Pulmonary Invasive Fungal Disease Research Articles

Diagnostic value of microbial cell-free DNA sequencing for suspected invasive fungal infections: a retrospective multicenter cohort study

Abstract Background An early diagnosis and treatment of invasive fungal disease(IFD) is associated with improved outcome, but the moderate sensitivity of non-invasive diagnostic tests makes this challenging. Invasive diagnostic procedures like bronchoalveolar lavage(BAL) have a higher yield but are not without risk. The detection and sequencing of microbial cell-free DNA(mcfDNA) may facilitate a non-invasive diagnosis. Materials In a prospective observational study, we collected plasma in the 120 hours preceding or following a BAL in patients with hematological malignancies suspected for a pulmonary IFD. The EORTC/MSGERC2020 criteria were used for IFD classification. Sequencing was performed by Karius(Redwood City, California) using their Karius Test® (KT) on plasma and a ‘research use only test'(RUO-KT) on BAL fluid if available. Cases with a probable/proven IFD were identified based on standard diagnostic tests on serum and BAL (microscopy, PCR, GM, culture) and used to calculate the sensitivity, specificity and additional diagnostic value of the KT. Results Of 106 patients enrolled, 39 (37%) had a proven/probable invasive aspergillosis (IA), 7 (7%) a non-Aspergillus IFD and 4 (4%) a mixed IFD. The KT detected fungal mcfDNA in 29 (28%) patients. Compared with usual diagnostic tests, the sensitivity and specificity were 44.0%(95%CI:31.2–57.7%) and 96.6%(95%CI:88.5–99.1%). Sensitivity of the KT was higher in non-Aspergillus IFD (Mucorales:2/3, Pneumocystis jirovecii:3/5). On BAL, the sensitivity was 72.2% (95%CI:62.1–96.3%) and specificity 83.3%(95%CI:49.1–87.5%). Conclusions Sequencing of mcfDNA may facilitate a non-invasive diagnosis of IFD in particular non-Aspergillus IFD. However, on plasma and similar to currently available diagnostics, it cannot be used as a “rule-out” test.

The Therapeutic Efficacy and Blood Drug Concentration of Posaconazole Enteric-Coated Tablets in Preventing Pulmonary Invasive Fungal Disease after HSCT

Introduction The risk of fungal infection in patients after HSCT is high. Prophylactic use of antifungal drugs can significantly reduce the occurrence of invasive fungal disease (IFD) and potential IFD-related mortality. Posaconazole oral suspension shows good preventive effects for patients with neutropenia and severe GVHD . However, there is still a lack of prospective research confirming the effectiveness of posaconazole enteric-coated tablets in preventing fungal infections in HSCT patients. Methods This study is a prospective, non-randomized, single-arm study. 143 patients who received hematopoietic stem cell transplantation at the Transplantation Center of Blood Diseases Hospital, the Chinese Academy of Medical Sciences from December, 2020 to May, 2022 were included. Posaconazole enteric-coated tablets were administered orally at a dose of 300mg QD (double dose for the first day) for the prevention of pulmonary invasive fungal disease from the first day to the 90th day after transplantation. The study collected baseline data, serum posaconazole concentrations, UGT1A4*3 genotype of the involved patients and observed whether pulmonary invasive fungal disease occurred. Retrospective data on the use of other antifungal drugs for the prevention of pulmonary invasive fungal disease at the center were collected as a control group for comparison. After applying propensity score matching at a ratio of 1:2, a comparative analysis was conducted on 140 cases in the posaconazole enteric-coated tablets group and 280 cases in the non-posaconazole group. Results Among the 143 patients who were included in the clinical trial and treated with posaconazole enteric-coated tablets alone for the prevention of fungal infection from day 1 to day 90 after hematopoietic stem cell transplantation, 4 cases developed invasive pulmonary fungal infection, including 1 case of mold and 3 cases of undefined pathogens, with a breakthrough rate of 2.80%, significantly lower than the historical control group breakthrough rate of 7.86% in the non-posaconazole group (P=0.014). In the 90 days after transplantation, a total of 246 measurements of posaconazole blood concentration were performed in the 143 patients in the clinical trial group. The average blood drug concentrations on the 4th, 8th, 15th, 22nd, and 30th day were 930.97 ng/ml, 1143.97 ng/ml, 1569.8 ng/ml, 1652.57 ng/ml, and 1644.75 ng/ml respectively. The blood drug concentration of posaconazole enteric-coated tablets tended to stabilize since the 15th day after treatment. In the 37 patients who tested the UGT1A4*3 genotype, there was no significant correlation between UGT1A4*3 gene polymorphism and posaconazole blood drug concentration. In terms of adverse reactions, the incidence of liver adverse events in this clinical study was 1.4%. Except for a slight increase in ALT after the 14-day medication (18.29 U/L vs. 26.22 U/L, P<0.001), there were no differences in other liver and kidney function laboratory test before and after treatment. Conclusion Posaconazole enteric-coated tablets is a highly safe prophylactic drug for invasive pulmonary fungal infections after HSCT, and its efficacy is superior to other antifungal prophylaxis regimens. Posaconazole enteric-coated tablet blood drug concentration in transplant patients gradually rose over time and tended to stabilize after 15 days of medication. The UGT1A4*3 gene polymorphism has no effect on the blood drug concentration of posaconazole enteric-coated tablets. Keywords Posaconazole enteric-coated tablets, hematopoietic stem cell transplantation, pulmonary invasive fungal disease

