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Koga S, Takazono T, Namie H, Okuno D, Ito Y, Nakada N, Hirayama T, Takeda K, Ide S, Iwanaga N, Tashiro M, Sakamoto N, Watanabe A, Izumikawa K, Yanagihara K, Tanaka Y, Mukae H. Human Vγ9Vδ2 T cells exhibit antifungal activity against Aspergillus fumigatus and other filamentous fungi. Microbiol Spectr 2024; 12:e0361423. [PMID: 38426765 PMCID: PMC10986472 DOI: 10.1128/spectrum.03614-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 02/11/2024] [Indexed: 03/02/2024] Open
Abstract
Invasive aspergillosis (IA) and mucormycosis are life-threatening diseases, especially among immunocompromised patients. Drug-resistant Aspergillus fumigatus strains have been isolated worldwide, which can pose a serious clinical problem. As IA mainly occurs in patients with compromised immune systems, the ideal therapeutic approach should aim to bolster the immune system. In this study, we focused on Vγ9Vδ2 T cells that exhibit immune effector functions and examined the possibility of harnessing this unconventional T cell subset as a novel therapeutic modality for IA. A potent antifungal effect was observed when A. fumigatus (Af293) hyphae were challenged by Vγ9Vδ2 T cells derived from peripheral blood. In addition, Vγ9Vδ2 T cells exhibited antifungal activity against hyphae of all Aspergillus spp., Cunninghamella bertholletiae, and Rhizopus microsporus but not against their conidia. Furthermore, Vγ9Vδ2 T cells also exhibited antifungal activity against azole-resistant A. fumigatus, indicating that Vγ9Vδ2 T cells could be used for treating drug-resistant A. fumigatus. The antifungal activity of Vγ9Vδ2 T cells depended on cell-to-cell contact with A. fumigatus hyphae, and degranulation characterized by CD107a mobilization seems essential for this activity against A. fumigatus. Vγ9Vδ2 T cells could be developed as a novel modality for treating IA or mucormycosis. IMPORTANCE Invasive aspergillosis (IA) and mucormycosis are often resistant to treatment with conventional antifungal agents and have a high mortality rate. Additionally, effective antifungal treatment is hindered by drug toxicity, given that both fungal and human cells are eukaryotic, and antifungal agents are also likely to act on human cells, resulting in adverse effects. Therefore, the development of novel therapeutic agents specifically targeting fungi is challenging. This study demonstrated the antifungal activity of Vγ9Vδ2 T cells against various Aspergillus spp. and several Mucorales in vitro and discussed the mechanism underlying their antifungal activity. We indicate that adoptive immunotherapy using Vγ9Vδ2 T cells may offer a new therapeutic approach to IA.
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Affiliation(s)
- Satoru Koga
- Department of Respiratory Medicine, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Takahiro Takazono
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Hodaka Namie
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Daisuke Okuno
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Yuya Ito
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Nana Nakada
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
- Health Center, Nagasaki University, Nagasaki, Japan
| | - Tatsuro Hirayama
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
- Department of Pharmacotherapeutics, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kazuaki Takeda
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Shotaro Ide
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
- Infectious Diseases Experts Training Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Naoki Iwanaga
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Masato Tashiro
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Noriho Sakamoto
- Department of Respiratory Medicine, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Akira Watanabe
- Medical Mycology Research Center, Chiba University, Chiba, Japan
| | - Koichi Izumikawa
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Katsunori Yanagihara
- Department of Laboratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Yoshimasa Tanaka
- Center for Medical Innovation, Nagasaki University, Nagasaki, Japan
| | - Hiroshi Mukae
- Department of Respiratory Medicine, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
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Martins AC, Psaltikidis EM, Cristiano de Lima T, Fagnani R, Gomide HCAC, Gilli FH, Schreiber AZ, de Oliveira Conterno L, Matsuzawa T, Watanabe A, Kamei K, Brandalise SR, Trabasso P, Resende MR, Moretti ML. Clinical outcomes of aspergillosis among paediatric and adult inpatients: A multicentre study in a Brazilian metropolitan area. J Mycol Med 2023; 33:101435. [PMID: 37708696 DOI: 10.1016/j.mycmed.2023.101435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 09/03/2023] [Accepted: 09/04/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND Invasive Aspergillosis (IA) is a disease of significant clinical relevance, especially among immunosuppressed patients, and is associated with high mortality rates. In this study, we evaluated the epidemiological features and clinical outcomes in children and adults with IA. METHODS This was an observational, multicentre, prospective surveillance study of inpatients with IA at two different hospitals in Campinas, Brazil, between 2018 and 2021. RESULTS A total of 44 patients were identified (54.5% males), with a median age of 42 years (interquartile range (IQR):19.25-59 years, varying between 1 and 89 years). The following baseline conditions were identified: 61.4% were oncohaematological patients and 20.5% were solid organ transplant recipients. Among oncohaematological patients, 77.8% exhibited severe or persistent neutropenia. The median time between the onset of neutropenia and the diagnosis of fungal infection was 20 days (IQR: 10.5-26 days; range, 0-68 days). The interval between neutropenia onset and fungal infection was longer in paediatric than in general hospital (average, 29 vs. 13.4 days; median 26 vs 11 days; p=0.010). After the diagnosis of IA, the survival rates were 44.2% and 30.0% at 180 and 360 days, respectively. Survival was greater in patients aged ≤ 21 years (p = 0.040; log-rank test). They observed no difference in IA mortality related to COVID-19 pandemic. CONCLUSION High mortality associated with IA was observed in both hospitals. Individuals over the age of 21 have a lower survival rate than younger patients.
