPD)
- DIHS, drug-induced hypersensitivity syndrome
- DRESS, drug reaction with eosinophilia and systemic syndrome
- Drug-induced hypersensitivity syndrome
- GGO, ground grass opacity
- GM, galactomannan antigenemia
- HHV-6, Human herpes virus 6
- Halo sign
- Human herpes virus 6 (HHV-6)
- IPA, invasive pulmonary aspergillosis
- Invasive pulmonary aspergillosis
- LAA, low attenuation area
- MCFG, micafungin
- VRCZ, voriconazole
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Affiliation(s)
- Tomoo Ikari
- Department of Respiratory Medicine, Center for Respiratory Diseases, JCHO Hokkaido Hospital, Japan
| | - Katsura Nagai
- Department of Respiratory Medicine, Center for Respiratory Diseases, JCHO Hokkaido Hospital, Japan
| | - Masashi Ohe
- Department of Connective Tissue Disease, JCHO Hokkaido Hospital, Japan
| | - Toshiyuki Harada
- Department of Respiratory Medicine, Center for Respiratory Diseases, JCHO Hokkaido Hospital, Japan
| | - Yasushi Akiyama
- Department of Respiratory Medicine, Center for Respiratory Diseases, JCHO Hokkaido Hospital, Japan
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Vehreschild JJ, Heussel CP, Groll AH, Vehreschild MJGT, Silling G, Würthwein G, Brecht M, Cornely OA. Serial assessment of pulmonary lesion volume by computed tomography allows survival prediction in invasive pulmonary aspergillosis. Eur Radiol 2017; 27:3275-3282. [PMID: 28083695 DOI: 10.1007/s00330-016-4717-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 12/01/2016] [Accepted: 12/16/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Serial chest CT is the standard of care to establish treatment success in invasive pulmonary aspergillosis (IPA). Data are lacking how response should be defined. METHODS Digital CT images from a clinical trial on treatment of IPA were re-evaluated and compared with available biomarkers. Total volume of pneumonia was added up after manual measurement of each lesion, followed by statistical analysis. RESULTS One-hundred and ninety CT scans and 309 follow-up datasets from 40 patients were available for analysis. Thirty-one were neutropenic. Baseline galactomannan (OR 4.06, 95%CI: 1.08-15.31) and lesion volume (OR 3.14, 95%CI: 0.73-13.52) were predictive of death. Lesion volume at d7 and trend between d7 and d14 were strong predictors of death (OR 20.01, 95%CI: 1.42-282.00 and OR 15.97, 95%CI: 1.62-157.32) and treatment being rated as unsuccessful (OR 4.75, 95%CI: 0.94-24.05 and OR 40.69, 95%CI: 2.55-649.03), which was confirmed by a Cox proportional hazards model using time-dependent covariates. CONCLUSION Any increase in CT lesion volume between day 7 and day 14 was a sensitive marker of a lethal outcome (>50%), supporting a CT rescan each one and 2 weeks after initial detection of IPA. The predictive value exceeded all other biomarkers. Further CT follow-up after response at day 14 was of low additional value. KEY POINTS • CT evaluation offers good prediction of outcome for invasive pulmonary aspergillosis. • Predictive capability exceeds galactomannan, blood counts, and lesion count. • Any progression between day 7 and day 14 constitutes a high-risk scenario.
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Affiliation(s)
- J J Vehreschild
- Department I of Internal Medicine, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
- German Centre for Infection Research, Partner Site Bonn-Cologne, Cologne, Germany.
| | - C P Heussel
- Diagnostic and Interventional Radiology with Nuclear Medicine, Chest Clinic at University Hospital Heidelberg, Heidelberg, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - A H Groll
- Infectious Disease Research Program, Department of Paediatric Haematology/Oncology, University Children's Hospital, Muenster, Germany
| | - M J G T Vehreschild
- Department I of Internal Medicine, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
- German Centre for Infection Research, Partner Site Bonn-Cologne, Cologne, Germany
| | - G Silling
- Department of Medicine A, Haematology/Oncology, University of Muenster, Muenster, Germany
| | - G Würthwein
- Centre for Clinical Trials, ZKS Muenster (BMBF 01KN1105), University Hospital Muenster, Muenster, Germany
| | - M Brecht
- Diagnostic and Interventional Radiology with Nuclear Medicine, Chest Clinic at University Hospital Heidelberg, Heidelberg, Germany
| | - O A Cornely
- Department I of Internal Medicine, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
- Clinical Trials Center Cologne, ZKS Koeln (BMBF 01KN1106), University of Cologne, Cologne, Germany
- Center for Integrated Oncology CIO KölnBonn, Cologne, Germany
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
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Lehrnbecher T, Becker K, Groll AH. Current Algorithms in Fungal Diagnosis in the Immunocompromised Host. Methods Mol Biol 2017; 1508:67-84. [PMID: 27837498 DOI: 10.1007/978-1-4939-6515-1_3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Invasive fungal diseases (IFDs) are a major cause of morbidity and mortality in immunocompromised patients such as patients with hematological malignancies or allogeneic hematopoietic stem cell transplant recipients. Whereas the definite diagnosis of IFD requires invasive diagnostic procedures, imaging and noninvasive diagnostic assays may help in decision making with regard to the institution and the choice of antifungal agents, the duration of therapy, surgical intervention, and monitoring of fungal manifestations.Unfortunately, signs and symptoms of IFD are often nonspecific in the immunocompromised patient. Therefore, in immunocompromised patients with suspected IFD, all samples collected need to be cultured for fungi, and, in the case of specimens obtained by invasive diagnostic procedures, also microscopically examined. For high sensitivity of the cultural and microscopic approaches, specific media and stains, respectively, are crucial. Non-culture based method such as the detection of galactomannan or ß-d-glucan and molecular tools such as polymerase chain reaction may help in the early diagnosis of IFD. Imaging studies may be indicative for IFD, but invasive diagnostics such as bronchoalveolar lavage and/or biopsy should be pursued in order to identify the causative pathogen. This chapter summarizes the current knowledge on diagnosing IFD and proposes practical help in the use of diagnostic tools.