Pulmonary Invasive Fungal Disease: Ultrasound and Computed Tomography Scan Findings.

The importance of ultrasound in diagnosing pulmonary invasive fungal diseases (IFD) has yet to be assessed. Thus, this study aimed to evaluate the frequency of sonographic findings in patients suspected of an invasive pulmonary fungal infection. This prospective longitudinal study examined all patients with lung lesions in imaging modalities and suspected IFDs referred to Dr. Sheikh and Akbar pediatric hospitals from 2019 to 2022. Considered variables were the halo sign in the computed tomography (CT) scan; the target sign in the ultrasound and contrast-enhanced CT scan; the cavity; wedge-shaped consoli- dation; and pleuritis and extrapulmonary invasion to the chest wall or subdiaphragmatic invasion in both modalities. All patients who underwent lung CT scans and ultrasounds until the final diagnosis were followed up. The degree of agreement between ultrasound and CT scan findings and the sensitivity, specificity, and diagnostic accuracy of these signs were assessed. This study involved 40 patients with an average age of 7.16 ± 4.23 years. Acute leukemia was the commonest underlying dis- ease detected in 17 (42.5%) cases. The target sign in ultrasound (61.9%) and the halo sign in CT scan (71.4%) had the highest frequency among the variables in patients with IFD. Cohen's kappa coefficient agreement in both modalities was 0.5 for the cavity, with significant relation (P = .02). The Cohen's kappa was less than .17 for other findings (P > .05). The diagnostic criteria in the simultaneous examina- tion of the fungus target in ultrasound and halo in CT scan showed a sensitivity of 82.4% and specificity of 76.5%, respectively. Combining the characteristic findings of ultrasound and CT-scan provides a higher value in diagnosing pulmonary invasive fungal disease.

Invasive fungal infections in children with leukemia in a tertiary hospital in Oman: An eight-year review.