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Affiliation(s)
- Antonio Camargo Martins
- School of Medical Sciences, University of Campinas, Campinas, São Paulo, Brazil; Young Medical Leadership Program of the National Academy of Medicine, Brazil
| | | | | | - Renata Fagnani
- School of Medical Sciences, University of Campinas, Campinas, São Paulo, Brazil
| | | | | | | | | | | | - Akira Watanabe
- Medical Mycology Research Center, Chiba University, Chiba, Japan
| | - Katsuhiko Kamei
- Medical Mycology Research Center, Chiba University, Chiba, Japan
| | | | - Plinio Trabasso
- School of Medical Sciences, University of Campinas, Campinas, São Paulo, Brazil
| | | | - Maria Luiza Moretti
- School of Medical Sciences, University of Campinas, Campinas, São Paulo, Brazil
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Mizushima R, Haruhara K, Fukasawa N, Satake M, Fukui A, Koike K, Tsuboi N, Takahashi H, Yokoo T. Two entities in pulmonary nodules of a diabetic patient receiving corticosteroid therapy for bullous pemphigoid: an autopsy case report. BMC Infect Dis 2022; 22:597. [PMID: 35799119 PMCID: PMC9264713 DOI: 10.1186/s12879-022-07566-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 06/23/2022] [Indexed: 11/25/2022] Open
Abstract
Background Invasive pulmonary aspergillosis (IPA) is a serious complication occurring in immunocompromised patients, who often show multiple nodular lesions with or without cavitation. Due to high mortality and poor prognosis, the earlier detection and initiation of treatment are needed, while the definitive diagnosis is often difficult to make in clinical settings. Septic pulmonary embolism (SPE) is a complication that occurs in patients with bloodstream infections (e.g., infectious endocarditis). Patients with SPE also present with multiple nodules, nodules with or without cavitation, which are quite similar to the findings of IPA. We herein report an autopsy case that showed multiple nodules due to IPA and infectious endocarditis-related SPE. Case A 69-year-old man receiving maintenance hemodialysis due to diabetic nephropathy was admitted with worsening skin rash due to bullous pemphigoid and toxic epidermal necrolysis. He was treated with intravenous methylprednisolone followed by an increased dose of oral prednisolone. On the 6th week of admission, he was diagnosed with infectious endocarditis after the isolation of Corynebacterium in blood samples, with a nodule lesion with cavitation in the right lung. Intravenous vancomycin was initiated. After antibacterial treatment, the nodules in the right lung gradually diminished, whereas a nodule with cavitation in the left lung emerged. The nodule in the left lung showed rapid growth along with elevation of serum β-d-glucan and galactomannan antigen. Despite starting treatment with antifungal agents, he died from respiratory failure. An autopsy revealed Groccott staining-positive aspergillus in the left lung, but not in the right lung. We found fibrosis with mitral valve vegetation, indicating a recovery from infectious endocarditis. Conclusion Although similar features of nodules with cavitation on CT imaging were shared with SPE and IPA, this case demonstrated that these heterogeneous diseases can occur within the lungs and the distinctly different transitions of CT imaging are helpful for suspecting the presence of multiple pathogeneses.
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Affiliation(s)
- Reimi Mizushima
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan.,Department of Respiratory Medicine, Tokyo Medical University Hospital, Tokyo, Japan
| | - Kotaro Haruhara
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan.