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Affiliation(s)
- Thomas Lehrnbecher
- Pediatric Hematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe-University, Theodor-Stern-Kai 7, Frankfurt, 60590, Germany.
| | - Karsten Becker
- Institute of Medical Microbiology, University Hospital Münster, Münster, Germany
| | - Andreas H Groll
- Department of Pediatric Hematology/Oncology, Infectious Disease Research Program, Center for Bone Marrow Transplantation, University Children's Hospital Münster, Münster, Germany
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Ruhnke M, Schwartz S. Recent developments in the management of invasive fungal infections in patients with oncohematological diseases. Ther Adv Hematol 2016; 7:345-359. [PMID: 27904738 DOI: 10.1177/2040620716656381] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Patients with hematological cancer have a high risk of invasive fungal diseases (IFDs). These infections are mostly life threatening and an early diagnosis and initiation of appropriate antifungal therapy are essential for the clinical outcome. Most commonly, Aspergillus and Candida species are involved. However, other non-Aspergillus molds are increasingly be identified in cases of documented IFDs. Important risk factors are long lasting granulocytopenia with neutrophil counts below 500/μl for more than 10 days or graft-versus-host disease resulting from allogeneic stem-cell transplantation. For definite diagnosis of IFD, various diagnostic tools have to be applied, including conventional mycological culture and nonconventional microbiological tests such as antibody/antigen and molecular tests, as well as histopathology and radiology. In the last few years, various laboratory methods, like the Aspergillus GM immunoassay (Aspergillus GM EIA), 1,3-ß-D-glucan (BG) assay or polymerase chain reaction (PCR) techniques have been developed for better diagnosis. Since no single indirect test, including radiological methods, provides the definite diagnosis of an invasive fungal infection, the combination of different diagnostic procedures, which include microbiological cultures, histological, serological and molecular methods like PCR together with the pattern of clinical presentation, may currently be the best strategy for the prompt diagnosis, initiation and monitoring of IFDs. Early start of antifungal therapy is mandatory, but clinical diagnostics often do not provide clear evidence of IFD. Integrated care pathways have been proposed for management and therapy of IFDs with either the diagnostic driven strategy using the preemptive antifungal therapy as opposed to the clinical or empirical driven strategy using the 'traditional' empirical antifungal therapy. Antifungal agents preferentially used for systemic therapy of invasive fungal infections are amphotericin B preparations, fluconazole, voriconazole, posaconazole, caspofungin, anidulafungin, micafungin, and most recently isavuconazole. Clinical decision making must consider licensing status, local experience and availability, pharmacological and economic aspects.
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Affiliation(s)
- Markus Ruhnke
- Department of Hematology and Oncology, Paracelsus-Kliniken Osnabrück, Am Natruper Holz 69, 49090 Osnabrück, Germany
| | - Stefan Schwartz
- Department of Internal Medicine, Division of Hematology, Oncology and Tumor Immunology, Charité University Medicine, Campus Benjamin Franklin, Berlin
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Abstract
ABSTRACT
Filamentous mycoses are often associated with significant morbidity and mortality. Prompt diagnosis and aggressive treatment are essential for good clinical outcomes in immunocompromised patients. The host immune response plays an essential role in determining the course of exposure to potential fungal pathogens. Depending on the effectiveness of immune response and the burden of organism exposure, fungi can either be cleared or infection can occur and progress to a potentially fatal invasive disease. Nonspecific cellular immunity (i.e., neutrophils, natural killer [NK] cells, and macrophages) combined with T-cell responses are the main immunologic mechanisms of protection. The most common potential mold pathogens include certain hyaline hyphomycetes, endemic fungi, the
Mucorales
, and some dematiaceous fungi. Laboratory diagnostics aimed at detecting and differentiating these organisms are crucial to helping clinicians make informed decisions about treatment. The purpose of this chapter is to provide an overview of the medically important fungal pathogens, as well as to discuss the patient characteristics, antifungal-therapy considerations, and laboratory tests used in current clinical practice for the immunocompromised host.