Invasive fungal disease (IFD) is a common and serious consequence of leukemia in children and the incidence of these infections has increased due to chemotherapy. This study aimed to present the epidemiology of IFD in a cohort of children with leukemia from a tertiary reference institution in Oman. A retrospective study of IFDs in pediatric patients below 13 years of age with newly diagnosed or relapsed leukemia was conducted at the Royal Hospital in Muscat, Oman. From 2010 to 2017, IFD episodes in children with leukemia were evaluated retrospectively, considering age, gender, type of leukemia, chemotherapy regimen, IFD detection phase, neutropenia, prevention, diagnostic method, and treatment. Between 2010 and 2017, 198 children with leukemia were admitted and treated at Royal Hospital. Invasive fungal infection (IFI) was diagnosed in 32 patients out of 198 (16.1%), and IFI was defined as probable and proven in 53% (n=17) and 47% (n=15) of the cases, respectively. At 1.1:1, the male-to-female ratio was roughly equal. According to chest computed tomography scans, 65.6% of patients had radiological features of fungal infections. Positive fungal cultures were found in the bronchoalveolar lavage of three patients, 37.5% of whom had positive blood cultures, and 3% had positive urine cultures as a neonatal invasive candidiasis. In three patients, invasive aspergillosis caused pulmonary IFD, accounting for 9.3% of all infection sites. Candidaemia was found in 28% of IFD patients, and the most common organism was Candida tropicalis (15.6%), followed by Candida parapsilosis (6.25%). Furthermore, the major risk factor was febrile neutropenia. In children with leukemia, invasive fungal infection is common and serious. Despite aggressive treatment, mortality among these high-risk patients remains high.

Sequential low-dose CT thorax scans to determine invasive pulmonary fungal infection incidence after allogeneic hematopoietic cell transplantation

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.

Low Incidence of Fungal Infections after Chimeric Antigen Receptor T-Cell Therapy for Non-Hodgkin Lymphoma in an Endemic Region for Coccidioidomycosis

Introduction: CD19-targeted chimeric antigen receptor T-cell therapy (CAR-T) has revolutionized the treatment of non-Hodgkin lymphomas (NHL). Due to underlying NHL, CAR-T therapy, and treatment of associated toxicities, CAR-T recipients are immunocompromised and, consequently, at high risk of infection. Evidence informing prophylaxis (PPx) is limited and often varies based on institutional practice. This study sought to determine the incidence of fungal infection after CAR-T in patients with NHL treated in Arizona and describe PPx strategies. Methods: Using Mayo Clinic Arizona's (MCA), Banner MD Anderson's (BMDACC), and Banner University Medical Center's (BUMC) CAR-T databases, patients who received commercial CD19-targeted CAR-T for NHL between September 2018 and June 2022 were identified. Disease characteristics, prior and subsequent therapy, antimicrobial use, and infectious disease testing were collected. Early and late adverse events including cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), hypogammaglobulinemia, and cytopenias were collected. The 2020 European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium consensus definitions were used to define probable and proven invasive fungal disease (IFD). Results: A total of 55 patients from MCA met inclusion criteria (Table 1). The median age at infusion was 60 years (range 19-78) and median follow-up time was 9.6 months (range 1.3-46.0) post CAR-T infusion. Most patients were male (78.2%, n=43), had diffuse large B-cell lymphoma (45.5%, n=25), and received axicabtagene ciloleucel (69.1%, n=38). Early and late toxicities (Table 2) included grade ≥3 CRS (7.2%, n=4), grade ≥3 ICANS (25.5%, n=14), immunoglobulin G <400 mg/dL (41.8%, n=23) and a CD4 T-cell count <200 cells/mm^3 (81.1%, n=30). Thirty-six patients (65.4%) received tocilizumab, 29 patients (52.7%) received steroids for CRS and/or ICANS. At MCA, two patients (3.6%) had mucocutaneous Candida infection, at day 10 and day 14 post-infusion, respectively. Four patients (7.3%) developed IFD, all of whom were in partial or complete response. Two (3.6%) had biopsy proven pulmonary IFD caused by Aspergillus and Coccidioides at day 64 and day 233 post-infusion, respectively. Two (3.6%) had probable pulmonary IFD caused by Aspergillus and Pneumocystis jirovecii at day 107 and day 209 post-infusion, respectively. These two patients died shortly after their IFD diagnosis, however also had proven COVID-19 infection and bacterial sepsis, respectively. Of those with IFD, only the patient with Pneumocystis jirovecii pneumonia (25%, n=1/4) had received steroids for the treatment of CAR-T related toxicity. No IFDs were identified by database review at Mayo Clinic in Rochester or Florida, thus leading our group to consider endemic risk factors in Arizona. At BUMC, 3 patients (8.5%, n=3/35) developed pulmonary IFD, 2 with Aspergillus and 1 with Coccidioides. At BMDACC, 1 patient (3%, n=1/37) developed Saccharomyces of the tongue at day 30 while receiving fluconazole. At MCA, antifungal PPx, most commonly with fluconazole, was used in those with neutropenia lasting >7 days (49%, n=27), whereas it was used routinely at BMDACC and BUMC for at least 180 days. All patients received trimethoprim-sulfamethoxazole PPx for at least 180 days unless an alternative was necessary. Patients at MCA, BUMC, and BMDACC are routinely screened for Coccidioides prior to CAR-T, although prior anti-B-cell therapy may impact these results. Serum Coccidioides antibody, complement fixation, and immunodiffusion were positive in only 1 MCA patient prior to receiving CAR-T and this patient had an uncomplicated course, although received extended PPx fluconazole. Conclusions: Fungal infection after CAR-T for NHL appears to be uncommon. IFD tends to occur later, often beyond the typical time frame of antifungal PPx and/or caused by organisms not necessarily prevented by typical PPx regimens. Future studies are needed to individualize infectious disease screenings, monitoring, and antifungal PPx in this population. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Application of metagenomic next-generation sequencing in the diagnosis of pulmonary invasive fungal disease.

