Clinical Characteristics and Outcomes of Invasive Aspergillosis in Patients with Hematological Malignancies and Transplantation and Cellular Therapies in the Contemporary Era.

COVID-19-associated pulmonary aspergillosis (CAPA): how big a problem is it?

A retrospective analysis of the medical data of 12 patients with COVID-19 was performed. For the diagnosis of invasive aspergillosis the international criteria ECMM/ISHAM 2020 were used. We analyzed the scientific literature data on the diagnosis and treatment of invasive aspergillosis in patients with COVID-19.Results. Among the 12 examined patients with a severe course of COVID-19, invasive aspergillosis was diagnosed in 5 patients. Four patients (80%) were treated in the ICU. Steroids or interleukin-6 inhibitors were used in 80% patients. Severe lymphocytopenia was in 80% patients, neutropenia 20%. A fever refractory to antibiotic therapy was noted in 80% patients, an increase in respiratory failure – 60%, acute respiratory distress syndrome – 60%. All patients showed negative dynamics of changes in the chest CT scan. Invasive aspergillosis was confirmed with a positive test for galactomannan in bronchoalveolar lavage and / or serum in 100% of cases. All patients received antifungal therapy with voriconazole and/or caspofungin. The overall 12-week survival rate was 80%.Conclusion. In ICU patients with severe COVID-19 and progressive pulmonary symptoms invasive aspergillosis should be excluded. Examination of substrates from the lower respiratory tract (BAL, tracheal aspirate, or nonbronchoscopic lavage) is necessary. Laboratory examination should include microscopy, culture and test for galactomannan. Voriconazole and isavuconazole are drugs of choice for the treatment of invasive aspergillosis in patients with COVID-19.

Invasive Aspergillosis in Solid Organ Transplant Recipients

The epidemiology of invasive aspergillosis (IA) in patients with acute lymphoid leukemia (ALL) has not been well characterized. To identify potential peculiarities in the natural history, treatment response and outcome of IA diagnosed in patients with ALL and AML. This is a retrospective cohort study conducted in seven tertiary-care hospitals between 2009 and 2017 of all consecutive episodes of IA occurring in adult patients with acute leukemia. Demographic characteristics, underlying disease and recent treatment, antifungal prophylaxis, neutropenia, receipt of corticosteroids, clinical and radiological findings, mycological results, antifungal therapy, and 6-week and 12-week survival were recorded. We identified 77 cases of IA in 54 patients with AML and 23 patients with ALL. The majority of patients developed IA in the context of induction chemotherapy for newly diagnosed (48.0%) or relapsed (41.6%) leukemia, with no differences between ALL and AML. Lung involvement was more frequent in AML (96.3% vs. 82.6%, p = 0.06) and rhinosinusitis was more common in ALL (43.5% vs. 24.1%, p = 0.09). Galactomannan was the microbiologic documentation of IA in 76.6%, with similar patterns of positivity in AML and ALL. The 6-week survival of IA in patients with AML and ALL was 63.0% and 56.5%, respectively (p = 0.60). The epidemiology, clinical presentation, diagnosis and outcome of IA in ALL patients are similar to patients with AML.

The 2015 International Society for Heart and Lung Transplant (ISHLT) fungal guidelines recommend the use of bronchoalveolar lavage (BAL) galactomannan over serum galactomannan for the diagnosis of invasive aspergillosis (IA) in lung transplant (LTx) recipients, based on limited evidence. Galactomannan testing is costly. A single-center, retrospective cohort study reviewing all 814 serum and BAL galactomannan samples received from 184 LTx recipients in our center between 2021 and 2022 and assessing their diagnostic performance in the diagnosis of IA. Over the study period, 394 serum galactomannan samples were received from 144 patients and 420 BAL galactomannan samples from 143 patients. Using a cut-off of ≥ 1.0 for BAL galactomannan, the sensitivity and specificity were 65.9% and 98.4%, respectively. In total, 30 patients had positive BAL galactomannan. Antifungal therapy was commenced or continued in 29 of these patients either as targeted or pre-emptive treatment. Using a cut-off of ≥ 0.5 for serum galactomannan, the sensitivity and specificity were 9.7% and 99.7%, respectively. In total, four patients had a positive serum galactomannan. All four patients were either already on antifungal treatment for IA or were started before the serum galactomannan result was available, supported by laboratory, clinical, and radiological findings. A positive serum galactomannan was used to monitor treatment response in one patient. Serum galactomannan is not a valuable test in the diagnosis of IA in our LTx recipients, is costly, and does not remove the need for bronchoscopy and BAL galactomannan. This supports the ISHLT recommendation.