| | - Nei Fukasawa
- Department of Pathology, The Jikei University School of Medicine, Tokyo, Japan
| | - Mari Satake
- Department of Pathology, The Jikei University School of Medicine, Tokyo, Japan
| | - Akira Fukui
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Kentaro Koike
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Nobuo Tsuboi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Hiroyuki Takahashi
- Department of Pathology, The Jikei University School of Medicine, Tokyo, Japan
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
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Lim YY, Mansfield C, Stevenson M, Thompson M, Davies D, Whitney J, James F, Tebb A, Fry D, Buob S, Hambrook L, Boo G, Dandrieux JRS. A retrospective multi-center study of treatment, outcome, and prognostic factors in 34 dogs with disseminated aspergillosis in Australia. J Vet Intern Med 2022; 36:580-590. [PMID: 35085412 PMCID: PMC8965214 DOI: 10.1111/jvim.16366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 01/05/2022] [Accepted: 01/07/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Disseminated aspergillosis (DA) in dogs has a guarded prognosis and there is a lack of a gold standard treatment protocol. OBJECTIVE To retrospectively assess survival times and factors influencing survival times. ANIMALS Dogs diagnosed with DA from January 2007 to June 2017. METHODS Disseminated aspergillosis case data were retrieved from 13 Australian veterinary referral centers, with a diagnosis confirmed with culture or PCR. Factors influencing survival time after diagnosis were quantified using a Cox proportional hazards regression model. RESULTS Thirty-four dogs met the study inclusion criteria. Twenty-two dogs were treated with antifungal treatment and 12 dogs received no antifungal treatment. Accounting for censoring of dogs that were either still alive on the date of data collection or were loss to follow-up, dogs treated with itraconazole alone (n = 8) had a median survival time (MST) of 63 (95% CI: 20-272) days compared to 830 (95% CI: 267-1259) days for the n = 14 dogs that received multimodal antifungal therapy ( χ 2 test statistic 8.6; df = 1; P < .01). The daily hazard of death (DHOD) for dogs with abnormally high serum creatinine concentration at the time of diagnosis was 7.4 (95% CI: 1.9-29) times that of dogs with serum creatinine within the reference interval. CONCLUSION AND CLINICAL IMPORTANCE Serum creatinine concentration at the time of diagnosis is a useful prognostic indicator for survival after a diagnosis of DA. The MST for dogs treated with multimodal antifungal therapy is longer than itraconazole alone and warrant further investigation (P < .01).
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Affiliation(s)
- Yi Yu Lim
- Faculty of Veterinary and Agricultural Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Caroline Mansfield
- Faculty of Veterinary and Agricultural Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Mark Stevenson
- Asia-Pacific Centre for Animal Health, Faculty of Veterinary and Agricultural Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Mary Thompson
- School of Veterinary and Life Sciences, Murdoch University, Perth, Western Australia, Australia
| | - David Davies
- Adelaide Veterinary Specialist & Referral Centre, Adelaide, South Australia, Australia
| | - Joanna Whitney
- Faculty of Veterinary Science, The University of Sydney, Sydney, New South Wales, Australia
| | - Fleur James
- Perth Veterinary Specialist, Perth, Western Australia, Australia
| | - Anna Tebb
- Western Australian Veterinary Emergency and Specialty, Perth, Western Australia, Australia
| | - Darren Fry
- Brisbane Veterinary Specialist Centre, Brisbane, Queensland, Australia
| | - Sibylle Buob
- Queensland Veterinary Specialists, Brisbane, Queensland, Australia
| | | | - Gladys Boo
- Eye Clinic for Animals, Sydney, New South Wales, Australia
| | - Julien R S Dandrieux
- Faculty of Veterinary and Agricultural Sciences, The University of Melbourne, Melbourne, Victoria, Australia
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Tong X, Liu T, Jiang K, Wang D, Liu S, Wang Y, Fan H. Clinical Characteristics and Prognostic Risk Factors of Patients With Proven Invasive Pulmonary Aspergillosis: A Single-Institution Retrospective Study. Front Med (Lausanne) 2022; 8:756237. [PMID: 35004724 PMCID: PMC8733578 DOI: 10.3389/fmed.2021.756237] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 12/06/2021] [Indexed: 02/05/2023] Open
Abstract
Background: The mortality and burden of medical costs associated with invasive pulmonary aspergillosis (IPA) is very high. Currently, the clinical features and prognostic factors of patients with proven IPA are not very clear, especially in the Chinese population. In this retrospective analysis, we aimed to identify the clinical features and prognostic factors of patients with proven IPA. Methods: The diagnostic criteria for proven IPA were based on the international consensus of the EORTC/MSG. Data of patients with proven IPA at the West China Hospital of Sichuan University between January 2012 and December 2018 were collected. The optimal cut-off value of continuous variables was determined by Receiver Operating Characteristic curve and maximum Youden's index. Finally, using the Cox regression analysis to identify correlations between the clinical parameters associated with morbidity. Results: A total of 117 patients with proven IPA were included in the study, and 32 (27.4%) patients died during the follow-up period. Compared with the survivor group, elderly, patients with comorbidities, and patients undergoing chemotherapy and the level of inflammatory biomarkers [erythrocyte sedimentation rate, platelet count, interleukin-6, C-reactive protein (CRP)] in the non-survivor group were higher, while the albumin level was lower (P = 0.018). The imaging features were consolidation, nodules, cavities, pleural effusion, ground-glass shadows, and halo signs in order. Overall, 41.0% patients had mixed imaging features. The results suggested the most appropriate cut-off value of age and CRP were 60 years and 14.1 mg/L, respectively. The multivariate Cox regression analysis suggested that advanced age (>60 years) [hazard ratio (HR): 10.7, confidence interval (CI): 2.5-44.9, P < 0.001), undergoing chemotherapy (HR: 9.5, CI: 2.7-32.9, P < 0.001), presence of pleural effusion (HR: 5.74, CI: 1.6-20.8, P = 0.008), and increased CRP levels (>14.1 mg/L) (HR: 6.3, CI: 1.2-34.3, P = 0.033) were risk factors for all-cause mortality in patients with proven aspergillosis. Conclusions: This study showed that the prognosis of proven IPA is poor, and the age >60 years, undergoing chemotherapy, pleural effusion on CT image, and CRP levels >14.1 mg/L may be as risk factors for mortality in patients with proven IPA. large samples and real-world studies are needed to confirm these results in the future.