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Improved Radiographic Imaging of Invasive Fungal Disease: The Cornerstone to Antifungal Stewardship in the Hematology Units? CURRENT FUNGAL INFECTION REPORTS 2016. [DOI: 10.1007/s12281-016-0258-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Maschmeyer G, Donnelly JP. How to manage lung infiltrates in adults suffering from haematological malignancies outside allogeneic haematopoietic stem cell transplantation. Br J Haematol 2016; 173:179-89. [PMID: 26729577 PMCID: PMC7161791 DOI: 10.1111/bjh.13934] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 12/13/2015] [Indexed: 12/20/2022]
Abstract
Pulmonary complications affect up to 40% of patients with severe neutropenia lasting for more than 10 d. As they are frequently associated with fever and elevation of C‐reactive protein or other signs of inflammation, they are mostly handled as pneumonia. However, the differential diagnosis is broad, and a causative microbial agent remains undetected in the majority of cases. Pulmonary side effects from cytotoxic treatment or pulmonary involvement by the underlying malignancy must always be taken into account and may provide grounds for invasive diagnostic procedures in selected patients. Pneumocystis jirovecii (in patients not receiving co‐trimoxazole as prophylaxis), multi‐resistant gram‐negative bacilli, mycobacteria or respiratory viruses may be involved. High‐risk patients may be infected by filamentous fungi, such as Aspergillus spp., but these infections are seldom proven when treatment is initiated. Microorganisms isolated from cultures of blood, bronchoalveolar lavage or respiratory secretions need careful interpretation as they may be irrelevant for determining the aetiology of pulmonary infiltrates, particularly when cultures yield coagulase‐negative staphylococci, enterococci or Candida species. Non‐culture based diagnostics for detecting Aspergillus galactomannan, beta‐D‐glucan or DNA from blood, bronchoalveolar lavage or tissue samples can facilitate the diagnosis, but must always be interpreted in the context of clinical and imaging findings. Systemic antifungal treatment with mould‐active agents, given in combination with broad‐spectrum antibiotics, improves clinical outcome when given pre‐emptively. Co‐trimoxazole remains the first‐line treatment for Pneumocystis pneumonia, while cytomegalovirus pneumonia will respond to ganciclovir or foscarnet in most cases. The clinical outcome of acute respiratory failure can also be successful with proper intensive care, when indicated.
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Affiliation(s)
- Georg Maschmeyer
- Department of Haematology, Oncology and Palliative Care, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - J Peter Donnelly
- Department of Haematology, Radboud University Medical Centre, Nijmegen, The Netherlands
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Arıkan Akdağlı S, Azap A, Başaran Demirkazık F, Ener B, Aşcıoğlu Hayran S, Özdemir Kumbasar Ö, Metan G, Odabaşı Z, Uzun Ö, Akan H. Diagnosis of Invasive Fungal Diseases in Hematological Malignancies: A Critical Review of Evidence and Turkish Expert Opinion (TEO-2). Turk J Haematol 2015; 31:342-56. [PMID: 25541650 PMCID: PMC4454048 DOI: 10.4274/tjh.2014.0218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
One of the most problematic issues in hematological malignancies is the diagnosis of invasive fungal diseases. Especially, the difficulty of mycological diagnosis and the necessity of immediate intervention in molds have led to the adoption of “surrogate markers” that do not verify but rather strongly suggest fungal infection. The markers commonly used are galactomannan (GM), beta-glucan, and imaging methods. Although there are numerous studies on these diagnostic approaches, none of these markers serve as a support for the clinician, as is the case in human immunodeficiency virus (HIV) or cytomegalovirus (CMV) infections. This paper has been prepared to explain the diagnostic tests. As molecular tests have not been standardized and are not used routinely in the clinics, they will not be mentioned here.
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35
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Radiologic Imaging Techniques for the Diagnosis and Management of Invasive Fungal Disease. CURRENT FUNGAL INFECTION REPORTS 2015. [DOI: 10.1007/s12281-015-0227-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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36
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Liss B, Vehreschild JJ, Bangard C, Maintz D, Frank K, Grönke S, Michels G, Hamprecht A, Wisplinghoff H, Markiefka B, Hekmat K, Vehreschild MJGT, Cornely OA. Our 2015 approach to invasive pulmonary aspergillosis. Mycoses 2015; 58:375-82. [DOI: 10.1111/myc.12319] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 03/09/2015] [Accepted: 03/09/2015] [Indexed: 12/13/2022]
Affiliation(s)
- B. Liss
- Department I of Internal Medicine; University Hospital of Cologne; Cologne Germany
- Center for Integrated Oncology CIO KölnBonn; University of Cologne; Cologne Germany