Aspergillosis in Solid Organ Transplantation

Invasive aspergillosis (IA) remains an important cause of mortality in acute leukaemia patients. Previous studies reported that serum galactomannan (GM) levels correlate strongly with IA outcomes in patients with haematological cancers. This study aimed to clarify the usefulness of serial GM testing for outcome evaluation of IA in acute leukaemia patients. We retrospectively analysed 58 acute leukaemia patients who had IA during neutropenic period after chemotherapy and whose serum GM was serially monitored until discharge or death. The kappa correlation coefficient was used to determine the strength of correlation between GM and clinical outcome (survival or death) of IA. The correlation between clinical outcome and GM kinetics was good at week 6 [κ = 0.663, 95% confidence interval (CI): 0.465-0.861] and excellent at week 12 (κ = 0.819, 95% CI: 0.667-0.91). Survival was significantly better in patients whose GM values normalised than in patients with persistently positive GM (P < 0.0001) regardless of whether neutropenia resolved or acute leukaemia responded to chemotherapy. In neutropenic patients with acute leukaemia, serum GM correlated strongly with survival outcome of IA. This finding further supports the usefulness of the GM index as a surrogate marker for assessing IA outcome and the need for serial GM testing in therapeutic monitoring.

The incidence of opportunistic invasive fungal infections (IFIs) is on the rise, largely driven by the growing number of immunocompromised patients who are at high risk of contracting fungal infections. Patients with haematological malignancies and lung transplantation are particularly vulnerable to IFIs caused by moulds, with Aspergillus species being the predominant fungal pathogen. At the same time, the less well-known moulds such as members of the Scedosporium genera are an emerging cause of IFIs. To date, the management of IFIs in immunocompromised patients remains to be optimised from the aspects of diagnostics, therapeutic antifungal drug monitoring and pharmacoeconomics of antifungal therapy. This thesis aimed to derive critical data to improve the clinical management of IFIs in immunocompromised patients. Specifically, the work in this thesis addresses: the utility of newer diagnostic platforms i.e. Aspergillus galactomannan (GM) and polymerase chain reaction (PCR) assays in haematology patients, voriconazole concentrations in lung transplant recipients, and the pharmacoeconomic of antifungal prophylaxis and invasive scedosporiosis in the haematology population. Non-culture-based diagnostic tests may assist the diagnosis of invasive aspergillosis and guide directed antifungal therapy. However, the clinical utility of Aspergillus GM antigen and Aspergillus genome when tested on bronchoalveolar lavage (BAL) fluid of patients with haematological malignancies remains uncertain. A systematic review and meta-analysis evaluating the diagnostic performance of BAL GM assay in haematology patients was performed. Results from the meta-analysis confirmed the usefulness of GM quantification in BAL fluid for the diagnosis of invasive aspergillosis, yielding a sensitivity, specificity, positive likelihood ratio and negative likelihood ratio of 92%, 98%, 53.7 and 0.08, respectively, at the index cutoff value of 1.5. Combining BAL GM with serum GM or PCR led to a marginal increase in overall sensitivity. Test specificity was significantly decreased by administration of a β-lactam antibiotic at the time of BAL, but sensitivity was not significantly reduced by receipt of mould-active antifungal agents. Many of the previous studies (included in the meta-analysis aforementioned) evaluating the diagnostic accuracy of BAL GM or PCR have restricted study population or bias, which could affect the test performance estimated. As such, to assess the utility of BAL GM and PCR for the diagnosis of invasive pulmonary aspergillosis in routine clinical practice, a multicentre retrospective study involving high-risk haematology patients undergoing BAL was conducted. Our data showed that, in this unselected group of haematology patients