BackgroundMetagenomic next-generation sequencing (mNGS) is increasingly being used to detect pathogens directly from clinical specimens. However, the optimal application of mNGS and subsequent result interpretation can be challenging. In addition, studies reporting the use of mNGS for the diagnosis of invasive fungal infections (IFIs) are rare.ObjectiveWe critically evaluated the performance of mNGS in the diagnosis of pulmonary IFIs, by conducting a multicenter retrospective analysis. The methodological strengths of mNGS were recognized, and diagnostic cutoffs were determined.MethodsA total of 310 patients with suspected pulmonary IFIs were included in this study. Conventional microbiological tests (CMTs) and mNGS were performed in parallel on the same set of samples. Receiver operating characteristic (ROC) curves were used to evaluate the performance of the logarithm of reads per kilobase per million mapped reads [lg(RPKM)], and read counts were used to predict true-positive pathogens.ResultThe majority of the selected patients (86.5%) were immunocompromised. Twenty species of fungi were detected by mNGS, which was more than was achieved with standard culture methods. Peripheral blood lymphocyte and monocyte counts, as well as serum albumin levels, were significantly negatively correlated with fungal infection. In contrast, C-reactive protein and procalcitonin levels showed a significant positive correlation with fungal infection. ROC curves showed that mNGS [and especially lg(RPKM)] was superior to CMTs in its diagnostic performance. The area under the ROC curve value obtained for lg(RPKM) in the bronchoalveolar lavage fluid of patients with suspected pulmonary IFIs, used to predict true-positive pathogens, was 0.967, and the cutoff value calculated from the Youden index was −5.44.ConclusionsIn this study, we have evaluated the performance of mNGS-specific indicators that can identify pathogens in patients with IFIs more accurately and rapidly than CMTs, which will have important clinical implications.

Impact of treatment intensity on infectious complications in patients with acute myeloid leukemia