| | - J. J. Vehreschild
- Department I of Internal Medicine; University Hospital of Cologne; Cologne Germany
- Center for Integrated Oncology CIO KölnBonn; University of Cologne; Cologne Germany
- German Centre for Infection Research (DZIF); partner site Bonn-Cologne; Cologne Germany
| | - C. Bangard
- Department of Radiology; University Hospital of Cologne; Cologne Germany
| | - D. Maintz
- Department of Radiology; University Hospital of Cologne; Cologne Germany
| | - K. Frank
- Department III of Internal Medicine; Heart Centre of the University of Cologne; Cologne Germany
| | - S. Grönke
- Department III of Internal Medicine; Heart Centre of the University of Cologne; Cologne Germany
| | - G. Michels
- Department III of Internal Medicine; Heart Centre of the University of Cologne; Cologne Germany
| | - A. Hamprecht
- Institute for Medical Microbiology; Immunology and Hygiene; University Hospital of Cologne; Cologne Germany
| | - H. Wisplinghoff
- Institute for Medical Microbiology; Immunology and Hygiene; University Hospital of Cologne; Cologne Germany
| | - B. Markiefka
- Institute of Pathology; University Hospital of Cologne; Cologne Germany
| | - K. Hekmat
- Department of Cardiothoracic Surgery; University Hospital of Cologne; Cologne Germany
| | - M. J. G. T. Vehreschild
- Department I of Internal Medicine; University Hospital of Cologne; Cologne Germany
- Center for Integrated Oncology CIO KölnBonn; University of Cologne; Cologne Germany
- German Centre for Infection Research (DZIF); partner site Bonn-Cologne; Cologne Germany
| | - O. A. Cornely
- Department I of Internal Medicine; University Hospital of Cologne; Cologne Germany
- Center for Integrated Oncology CIO KölnBonn; University of Cologne; Cologne Germany
- German Centre for Infection Research (DZIF); partner site Bonn-Cologne; Cologne Germany
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD); University of Cologne; Cologne Germany
- Clinical Trials Centre Cologne; ZKS Köln; University of Cologne; Cologne Germany
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Stanzani M, Sassi C, Lewis RE, Tolomelli G, Bazzocchi A, Cavo M, Vianelli N, Battista G. High Resolution Computed Tomography Angiography Improves the Radiographic Diagnosis of Invasive Mold Disease in Patients With Hematological Malignancies. Clin Infect Dis 2015; 60:1603-10. [DOI: 10.1093/cid/civ154] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 02/13/2015] [Indexed: 11/12/2022] Open
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Maschmeyer G, Carratalà J, Buchheidt D, Hamprecht A, Heussel CP, Kahl C, Lorenz J, Neumann S, Rieger C, Ruhnke M, Salwender H, Schmidt-Hieber M, Azoulay E. Diagnosis and antimicrobial therapy of lung infiltrates in febrile neutropenic patients (allogeneic SCT excluded): updated guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO). Ann Oncol 2015; 26:21-33. [PMID: 24833776 PMCID: PMC4269340 DOI: 10.1093/annonc/mdu192] [Citation(s) in RCA: 100] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2014] [Revised: 04/29/2014] [Accepted: 05/02/2014] [Indexed: 12/13/2022] Open
Abstract
Up to 25% of patients with profound neutropenia lasting for >10 days develop lung infiltrates, which frequently do not respond to broad-spectrum antibacterial therapy. While a causative pathogen remains undetected in the majority of cases, Aspergillus spp., Pneumocystis jirovecii, multi-resistant Gram-negative pathogens, mycobacteria or respiratory viruses may be involved. In at-risk patients who have received trimethoprim-sulfamethoxazole (TMP/SMX) prophylaxis, filamentous fungal pathogens appear to be predominant, yet commonly not proven at the time of treatment initiation. Pathogens isolated from blood cultures, bronchoalveolar lavage (BAL) or respiratory secretions are not always relevant for the etiology of pulmonary infiltrates and should therefore be interpreted critically. Laboratory tests for detecting Aspergillus galactomannan, β-D-glucan or DNA from blood, BAL or tissue samples may facilitate the diagnosis; however, most polymerase chain reaction assays are not yet standardized and validated. Apart from infectious agents, pulmonary side-effects from cytotoxic drugs, radiotherapy or pulmonary involvement by the underlying malignancy should be included into differential diagnosis and eventually be clarified by invasive diagnostic procedures. Pre-emptive treatment with mold-active systemic antifungal agents improves clinical outcome, while other microorganisms are preferably treated only when microbiologically documented. High-dose TMP/SMX is first choice for treatment of Pneumocystis pneumonia, while cytomegalovirus pneumonia is treated primarily with ganciclovir or foscarnet in most patients. In a considerable number of patients, clinical outcome may be favorable despite respiratory failure, so that intensive care should be unrestrictedly provided in patients whose prognosis is not desperate due to other reasons.
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Affiliation(s)
- G Maschmeyer
- Department of Hematology, Oncology and Palliative Care, Klinikum Ernst von Bergmann, Potsdam, Germany.