in receipt of mould-active antifungal agents and β-lactam antibiotic, BAL GM had lower sensitivity than PCR (61% versus 78%) at an index cutoff of 0.8, but the specificity was higher (93% versus 81%). The optimal OD index cutoff for BAL GM determined in this observational study was lower than that in the aforementioned meta-analysis, probably related to the case-mix of haematology patients, use of therapeutic agents, and BAL protocol. Similar to the findings in our meta-analysis, the sensitivity of both tests was not significantly decreased by administration of mould-active antifungal agent, and the detection rate of invasive pulmonary aspergillosis was not improved by a combination of BAL GM and PCR diagnostic modalities. The thesis also investigated the relationship between trough plasma and pulmonary epithelial lining fluid (ELF) concentrations of voriconazole in lung transplant recipients, with the intention of exploring if plasma voriconazole concentration can be used as a surrogate for the corresponding concentration in ELF. A high-performance liquid chromatographic fluorescence detection method was developed and validated to facilitate measurement of voriconazole concentration in human BAL fluid; a modification of the method was used to quantify voriconazole in plasma. Simultaneous trough concentrations of voriconazole in plasma and ELF (the latter determined from BAL concentration) of 12 lung transplant recipients were determined in a prospective pilot study. Voriconazole achieved consistently higher concentration in the ELF than plasma (mean ± SD ELF:plasma ratio = 12.5 ± 6.3). A strong positive linear relationship between trough plasma and ELF voriconazole concentrations was observed (r2=0.868), which can be described by the equation [VRC]ELF=15.4*[VRC]plasma–1.16, where [VRC]ELF is the voriconazole concentration in ELF and [VRC]plasma is the plasma voriconazole concentration. Findings from this preliminary study suggested the potential for using trough plasma voriconazole concentration as a surrogate for the corresponding concentration in ELF. Another major work of this thesis focuses on the pharmacoeconomics of managing IFIs in the haematology population. Antifungal therapy has a large impact on health resource utilisation and there is currently a paucity of data to guide the selection of antifungal agent for prophylactic use in patients undergoing consolidation chemotherapy for acute myeloid leukaemia. Hence, a pharmacoeconomic evaluation comparing fluconazole, posaconazole and voriconazole prophylaxis was conducted, using retrospective data collected from medical records and cost inputs obtained from Australian databases. The decision-analytical modelling was performed from the perspective of Australian public hospitals. Fluconazole prophylaxis was the most cost-effective approach, with a mean per-patient cost saving of AU$8430 (95% CI AU$5803–AU$11 054) versus posaconazole, and AU$3681 (95% CI AU$990–AU$6319) versus voriconazole. The robustness of the model was confirmed in one-way sensitivity analyses. Little is known about the costs of treating scedosporiosis despite its increasing importance. A multicentre retrospective case-control study was undertaken. Case patients with scedosporiosis were matched (1:2) to controls. Median regression modelling was used to adjust for variables that were not accounted for in the matched-pairs analysis. Invasive scedosporiosis was shown to impose substantial impact on the hospital resources at an adjusted median excess cost of AU$23611, increased median duration of hospitalisation by 13 days and result in a 38-fold elevation in the mortality rate in haematology patients. This is the first report of the attributable economic and clinical outcomes of invasive scedosporiosis in patients with haematological malignancies. In conclusion, this thesis has explored several critical aspects related to the management of IFIs in immunocompromised patients. Importantly, the data generated will assist healthcare providers such as clinicians and pharmacists in moving towards enhanced utilisation of newer fungal diagnostics and antifungal therapy to manage IFIs.