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Affiliation(s)
- Xiang Tong
- Department of Respiratory Medicine and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Tao Liu
- Department of Respiratory Medicine and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Kexin Jiang
- Clinical Medicine of Eight-Year Program, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Dongguang Wang
- Department of Respiratory Medicine and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Sitong Liu
- Department of Respiratory Medicine and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Ye Wang
- Department of Respiratory Medicine and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Hong Fan
- Department of Respiratory Medicine and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
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Kluge S, Strauß R, Kochanek M, Weigand MA, Rohde H, Lahmer T. Aspergillosis: Emerging risk groups in critically ill patients. Med Mycol 2021; 60:6408468. [PMID: 34677613 DOI: 10.1093/mmy/myab064] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 09/23/2021] [Accepted: 10/19/2021] [Indexed: 02/06/2023] Open
Abstract
Information on invasive aspergillosis (IA) and other invasive filamentous fungal infections is limited in non-neutropenic patients admitted to the intensive care unit (ICU) and presenting with no classic IA risk factors. This review is based on the critical appraisal of relevant literature, on the authors' own experience and on discussions that took place at a consensus conference. It aims to review risk factors favoring aspergillosis in ICU patients, with a special emphasis on often overlooked or neglected conditions. In the ICU patients, corticosteroid use to treat underlying conditions such as chronic obstructive pulmonary disease (COPD), sepsis, or severe COVID-19, represents a cardinal risk factor for IA. Important additional host risk factors are COPD, decompensated cirrhosis, liver failure, and severe viral pneumonia (influenza, COVID-19). Clinical observations indicate that patients admitted to the ICU because of sepsis or acute respiratory distress syndrome are more likely to develop probable or proven IA, suggesting that sepsis could also be a possible direct risk factor for IA, as could small molecule inhibitors used in oncology. There are no recommendations for prophylaxis in ICU patients; posaconazole mold-active primary prophylaxis is used in some centers according to guidelines for other patient populations and IA treatment in critically ill patients is basically the same as in other patient populations. A combined evaluation of clinical signs and imaging, classical biomarkers such as the GM assay, and fungal cultures examination, remain the best option to assess response to treatment. LAY SUMMARY The use of corticosteroids and the presence of co-morbidities such as chronic obstructive pulmonary disease, acute or chronic advanced liver disease, or severe viral pneumonia caused by influenza or Covid-19, may increase the risk of invasive aspergillosis in intensive care unit patients.
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Affiliation(s)
- Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg - Eppendorf, Hamburg, D-20246, Germany
| | - Richard Strauß
- Department of Medicine 1, Medizinische Klinik 1, University Hospital Erlangen, Erlangen, D-91054, Germany
| | - Matthias Kochanek
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, D-50937, Germany
| | - Markus A Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, D-69120, Germany
| | - Holger Rohde
- Institute of Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, D-20246, Germany
| | - Tobias Lahmer
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität Munich, Munich, D-81675, Germany
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Gregoire E, Pirotte BF, Moerman F, Altdorfer A, Gaspard L, Firre E, Moonen M, Fraipont V, Ernst M, Darcis G. Incidence and Risk Factors of COVID-19-Associated Pulmonary Aspergillosis in Intensive Care Unit-A Monocentric Retrospective Observational Study. Pathogens 2021; 10:pathogens10111370. [PMID: 34832526 PMCID: PMC8623919 DOI: 10.3390/pathogens10111370] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 10/12/2021] [Accepted: 10/20/2021] [Indexed: 12/12/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19)-associated pulmonary aspergillosis (CAPA) is an increasingly recognized complication of COVID-19 and is associated with significant over-mortality. We performed a retrospective monocentric study in patients admitted to the intensive care unit (ICU) for respiratory insufficiency due to COVID-19 from March to December 2020, in order to evaluate the incidence of CAPA and the associated risk factors. We also analysed the diagnostic approach used in our medical centre for CAPA diagnosis. We defined CAPA using recently proposed consensus definitions based on clinical, radiological and microbiological criteria. Probable cases of CAPA occurred in 9 out of 141 patients included in the analysis (6.4%). All cases were diagnosed during the second wave of the pandemic. We observed a significantly higher realization rate of bronchoalveolar lavage (BAL) (51.1% vs. 28.6%, p = 0.01) and Aspergillus testing (through galactomannan, culture, PCR) on BAL samples during the second wave (p < 0.0001). The testing for Aspergillus in patients meeting the clinical and radiological criteria of CAPA increased between the two waves (p < 0.0001). In conclusion, we reported a low but likely underestimated incidence of CAPA in our population. A greater awareness and more systematic testing for Aspergillus are necessary to assess the real incidence and characteristics of CAPA.
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Affiliation(s)
- Emilien Gregoire
- Department of Internal Medicine and Infectious Diseases, Centre Hospitalier Régional (CHR) de Liège, 4000 Liège, Belgium; (B.F.P.); (F.M.); (A.A.); (L.G.); (E.F.); (M.M.)