| | - J Carratalà
- Department of Infectious Diseases, Bellvitge University Hospital, University of Barcelona, Barcelona, Spain
| | - D Buchheidt
- Department of Hematology and Oncology, Mannheim University Hospital, Mannheim
| | - A Hamprecht
- Institution for Medical Microbiology, Immunology and Hygiene, University Hospital Cologne, Cologne
| | - C P Heussel
- Department of Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik, University Hospital, Heidelberg
| | - C Kahl
- Department of Hematology and Oncology, Klinikum Magdeburg, Magdeburg
| | - J Lorenz
- Department of Pneumology, Infectious Diseases, Sleep Medicine and Intensive Care, Klinikum Lüdenscheid, Lüdenscheid
| | - S Neumann
- Medical Oncology, AMO MVZ, Wolfsburg
| | - C Rieger
- Department of Medicine III, University Hospital Großhadern, München
| | - M Ruhnke
- Department of Medical Oncology and Hematology, Charité University Medicine Campus Mitte, Berlin
| | - H Salwender
- Department of Hematology, Oncology, Stem Cell Transplantation, Asklepios Klinik Altona, Hamburg
| | - M Schmidt-Hieber
- Department of Hematology, Oncology and Tumor Immunology, Helios-Klinikum Berlin-Buch, Berlin, Germany
| | - E Azoulay
- AP-HP, Hopital Saint-Louis, Service de Réanimation Médicale, Université Paris-Diderot, Sorbonne Paris-Cité, Faculté de Médecine, Paris, France
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Morrissey CO, Gilroy NM, Macesic N, Walker P, Ananda-Rajah M, May M, Heath CH, Grigg A, Bardy PG, Kwan J, Kirsa SW, Slavin M, Gottlieb T, Chen S. Consensus guidelines for the use of empiric and diagnostic-driven antifungal treatment strategies in haematological malignancy, 2014. Intern Med J 2014; 44:1298-314. [DOI: 10.1111/imj.12596] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- C. O. Morrissey
- Department of Infectious Diseases; Alfred Health and Monash University; Prahran Victoria
- Department of Clinical Haematology; Alfred Health; Prahran Victoria
| | - N. M. Gilroy
- Blood and Marrow Transplant (BMT) Network; Agency for Clinical Innovation; Chatswood New South Wales
- Department of Infectious Diseases and Clinical Microbiology; St Vincent's Hospital; Darlinghurst New South Wales
| | - N. Macesic
- Departmentof Infectious Diseases; Austin Health; Heidelberg Victoria
| | - P. Walker
- Malignant Haematology and Stem Cell Transplantation Service; Alfred Health; Prahran Victoria
- Australian Centre for Blood Diseases; Monash University; Melbourne Victoria
| | - M. Ananda-Rajah
- Department of Infectious Diseases; Alfred Health and Monash University; Prahran Victoria
- Department of General Medicine; Alfred Health; Prahran Victoria
| | - M. May
- Department of Microbiology; Sullivan Nicolaides Pathology; Brisbane Queensland
| | - C. H. Heath
- Department of Microbiology and Infectious Diseases; Royal Perth Hospital; Perth Western Australia
- School of Medicine and Pharmacology (RPH Unit); University of Western Australia; Perth Western Australia
| | - A. Grigg
- Department of Clinical Haematology; Austin Health; Heidelberg Victoria
- School of Medicine; The University of Melbourne; Melbourne Victoria
| | - P. G. Bardy
- Royal Adelaide Hospital Cancer Centre; Royal Adelaide Hospital; Adelaide South Australia
- Division of Medicine; The Queen Elizabeth Hospital; Woodville South South Australia
- Discipline of Medicine; School of Medicine; The University of Adelaide; Adelaide South Australia
| | - J. Kwan
- Department of Haematology and Bone Marrow Transplant; Westmead Hospital; Westmead New South Wales
| | - S. W. Kirsa
- Pharmacy Department; Peter MacCallum Cancer Centre; East Melbourne Victoria
| | - M. Slavin
- School of Medicine; The University of Melbourne; Melbourne Victoria
- Department of Infectious Diseases and Infection Control; Peter MacCallum Cancer Centre; East Melbourne Victoria
- Victorian Infectious Diseases Service; The Doherty Institute for Infection and Immunity; Parkville Victoria
| | - T. Gottlieb
- The Infectious Diseases and Microbiology Department; Concord Repatriation General Hospital; Concord New South Wales
| | - S. Chen
- Centre for Infectious Diseases and Microbiology Laboratory Services; ICPMR - Pathology West; Westmead New South Wales
- Department of Infectious Diseases; Westmead Hospital; Westmead New South Wales
- Sydney Medical School; The University of Sydney; Sydney New South Wales
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Potenza L, Vallerini D, Barozzi P, Riva G, Forghieri F, Beauvais A, Beau R, Candoni A, Maertens J, Rossi G, Morselli M, Zanetti E, Quadrelli C, Codeluppi M, Guaraldi G, Pagano L, Caira M, Giovane CD, Maccaferri M, Stefani A, Morandi U, Tazzioli G, Girardis M, Delia M, Specchia G, Longo G, Marasca R, Narni F, Merli F, Imovilli A, Apolone G, Carvalho A, Comoli P, Romani L, Latgè JP, Luppi M. Characterization of specific immune responses to different Aspergillus antigens during the course of invasive Aspergillosis in hematologic patients. PLoS One 2013; 8:e74326. [PMID: 24023936 PMCID: PMC3762751 DOI: 10.1371/journal.pone.0074326] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2013] [Accepted: 07/31/2013] [Indexed: 01/26/2023] Open
Abstract
Several studies in mouse model of invasive aspergillosis (IA) and in healthy donors have shown that different Aspergillus antigens may stimulate different adaptive immune responses. However, the occurrence of Aspergillus-specific T cells have not yet been reported in patients with the disease. In patients with IA, we have investigated during the infection: a) whether and how specific T-cell responses to different Aspergillus antigens occur and develop; b) which antigens elicit the highest frequencies of protective immune responses and, c) whether such protective T cells could be expanded ex-vivo. Forty hematologic patients have been studied, including 22 patients with IA and 18 controls. Specific T cells producing IL-10, IFN-γ, IL-4 and IL-17A have been characterized through enzyme linked immunospot and cytokine secretion assays on 88 peripheral blood (PB) samples, by using the following recombinant antigens: GEL1p, CRF1p, PEP1p, SOD1p, α1–3glucan, β1–3glucan, galactomannan. Specific T cells were expanded through short term culture. Aspergillus-specific T cells producing non-protective interleukin-10 (IL-10) and protective interferon-gamma (IFN-γ) have been detected to all the antigens only in IA patients. Lower numbers of specific T cells producing IL-4 and IL-17A have also been shown. Protective T cells targeted predominantly Aspergillus cell wall antigens, tended to increase during the IA course and to be associated with a better clinical outcome. Aspergillus-specific T cells could be successfully generated from the PB of 8 out of 8 patients with IA and included cytotoxic subsets able to lyse Aspergillus hyphae. Aspergillus specific T-cell responses contribute to the clearance of the pathogen in immunosuppressed patients with IA and Aspergillus cell wall antigens are those mainly targeted by protective immune responses. Cytotoxic specific T cells can be expanded from immunosuppressed patients even during the infection by using the above mentioned antigens. These findings may be exploited for immunotherapeutic purposes in patients with IA.