Limited specific data and investigations are available for invasive aspergillosis (IA) in pediatric patients. We evaluated the diagnostic potential of three noninvasive tests including the Platelia Aspergillus EIA kit for using galactomannan antigen, (1,3)-β-D-glucan Detection Reagent Kit, and nested-PCR for Aspergillus DNA in sera. We evaluated the diagnostic potential of three noninvasive tests including EIA for galactomannan antigen (Platelia Aspergillus), nested PCR assay for Aspergillus DNA and test for(1→3)-β-D-glucan (Glucatell assay Kit). All pediatric patients treated at the hematology/oncology unit who were at increased risk of developing invasive aspergillosis were enrolled. Clinical samples were examined for Aspergillus infections by mycological methods. Serial blood samples were collected twice weekly and evaluated by noninvasive tests. We analyzed 230 consecutive blood samples from 62 pediatric patients. The incidence rate of invasive aspergillosis in the patients was found to be 27.4%, and the etiologic agents were Aspergillus flavus, Aspergillus fumigatus, and Aspergillus spp. The sensitivity, specificity, positive and negative predictive values, and likelihood ratios for positive and negative results of galactomannan in patients with proven and probable IA were 90%, 92%, 81.8%, 96%, 11.25, and 0.1; for beta-D-glucan they were 50%, 46%, 26%, 70.6%, 0.9, 0.9; and for nested-PCR they were 80%, 96.2%, 88.9%, 92.6%, 21, and 0.2, respectively. The conventional methods are not able to detect IA, due to the lack of valid and proper sampling. Galactomannan and nested-PCR tests in serum, with enough accuracy and reliability, can serve as noninvasive methods for the detection of IA in pediatric patients. However, the beta-D-glucan test cannot serve as an efficient diagnostic tool in those with hematologic disorders.

Data concerning the incidence of invasive aspergillosis (IA) in high-risk patients in Greece are scarce, while the impact of the revised 2020 EORTC/MSGERC consensus criteria definitions on the reported incidence rate of IA remains unknown. A total of 93 adult hematology patients were screened for IA for six months in four tertiary care Greek hospitals. Serial serum specimens (n = 240) the sample was considered negative by PCR were collected twice-weekly and tested for galactomannan (GM) and Aspergillus DNA (PCR) detection. IA was defined according to both the 2008 EORTC/MSG and the 2020 EORTC/MSGERC consensus criteria. Based on the 2008 EORTC/MSG criteria, the incidence rates of probable and possible IA was 9/93 (10%) and 24/93 (26%), respectively, while no proven IA was documented. Acute myeloid leukemia was the most (67%) common underlying disease with most (82%) patients being on antifungal prophylaxis/treatment. Based on the new 2020 EORTC/MSGERC criteria, 2/9 (22%) of probable and 1/24 (4%) of possible cases should be reclassified as possible and probable, respectively. The episodes of probable IA were reduced by 33% when GM alone and 11% when GM + PCR were used as mycological criterion. The incidence rate of IA in hematology patients was 10%. Application of the 2020 EORTC/MSGERC updated criteria results in a reduction in the classification of probable IA particularly when PCR is not available.

Cerebral aspergillosis is a rare complication of multiple trauma. In this report, we present a remarkable case of multiple lung and brain lesions caused by aspergillosis after a falling incident. A 54-year-old male was admitted with multiple trauma (brain contusion, aspiration pneumonitis with pulmonary contusion, right humerus fracture and right scapular fracture) due to a 6-m fall and aspiration of slops. In view of aspiration pneumonitis (Figure ​(Figure1,1, day 1), intravenous antibiotic treatment (tazocin, moxifloxacin hydrochloride and metronidazole) was started. Brain computerized tomography (CT) on day 12 indicated a focus of encephalomalacia in the left frontal lobe, which was thought to be the progress of brain contusion (Figure ​(Figure1,1, day 12). On the same day, chest CT showed a pulmonary halo sign on the left upper lung (Figure ​(Figure1,1, day 12), and voriconazole therapy was used because of high suspicion of invasive pulmonary fungal infection. Voriconazole treatment had to be stopped, however, due to severe rash 5 days later. Anti-fungus therapy was continued with caspofungin. On day 19, the brain CT showed signs of fungus infection (Figure ​(Figure1,1, day 19). Twenty-two days after injury, the central venous catheter culture grew aspergillus species and established the diagnosis of invasive aspergillosis in this patient; liposomal amphotericin B was then also added to the patient's treatment. On day 34, enhanced CT imaging of the brain showed progression of multiple lesions of fungus infection (Figure ​(Figure1,1, day 34). Unfortunately, the patient died 40 days after injury. Figure 1 Chest and brain computerized tomography on days 1, 12, 19, 28, and 34. Aspiration pneumonitis with pulmonary contusion was shown on day 1. Black arrows, multiple lesions of fungus infection in both the lung and the brain. White arrows, progression of ... We have described invasive aspergillosis with a rapidly progressive and fatal pulmonary and cerebral course in a previously healthy man. Neuroaspergillosis is an uncommon infection associated with an exceedingly high mortality. The diagnosis of neuroaspergillosis is difficult, often made at the terminal stage of disease or on autopsy [1]. Perhaps due to the greater penetration into the central nervous system (CNS), voriconazole treatment greatly improved clinical outcomes with a survival rate of 30% in high-risk patients [2,3]. According to the guidelines for treating invasive pulmonary aspergillosis, voriconazole is recommended for primary treatment [4]. Unfortunately, this patient was refractory to voriconazole because of severe rash, and then caspofungin was selected for salvage therapy. Owing to the large molecular mass, high protein binding and water solubility of caspofungin, its penetration into the CNS was limited [5]; this invasive pulmonary aspergillosis was then further complicated by dissemination to the CNS on day 19. In conclusion, we report a rare trauma case accompanied with invasive pulmonary and CNS aspergillosis following slops aspiration. This case highlights the diagnostic challenge presented by invasive aspergillosis in non-neutropenic patients and underscores its poor prognosis.