- Correspondence:
| | - Benoit François Pirotte
- Department of Internal Medicine and Infectious Diseases, Centre Hospitalier Régional (CHR) de Liège, 4000 Liège, Belgium; (B.F.P.); (F.M.); (A.A.); (L.G.); (E.F.); (M.M.)
| | - Filip Moerman
- Department of Internal Medicine and Infectious Diseases, Centre Hospitalier Régional (CHR) de Liège, 4000 Liège, Belgium; (B.F.P.); (F.M.); (A.A.); (L.G.); (E.F.); (M.M.)
| | - Antoine Altdorfer
- Department of Internal Medicine and Infectious Diseases, Centre Hospitalier Régional (CHR) de Liège, 4000 Liège, Belgium; (B.F.P.); (F.M.); (A.A.); (L.G.); (E.F.); (M.M.)
| | - Laura Gaspard
- Department of Internal Medicine and Infectious Diseases, Centre Hospitalier Régional (CHR) de Liège, 4000 Liège, Belgium; (B.F.P.); (F.M.); (A.A.); (L.G.); (E.F.); (M.M.)
| | - Eric Firre
- Department of Internal Medicine and Infectious Diseases, Centre Hospitalier Régional (CHR) de Liège, 4000 Liège, Belgium; (B.F.P.); (F.M.); (A.A.); (L.G.); (E.F.); (M.M.)
| | - Martial Moonen
- Department of Internal Medicine and Infectious Diseases, Centre Hospitalier Régional (CHR) de Liège, 4000 Liège, Belgium; (B.F.P.); (F.M.); (A.A.); (L.G.); (E.F.); (M.M.)
| | - Vincent Fraipont
- Intensive Care Unit, Centre Hospitalier Régional (CHR) de Liège, 4000 Liège, Belgium;
| | - Marie Ernst
- Biostatistics and Medico-Economic Information Department, Centre Hospitalier Universitaire (CHU) de Liège, 4000 Liege, Belgium;
| | - Gilles Darcis
- Department of Internal Medicine and Infectious Diseases, Centre Hospitalier Universitaire (CHU) de Liège, 4000 Liège, Belgium;
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Vélez Pintado M, Camiro-Zúñiga A, Aguilar Soto M, Cuenca D, Mercado M, Crabtree-Ramirez B. COVID-19-associated invasive pulmonary aspergillosis in a tertiary care center in Mexico City. Med Mycol 2021; 59:828-833. [PMID: 33724423 PMCID: PMC7989422 DOI: 10.1093/mmy/myab009] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/15/2021] [Indexed: 12/14/2022] Open
Abstract
Invasive pulmonary aspergillosis (IPA) is a severe infection caused by aspergillus sp. that usually develops in patients with severe immunosuppression. IPA has been recently described in critically ill COVID-19 patients (termed as COVID-associated pulmonary aspergillosis, or CAPA) that are otherwise immunocompetent. In order to describe the characteristics of patients with CAPA, we conducted a retrospective cohort study in a tertiary care center in Mexico City. We included all patients with confirmed COVID-19 admitted to the intensive care unit that had serum or bronchoalveolar lavage galactomannan measurements. We used the criteria proposed by Koehler et al. to establish the diagnosis of CAPA. Main outcomes were the need for invasive mechanical ventilation (IMV) and in-hospital mortality. Out of a total of 83 hospitalized patients with COVID-19 in the ICU, 16 (19.3%) met the criteria for CAPA. All patients diagnosed with CAPA required IMV whereas only 84% of the patients in the non-IPA group needed this intervention (P = 0.09). In the IPA group, 31% (n = 5) of the patients died, compared to 13% (n = 9) in the non-CAPA group (P = 0.08). We conclude that CAPA is a frequent co-infection in critically ill COVID-19 patients and is associated with a high mortality rate. The timely diagnosis and treatment of IPA in these patients is likely to improve their outcome. LAY SUMMARY We studied the characteristics of patients with COVID-19-associated invasive pulmonary aspergillosis (CAPA). Patients with CAPA tended to need invasive mechanical ventilation more frequently and to have a higher mortality rate. Adequate resources for its management can improve their outcome.