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Affiliation(s)
- Leonardo Potenza
- Section of Hematology, Department of Surgical and Medical Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliera Policlinico, Modena, Italy
| | - Daniela Vallerini
- Section of Hematology, Department of Surgical and Medical Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliera Policlinico, Modena, Italy
| | - Patrizia Barozzi
- Section of Hematology, Department of Surgical and Medical Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliera Policlinico, Modena, Italy
| | - Giovanni Riva
- Section of Hematology, Department of Surgical and Medical Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliera Policlinico, Modena, Italy
| | - Fabio Forghieri
- Section of Hematology, Department of Surgical and Medical Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliera Policlinico, Modena, Italy
| | - Anne Beauvais
- Unitè des Aspergillus, Pasteur Institut, Paris, France
| | - Remi Beau
- Unitè des Aspergillus, Pasteur Institut, Paris, France
| | - Anna Candoni
- Hematology and Bone Marrow Transplantation, Udine, Italy
| | - Johan Maertens
- Department of Hematology, Universitaire Ziekenhuizen Leuven, Campus Gasthuisberg, Leuven, Belgium
| | - Giulio Rossi
- Section of Histopathology, IRCCS/Arcispedale S.Maria Nuova Reggio, Emilia, Italy
| | - Monica Morselli
- Section of Hematology, Department of Surgical and Medical Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliera Policlinico, Modena, Italy
| | - Eleonora Zanetti
- Section of Hematology, Department of Surgical and Medical Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliera Policlinico, Modena, Italy
| | - Chiara Quadrelli
- Section of Hematology, Department of Surgical and Medical Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliera Policlinico, Modena, Italy
| | - Mauro Codeluppi
- Infectious Diseases Clinics, Department of Surgical and Medical Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliera Policlinico, Modena, Italy
| | - Giovanni Guaraldi
- Infectious Diseases Clinics, Department of Surgical and Medical Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliera Policlinico, Modena, Italy
| | - Livio Pagano
- Department of Hematology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Morena Caira
- Department of Hematology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Cinzia Del Giovane
- Section of Hematology, Department of Surgical and Medical Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliera Policlinico, Modena, Italy
| | - Monica Maccaferri
- Section of Hematology, Department of Surgical and Medical Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliera Policlinico, Modena, Italy
| | - Alessandro Stefani
- Division of Thoracic Surgery, Department of Surgical and Medical Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliera Policlinico, Modena, Italy
| | - Uliano Morandi
- Division of Thoracic Surgery, Department of Surgical and Medical Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliera Policlinico, Modena, Italy
| | - Giovanni Tazzioli
- Division of General Surgery, Department of Surgical and Medical Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliera Policlinico, Modena, Italy
| | - Massimo Girardis
- Division of Anaesthesiology and Intensive Care, University of Modena and Reggio Emilia, Azienda Ospedaliera Policlinico, Modena, Italy
| | - Mario Delia
- Hematology Department, DAP, University of Bari, Bari, Italy
| | | | - Giuseppe Longo
- Section of Hematology, Department of Surgical and Medical Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliera Policlinico, Modena, Italy
| | - Roberto Marasca
- Section of Hematology, Department of Surgical and Medical Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliera Policlinico, Modena, Italy
| | - Franco Narni
- Section of Hematology, Department of Surgical and Medical Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliera Policlinico, Modena, Italy
| | - Francesco Merli
- Division of Hematology, IRCCS/Arcispedale S.Maria Nuova Reggio, Emilia, Italy
| | - Annalisa Imovilli
- Division of Hematology, IRCCS/Arcispedale S.Maria Nuova Reggio, Emilia, Italy
| | - Giovanni Apolone
- Division of Hematology, IRCCS/Arcispedale S.Maria Nuova Reggio, Emilia, Italy
| | - Agostinho Carvalho
- Department of Experimental Medicine and Biochemical Sciences, University of Perugia, Perugia, Italy
| | - Patrizia Comoli
- Pediatric Hematology/Oncology and Transplantation, IRCCS S. Matteo Hospital, Pavia, Italy
| | - Luigina Romani
- Department of Experimental Medicine and Biochemical Sciences, University of Perugia, Perugia, Italy
| | | | - Mario Luppi
- Section of Hematology, Department of Surgical and Medical Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliera Policlinico, Modena, Italy
- * E-mail:
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Abstract
BACKGROUND Morbidity and mortality remain high for patients with invasive fungal infections (IFIs) despite an increasing number of antifungals and other treatments. Many studies indicate that delayed or inaccurate diagnosis and treatment are major causes of poor outcomes in patients with IFIs. OBJECTIVE The aim of the current paper is to provide a review of traditional and newer approaches to the diagnosis of IFIs, with a particular focus on invasive candidiasis (IC) and aspergillosis (IA). Recent studies from the author's institution are highlighted, along with an advancement in cryptococcal meningitis diagnosis that should improve the care of AIDS and its opportunistic infection in many developing countries. FINDINGS Currently available tools for the diagnosis of IFIs include traditional methods like histopathology, culture, and radiology, and newer antigen- and PCR-based diagnostic assays. Attempts have also been made to predict IFIs based on colonization or other factors, including genetic polymorphisms impacting IFI susceptibility