Reliable data defining risk factors for invasive aspergillosis (IA) in haematological patients are limited. Analysis of factors influencing IA-associated death is especially valuable in the light of recent progress in managing IA. Between 1997 and 2005 we evaluated factors influencing IA-attributable mortality. For univariate analyses we used Wilcoxon and log-rank test, and for multivariate analysis a Cox model of logistic backward regression was applied. Attributable mortality was 41% after 1 y. 50% of attributable deaths occurred within 6 weeks after IA diagnosis. Various parameters significantly correlated with death after IA: 1) uncontrolled malignancy (p =0.007); 2) extrapulmonary disease (p =0.0003); 3) stable disease, mixed response or progressive disease at first radiological evaluation (p =0.004); 4) proven IA (p =0.02); 5) IA > 110 d after PBSCT (p =0.0112). Prolonged duration of neutropenia was associated with increased mortality (p =0.0001). We observed a trend towards improved survival of IA during recent y (2003-2005). In a multivariate analysis, factors independently associated with attributable mortality included y of first diagnosis (p =0.0492), extrapulmonary IA (p =0.0353) and duration of neutropenia (p =0.0088). In conclusion, the identified risk factors may serve for the definition of high-risk situations. In these settings, increased efforts of prevention, early diagnosis and aggressive treatment of IA are warranted in order to improve survival.

The aim of this study was to determine the prevalence of invasive aspergillosis (IA) in patients with liver cirrhosis and the performance of serum galactomannan (GM) screening. Patients with decompensated liver cirrhosis and patients with compensated liver cirrhosis presenting with fever and/or respiratory symptoms were prospectively enrolled. All patients were screened by serum GM twice weekly irrespective of clinical signs and symptoms. Positive serum GM triggered work-up consisting of chest computed tomography and in case of pathological findings bronchoscopy. 150 patients were included in the study. Two (1.3%) had probable, one (0.7%) had possible, and 147 (98%) had no evidence of IA. Both patients with probable IA had compensated liver cirrhosis. Sensitivity for serum GM screening for probable versus no IA was 0.5 (95% CI, 0.09-0.91), specificity 0.97 (95% CI: 0.92-0.99), negative predictive value 0.99 (95% CI, 0.96-0.99) and positive predictive value (PPV) 0.17 (95% CI, 0.01-0.64). PPV was 0.5 (95% CI, 0.03-0.98) in patients with clinical suspicion of IA. In conclusion, prevalence of IA in patients with liver cirrhosis seems to be low. Targeted GM testing in case of clinical suspicion of IA may be associated with markedly higher PPVs when compared to universal GM screening in patients with liver cirrhosis.

Survey of aspergillosis in non-neutropenic patients in Swiss teaching hospitals

INVASIVE PULMONARY ASPERGILLOSIS SUPERINFECTION IN A CRITICALLY ILL PATIENT WITH INFLUENZA A AND LIMITED CORTICOSTEROID EXPOSURE