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Affiliation(s)
- Mariana Vélez Pintado
- Department of Medicine, Centro Médico ABC, Mexico City, Mexico. Sur 136 No. 116, Col. Las Américas, Álvaro Obregón, 01120
| | - Antonio Camiro-Zúñiga
- Department of Medicine, Centro Médico ABC, Mexico City, Mexico. Sur 136 No. 116, Col. Las Américas, Álvaro Obregón, 01120
| | - Mercedes Aguilar Soto
- Department of Medicine, Centro Médico ABC, Mexico City, Mexico. Sur 136 No. 116, Col. Las Américas, Álvaro Obregón, 01120
| | - Dalia Cuenca
- Department of Medicine, Centro Médico ABC, Mexico City, Mexico. Sur 136 No. 116, Col. Las Américas, Álvaro Obregón, 01120
| | - Moisés Mercado
- Research Unit in Endocrine Diseases, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City. Av. Cuauhtémoc 330, Doctores, Cuauhtémoc, 06720
| | - Brenda Crabtree-Ramirez
- Department of Infectious Diseases, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Secc 16, Tlalpan, 14080 Ciudad de México, CDMX
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9
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Budin S, Salmanton-García J, Koehler P, Stemler J, Cornely OA, Mellinghoff SC. Validation of the EQUAL Aspergillosis Score by analysing guideline-adherent management of invasive pulmonary aspergillosis. J Antimicrob Chemother 2021; 76:1070-1077. [PMID: 33394007 DOI: 10.1093/jac/dkaa518] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 11/16/2020] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES To investigate the diagnosis and treatment standards at the University Hospital of Cologne, Germany, by applying the EQUAL Aspergillosis Score to invasive pulmonary aspergillosis (IPA) patients. METHODS The charts of 103 patients with probable or proven IPA at the University Hospital of Cologne were reviewed and the score retrospectively applied to all patients. RESULTS Patients were stratified into two groups according to the underlying disease: a haematology group (n = 76, 73.8%) and a non-haematology group (n = 27, 26.2%). While the haematology group attained 67.8% of achievable score points (median: 15; IQR: 13-18; range: 8-25), the non-haematology group reached 48.4% (median: 12 points; IQR: 9-14; range: 4-18) (P < 0.001). Regarding diagnostics, haematological patients achieved 81.3% of achievable points (median: 7; IQR: 8-10; range: 3-13) and non-haematological 56.3% (median: 7; IQR: 5-9; range: 3-11). Concerning treatment, haematological patients gained 86.3% (median: 5; IQR: 5-5; range: 0-5) and non-haematological 68.1% (median: 5; IQR: 0-5; range: 0-5) of achievable points. Among the haematological patients with versus those without mould-active prophylaxis, 90 day mortality was 46.0% and 59.3% (P = 0.004), respectively. Guideline adherent management of IPA was observed in 31.1% of cases (39.5% in haematological patients and 7.4% in non-haematological). CONCLUSIONS The EQUAL Aspergillosis Score is more suitable for evaluation of management of haematological patients compared with those without such underlying disease. In both groups there was no correlation between score points and survival. Larger prospective studies may be suitable to correlate outcome and score. A revision of the score should be considered based on the data presented.
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Affiliation(s)
- Sofia Budin
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Excellence Centre for Medical Mycology (ECMM), Cologne, Germany.,University of Cologne, Faculty of Medicine and University Hospital Cologne, Chair Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany
| | - Jon Salmanton-García
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Excellence Centre for Medical Mycology (ECMM), Cologne, Germany.,University of Cologne, Faculty of Medicine and University Hospital Cologne, Chair Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany
| | - Philipp Koehler
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Excellence Centre for Medical Mycology (ECMM), Cologne, Germany.,University of Cologne, Faculty of Medicine and University Hospital Cologne, Chair Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany
| | - Jannik Stemler
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Excellence Centre for Medical Mycology (ECMM), Cologne, Germany.,University of Cologne, Faculty of Medicine and University Hospital Cologne, Chair Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany.,German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Oliver A Cornely
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Excellence Centre for Medical Mycology (ECMM), Cologne, Germany.,University of Cologne, Faculty of Medicine and University Hospital Cologne, Chair Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany.,German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany.,University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinical Trials Centre Cologne (ZKS Köln), Cologne, Germany
| | - Sibylle C Mellinghoff
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Excellence Centre for Medical Mycology (ECMM), Cologne, Germany.,University of Cologne, Faculty of Medicine and University Hospital Cologne, Chair Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany.,German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
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10
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Shishido AA, Vostal A, Mayer R, Ho CY, Baddley JW. Diagnosis of central nervous system invasive aspergillosis in a liver transplant recipient using microbial cell-free next generation DNA sequencing. Transpl Infect Dis 2021; 23:e13592. [PMID: 33655668 DOI: 10.1111/tid.13592] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 02/06/2021] [Accepted: 02/14/2021] [Indexed: 12/20/2022]
Abstract
Invasive aspergillosis (IA) is an important opportunistic infection among patients with liver disease and liver transplants. Diagnosis of IA may be challenging, especially among patients with central nervous system infection. Herein, we demonstrate the utility of next-generation sequencing of microbial cell-free DNA in the diagnosis of fungal brain abscess in a liver transplant recipient.