in high-risk patients. Biopsy with histopathologic analysis is often not possible in patients suspected of pulmonary aspergillosis due to increased bleeding risk, and blood cultures for IC, IA, or other IFIs are hindered by poor sensitivity and slow turnaround time which delays diagnosis. Radiology is often used to predict IFI but suffers from inability to differentiate certain pathogens and does not generally provide certainty of IFI diagnosis. Newer antigen-based diagnostics for early diagnosis include the β-glucan assay for IFIs, galactomannan assay for IA, and a recent variation on the traditional cryptococcal antigen (CRAG) test with a Lateral Flow Assay for invasive cryptococcosis. PCR-based diagnostics represent additional tools with high sensitivity for the rapid diagnosis of IFIs, although better standardization of these methods is still required for their routine clinical use. CONCLUSION Better understanding of the strengths and weaknesses of currently available diagnostic tools, and further devising linked strategies to best implement them either alone or in combination, would greatly improve early and accurate diagnosis of IFIs and improve their successful management.
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Lim C, Seo J, Park SY, Hwang HJ, Lee H, Lee SO, Chae E, Do KH, Song JW, Kim M, Kim SH. Analysis of initial and follow-up CT findings in patients with invasive pulmonary aspergillosis after solid organ transplantation. Clin Radiol 2012; 67:1179-86. [DOI: 10.1016/j.crad.2012.02.018] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Revised: 02/03/2012] [Accepted: 02/13/2012] [Indexed: 02/05/2023]
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Qin J, Xu J, Dong Y, Tang W, Wu B, An Y, Shan H. High-resolution CT findings of pulmonary infections after orthotopic liver transplantation in 453 patients. Br J Radiol 2012; 85:e959-65. [PMID: 22993384 DOI: 10.1259/bjr/26230943] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES The objective of this study was to review the high-resolution CT (HRCT) findings in patients with pulmonary infection after orthotopic liver transplantation (OLT) and to determine distinguishing findings among the various types of infection. METHODS This study included 453 consecutive liver transplant recipients with pulmonary infection, on whom HRCT of the chest was performed within 24 h of the beginning of symptoms and for whom proven diagnosis had taken place within 1 week of the onset of symptoms. Two radiologists analysed the CT images; final decisions regarding the findings were reached by consensus. RESULTS Bacterial and viral pneumonia made up the bulk of infections (63.4% and 29.4%, respectively), followed by fungal infiltrates (24.5%). Large nodules were most common in patients with fungal pneumonia, having been seen in 38 (54%) of the 70 patients with fungal pneumonia, 22 (10%) of 220 with bacterial pneumonia (p=0.0059) and 6 (8%) of 78 with viral pneumonia (p=0.0011). The halo sign was also more frequent in patients with fungal pneumonia, having been seen in 38 (54%) of the 70 patients with fungal pneumonia, 17 (8%) of 220 with bacterial pneumonia (p=0.0026) and 7 (9%) of 78 with viral pneumonia (p=0.0015). There was no statistically significant difference in the prevalence of the other HRCT patterns including air-space consolidation, ground-glass attenuation and small nodules among bacterial, viral and fungal infections (all p>0.05). CONCLUSION The presence of large nodules with the halo sign is most suggestive of fungal infection after OLT. Other HRCT patterns are not helpful in distinguishing among the various types of infection seen in liver transplant recipients.
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Affiliation(s)
- J Qin
- Department of Radiology, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
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Qin J, Fang Y, Dong Y, Zhu K, Wu B, An Y, Shan H. Radiological and clinical findings of 25 patients with invasive pulmonary aspergillosis: retrospective analysis of 2150 liver transplantation cases. Br J Radiol 2012; 85:e429-35. [PMID: 22496071 DOI: 10.1259/bjr/39784231] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE The purpose of this study was to evaluate the radiological and clinical findings of invasive pulmonary aspergillosis (IPA) after liver transplantation. METHODS This study included 25 consecutive liver transplant recipients with histologically confirmed IPA after liver transplantation. Radiological examinations performed for diagnosis were available in all patients. Clinical findings and changes in clinical response and radiological findings after treatment were also evaluated. RESULTS 3 main radiological findings were identified: nodules, 64% (16/25); masses, 36% (9/25); and consolidations in a patchy pattern, 20% (5/25). A tree-in-bud pattern was found in 12% (3/25) of patients. In 8 (32%) of 25 patients, we found a combination of 2 or more of these signs: 5 (20%) patients presented with concurrent nodules accompanied by patchy consolidations and/or tree-in-bud, and 3 (12%) patients showed masses accompanied by large consolidations. A halo sign was observed in 20 (80%) of 25 patients. Hypodense sign and cavitary lesions were encountered in 17 (68%) of 25 patients. Follow-up radiological findings after treatment showed improvement in 18 patients, no change in 4 patients and progression in 3 patients. There were three aspergillosis-associated deaths during the follow-up period. The onset time of IPA was a median of 31 days after transplantation. The most common symptom at diagnosis was fever (n=15). None of the 25 patients had leukopaenia at the time of the diagnosis of IPA. CONCLUSIONS The most common radiological findings of IPA after liver transplantation are multiple nodules with or without halo sign, masses and consolidations, which usually appear about 1 month after transplantation.