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Affiliation(s)
- Akira A Shishido
- Division of Infectious Diseases, University of Maryland Medical Center, Baltimore, MD, USA
| | - Alexander Vostal
- Division of Infectious Diseases, University of Maryland Medical Center, Baltimore, MD, USA
| | - Romana Mayer
- Department of Pathology, University of Maryland, Baltimore, MD, USA
| | - Cheng-Ying Ho
- Department of Pathology, University of Maryland, Baltimore, MD, USA
| | - John W Baddley
- Division of Infectious Diseases, University of Maryland Medical Center, Baltimore, MD, USA
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11
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Koehler P, Bassetti M, Chakrabarti A, Chen SCA, Colombo AL, Hoenigl M, Klimko N, Lass-Flörl C, Oladele RO, Vinh DC, Zhu LP, Böll B, Brüggemann R, Gangneux JP, Perfect JR, Patterson TF, Persigehl T, Meis JF, Ostrosky-Zeichner L, White PL, Verweij PE, Cornely OA. Defining and managing COVID-19-associated pulmonary aspergillosis: the 2020 ECMM/ISHAM consensus criteria for research and clinical guidance. Lancet Infect Dis 2020; 21:e149-e162. [PMID: 33333012 PMCID: PMC7833078 DOI: 10.1016/s1473-3099(20)30847-1] [Citation(s) in RCA: 498] [Impact Index Per Article: 124.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 10/10/2020] [Accepted: 10/14/2020] [Indexed: 01/08/2023]
Abstract
Severe acute respiratory syndrome coronavirus 2 causes direct damage to the airway epithelium, enabling aspergillus invasion. Reports of COVID-19-associated pulmonary aspergillosis have raised concerns about it worsening the disease course of COVID-19 and increasing mortality. Additionally, the first cases of COVID-19-associated pulmonary aspergillosis caused by azole-resistant aspergillus have been reported. This article constitutes a consensus statement on defining and managing COVID-19-associated pulmonary aspergillosis, prepared by experts and endorsed by medical mycology societies. COVID-19-associated pulmonary aspergillosis is proposed to be defined as possible, probable, or proven on the basis of sample validity and thus diagnostic certainty. Recommended first-line therapy is either voriconazole or isavuconazole. If azole resistance is a concern, then liposomal amphotericin B is the drug of choice. Our aim is to provide definitions for clinical research and up-to-date recommendations for clinical management of the diagnosis and treatment of COVID-19-associated pulmonary aspergillosis.
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Affiliation(s)
- Philipp Koehler
- Faculty of Medicine, University of Cologne, Cologne, Germany; Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, University of Cologne, Cologne, Germany; Department I of Internal Medicine, European Excellence Center for Medical Mycology (ECMM), University Hospital Cologne, Cologne, Germany
| | - Matteo Bassetti
- Infectious Diseases Clinic, Department of Health Sciences, University of Genoa, Genoa, Italy; Policlinico San Martino Hospital, Genoa, Italy
| | - Arunaloke Chakrabarti
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sharon C A Chen
- Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, New South Wales Health Pathology, Sydney, NSW, Australia; Department of Infectious Diseases, Westmead Hospital, Sydney, NSW, Australia; School of Medicine, University of Sydney, Sydney, NSW, Australia
| | | | - Martin Hoenigl
- Clinical and Translational Fungal-Working Group and Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, CA, USA; Section of Infectious Diseases and Tropical Medicine and Division of Pulmonology, Medical University of Graz, Graz, Austria
| | - Nikolay Klimko
- Department of Clinical Mycology, Allergology and Immunology, North Western State Medical University, St Petersburg, Russia
| | - Cornelia Lass-Flörl
- Institute of Hygiene and Medical Microbiology, ECMM, Medical University of Innsbruck, Innsbruck, Austria
| | - Rita O Oladele
- Department of Medical Microbiology and Parasitology, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Donald C Vinh
- Division of Infectious Diseases, Department of Medicine, Department of Medical Microbiology, and Infectious Diseases and Immunity in Global Health Program, Research Institute of the McGill University Health Centre, McGill University Health Centre, Montreal, QC, Canada
| | - Li-Ping Zhu
- Department of Infectious Diseases, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Boris Böll
- Faculty of Medicine, University of Cologne, Cologne, Germany; Department I of Internal Medicine, European Excellence Center for Medical Mycology (ECMM), University Hospital Cologne, Cologne, Germany
| | - Roger Brüggemann
- Department of Pharmacy, ECMM, Center of Expertise in Mycology Radboudumc/CWZ, Radboud University Medical Center, Radboud University, Nijmegen, Netherlands; Radboudumc Institute of Health Science, ECMM, Center of Expertise in Mycology Radboudumc/CWZ, Radboud University Medical Center, Radboud University, Nijmegen, Netherlands
| | - Jean-Pierre Gangneux
- Université de Rennes, CHU de Rennes, EHESP, Institut de Recherche en Santé, Environnement et travail, Inserm UMR_S 1085, Rennes, France
| | - John R Perfect
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Duke University, Durham, NC, USA
| | - Thomas F Patterson
- University of Texas Health San Antonio, San Antonio, TX, USA; University Health, San Antonio, TX, USA; South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Thorsten Persigehl
- Faculty of Medicine, University of Cologne, Cologne, Germany; Department of Radiology, University Hospital Cologne, Cologne, Germany
| | - Jacques F Meis
- Department of Medical Microbiology, ECMM, Center of Expertise in Mycology Radboudumc/CWZ, Radboud University Medical Center, Radboud University, Nijmegen, Netherlands; Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital, Nijmegen, Netherlands; Bioprocess Engineering and Biotechnology Graduate Program, Federal University of Paraná, Curitiba, Brazil
| | - Luis Ostrosky-Zeichner
- Division of Infectious Diseases, McGovern Medical School, University of Texas, Houston, TX, USA
| | - P Lewis White
- Mycology Reference Laboratory, Public Health Wales Microbiology Cardiff, Cardiff, UK
| | - Paul E Verweij
- Department of Medical Microbiology, ECMM, Center of Expertise in Mycology Radboudumc/CWZ, Radboud University Medical Center, Radboud University, Nijmegen, Netherlands; Center for Infectious Diseases Research, Diagnostics and Laboratory Surveillance, National Institute for Public Health and the Environment, Bilthoven, Netherlands
| | - Oliver A Cornely
- Faculty of Medicine, University of Cologne, Cologne, Germany; Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, University of Cologne, Cologne, Germany; Department I of Internal Medicine, European Excellence Center for Medical Mycology (ECMM), University Hospital Cologne, Cologne, Germany; Clinical Trials Centre Cologne, ZKS Köln, Cologne, Germany; German Center for Infection Research, Partner Site Bonn-Cologne, Cologne, Germany.
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12
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Bienvenu AL, Bleyzac N, Richard JC, Leboucher G. No time for pending confirmation of invasive fungal disease in critically ill COVID-19 patients-think empirical treatment. Crit Care 2020; 24:588. [PMID: 32993759 PMCID: PMC7523265 DOI: 10.1186/s13054-020-03307-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 09/22/2020] [Indexed: 01/22/2023]
Affiliation(s)
- Anne-Lise Bienvenu
- Service Pharmacie, Groupement Hospitalier Nord, Hospices Civils de Lyon, 103 grande rue de la Croix-Rousse, 69004, Lyon, France. .,ICBMS CNRS 5246, Campus Lyon-Tech La Doua, Université de Lyon, Lyon, France.
| | - Nathalie Bleyzac
- Service Pharmacie, Groupement Hospitalier Nord, Hospices Civils de Lyon, 103 grande rue de la Croix-Rousse, 69004, Lyon, France
| | - Jean-Christophe Richard
- Service de réanimation médicale, Groupement Hospitalier Nord, Hospices Civils de Lyon, Lyon, France
| | - Gilles Leboucher
- Service Pharmacie, Groupement Hospitalier Nord, Hospices Civils de Lyon, 103 grande rue de la Croix-Rousse, 69004, Lyon, France
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13
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Schein F, Munoz-Pons H, Mahinc C, Grange R, Cathébras P, Flori P. Fatal aspergillosis complicating severe SARS-CoV-2 infection: A case report. J Mycol Med 2020; 30:101039. [PMID: 32861584 PMCID: PMC7440034 DOI: 10.1016/j.mycmed.2020.101039] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 08/03/2020] [Accepted: 08/17/2020] [Indexed: 01/16/2023]
Abstract
As aspergillosis is a well-known complication of severe influenza, we suggest that SARS-CoV-2 might be a risk factor for invasive aspergillosis (IA). We report the case of an 87 year-old woman, with no history of immune deficit, admitted in our emergency room for severe respiratory distress. Coronavirus disease 2019 (COVID-19) diagnosis was confirmed by a SARS-CoV-2 reverse transcriptase polymerase chain reaction (PCR) on nasal swab. On day 14, pulmonary examination deteriorated with haemoptysis and a major increase of inflammatory response. A computed tomography (CT) scan revealed nodules highly suggestive of IA. Aspergillus antigen was found highly positive in sputum and blood, as was Aspergillusspp PCR on serum. Sputum cultures remained negative for Aspergillus. This patient died rapidly from severe respiratory failure, despite the addition of voriconazole. Considering SARS-CoV-2 acute respiratory distress syndrome (ARDS) as an acquired immunodeficiency, we report here a new case of "probable" IA based on clinical and biological arguments, in accordance with the last consensus definition of invasive fungal disease. On a routine basis, we have detected 30% of aspergillosis carriage (positive culture and antigen in tracheal secretions) in critically ill patients with COVID-19 in our centre. Further studies will have to determine whether sputum or tracheal secretions should be systematically screened for fungal investigations in intensive care unit (ICU) COVID-19 patients to early diagnose and treat aspergillosis.
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Affiliation(s)
- F Schein
- Department of internal medicine, University Hospital of Saint-Étienne, Saint-Étienne, France
| | - H Munoz-Pons
- Department of internal medicine, University Hospital of Saint-Étienne, Saint-Étienne, France
| | - C Mahinc
- Laboratory of infectious agents, Parasitology-Mycology Section, University Hospital of Saint-Étienne, Saint-Étienne, France
| | - R Grange
- Department of Radiology, University Hospital of Saint-Étienne, Saint-Étienne, France
| | - P Cathébras
- Department of internal medicine, University Hospital of Saint-Étienne, Saint-Étienne, France
| | - P Flori
- Laboratory of infectious agents, Parasitology-Mycology Section, University Hospital of Saint-Étienne, Saint-Étienne, France.
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