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Affiliation(s)
- J Qin
- Department of Radiology/Institute of Interventional Radiology, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
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Computed Tomography and Clinical Features of Invasive Pulmonary Aspergillosis in Liver Transplant Recipients. J Thorac Imaging 2012; 27:107-12. [DOI: 10.1097/rti.0b013e31820bb462] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Mujer de 20 años con fiebre y neutropenia. Med Clin (Barc) 2012; 138:262-9. [DOI: 10.1016/j.medcli.2011.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Revised: 11/19/2011] [Accepted: 11/24/2011] [Indexed: 11/20/2022]
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Kim SH, Park C, Kwon EY, Shin NY, Kwon JC, Park SH, Choi SM, Lee DG, Choi JH, Yoo JH. Real-time nucleic acid sequence-based amplification to predict the clinical outcome of invasive aspergillosis. J Korean Med Sci 2012; 27:10-5. [PMID: 22219607 PMCID: PMC3247764 DOI: 10.3346/jkms.2012.27.1.10] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2011] [Accepted: 11/07/2011] [Indexed: 11/23/2022] Open
Abstract
Monitoring the response to therapy for invasive aspergillosis (IA) is essential for the management of patients with hematologic diseases. We evaluated the correlation between the outcome of real-time nucleic acid sequence-based amplification (RTi-NASBA) for Aspergillus 18S rRNA and the clinical outcome of IA. A total of 157 serum samples from 29 patients with IA were tested for RTi-NASBA. The treatment response and mortality were compared with the NASBA outcome (whether the NASBA value was converted to negative or not) at 12 weeks after the start of antifungal therapy. At 12 weeks, there was a moderate correlation between the treatment failure and persistently positive NASBA (κ = 0.482; P = 0.019). Deaths attributable to IA were more prevalent in patients without negative conversion of NASBA than in those with negative conversion (50% vs 5%; P = 0.013). Significant factors of treatment failure at 12 weeks were the status of hematologic disease (nonremission; P = 0.041) and the NASBA outcome (failure of negative conversion; P = 0.024). Survival was significantly better in patients with negative conversion of NASBA than those with persistently positive values (P = 0.036). This study suggests that the serial monitoring of RTi-NASBA could be useful for prediction of the clinical outcome in hematologic patients with IA.
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Affiliation(s)
- Si-Hyun Kim
- Division of Infectious Diseases, Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Chulmin Park
- Clinical Research Institutes of Medical Science, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Eun-Young Kwon
- Clinical Research Institutes of Medical Science, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Na-Young Shin
- Clinical Research Institutes of Medical Science, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Jae-Cheol Kwon
- Division of Infectious Diseases, Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Sun Hee Park
- Division of Infectious Diseases, Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Su-Mi Choi
- Division of Infectious Diseases, Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Dong-Gun Lee
- Division of Infectious Diseases, Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Jung-Hyun Choi
- Division of Infectious Diseases, Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Jin-Hong Yoo
- Division of Infectious Diseases, Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
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Stanzani M, Battista G, Sassi C, Lewis RE, Tolomelli G, Clissa C, Femia R, Bazzocchi A, Tumietto F, Viale P, Ambretti S, Baccarani M, Vianelli N. Computed Tomographic Pulmonary Angiography for Diagnosis of Invasive Mold Diseases in Patients With Hematological Malignancies. Clin Infect Dis 2011; 54:610-6. [DOI: 10.1093/cid/cir861] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
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Imaging studies for diagnosing invasive fungal pneumonia in immunocompromised patients. Curr Opin Infect Dis 2011; 24:309-14. [PMID: 21673574 DOI: 10.1097/qco.0b013e328348b2e1] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The aim is to review imaging advances in invasive fungal pneumonia in cancer and transplant recipients and how their use can help guide treatment. RECENT FINDINGS Early chest computed tomographic (CT) imaging of immunocompromised patients with neutropenic fever leads to improved survival. Some of the typical CT findings of invasive fungal pneumonia are transitory and are most common during the first week of symptoms. The reversed halo sign, an early sign of disease, is more common in mucormycosis. During the first 10 days of infection, invasive fungal pneumonia nodules may grow on follow-up CT scans, but this does not necessarily equate to worsening disease. Because of the excessive radiation of chest CT and because pulmonary nodule size typically expands during the first few weeks of treatment, follow-up CT scans should be ordered only when therapy changes are dependent on imaging findings. SUMMARY Early chest CT imaging in immunocompromised patients suspected of having invasive fungal pneumonia can help identify disease early, leading to improved outcome.
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Maschmeyer G. Diagnosis and Antimicrobial Therapy of Lung Infiltrates in Febrile Neutropenic Cancer Patients. Curr Infect Dis Rep 2011; 13:510-6. [DOI: 10.1007/s11908-011-0219-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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