BackgroundInfectious complications reflect a major challenge in the treatment of patients with acute myeloid leukemia (AML). Both induction chemotherapy and epigenetic treatment with hypomethylating agents (HMA) are associated with severe infections, while neutropenia represents a common risk factor. Here, 220 consecutive and newly diagnosed AML patients were analyzed with respect to infectious complications dependent on treatment intensity and antifungal prophylaxis applied to these patients.Patients and methodsWe retrospectively analyzed 220 patients with newly diagnosed AML at a tertiary care hospital between August 2016 and December 2020. The median age of AML patients undergoing induction chemotherapy (n = 102) was 61 years (25–76 years). Patients receiving palliative AML treatment (n = 118) had a median age of 75 years (53–91 years). We assessed the occurrence of infectious complication including the classification of pulmonary invasive fungal disease (IFD) according to the EORTC/MSG criteria at diagnosis and until day 100 after initiation of AML treatment. Furthermore, admission to intensive care unit (ICU) and subsequent outcome was analyzed for both groups of AML patients, respectively.ResultsAML patients subsequently allocated to palliative AML treatment have a significantly higher risk of pneumonia at diagnosis compared to patients undergoing induction chemotherapy (37.3% vs. 13.7%, P < 0.001) including a higher probability of atypical pneumonia (22.0% vs. 10.8%, P = 0.026). Furthermore, urinary tract infections are more frequent in the palliative subgroup at the time of AML diagnosis (5.1% vs. 0%, P = 0.021). Surprisingly, the incidence of pulmonary IFD is significantly lower after initiation of palliative AML treatment compared to the occurrence after induction chemotherapy (8.4% vs. 33.3%, P < 0.001) despite only few patients of the palliative treatment group received Aspergillus spp.-directed antifungal prophylaxis. The overall risk for infectious complications at AML diagnosis is significantly higher for palliative AML patients at diagnosis while patients undergoing induction chemotherapy have a significantly higher risk of infections after initiation of AML treatment. In addition, there is a strong correlation between the occurrence of pneumonia including atypical pneumonia and pulmonary IFD and the ECOG performance status at diagnosis in the palliative AML patient group. Analysis of intensive care unit (ICU) treatment (e.g. in case of sepsis or pneumonia) for both subgroups reveals a positive outcome in 10 of 15 patients (66.7%) with palliative AML treatment and in 15 of 18 patients (83.3%) receiving induction chemotherapy. Importantly, the presence of infections and the ECOG performance status at diagnosis significantly correlate with the overall survival (OS) of palliative AML patients (315 days w/o infection vs. 69 days with infection, P 0.0049 and 353 days for ECOG < 1 vs. 50 days for ECOG > 2, P < 0.001, respectively) in this intent-to-treat analysis.ConclusionThe risk and the pattern of infectious complications at diagnosis and after initiation of AML therapy depends on age, ECOG performance status and subsequent treatment intensity. A comprehensive diagnostic work-up for identification of pulmonary IFD is indispensable for effective treatment of pneumonia in AML patients. The presence of infectious complications at diagnosis contributes to an inferior outcome in elderly AML patients.

A Novel Diagnostic Method for Invasive Fungal Disease Using the Factor G Alpha Subunit From Limulus polyphemus.

Deaths due to invasive fungal disease (IFD) have been increasing every year. Early and rapid detection is important to reduce the mortality rate associated with IFD. In this study, we explored a novel diagnostic method for detecting IFD, which involves the G Factor α subunit (GFαSub) from Limulus polyphemus. The GFαSub double-sandwich method was developed to detect (1,3)-β-D-glucans in human serum using purified GFαSub and horseradish peroxidase-labeled GFαSub. The GFαSub double-sandwich method and the G test were performed and compared. Using GFαSub sequence analysis, the expression plasmid pET30a-GFαSub252-668 was synthesized, and GFαSub252-668 was expressed and purified via isopropyl-β-d-thiogalactoside induction and nickel-nitrilotriacetic acid affinity. The optimization method was established via the orthogonal method. Using this method, the sera of 36 patients with IFD and 92 volunteers without IFD underwent detection, and the receiver operating characteristic curve of the GFαSub252-668 double-sandwich method was described. The sensitivity and specificity of the GFαSub252-668 double-sandwich method were 91.67 and 82.61%, respectively, and there was good correlation with the G test for the serum specimens of 36 patients with pulmonary IFD (R2 = 0.7592). In conclusion, our study suggests that the GFαSub252-668 double-sandwich method was satisfactory at detecting IFD cases. This method can be promoted and further developed as a novel method for diagnosing IFD.

Presentation of Sonographic Features of Pulmonary Invasive Fungal Disease in Six Children with Leukemia

Background The early diagnosis of invasive fungal diseases is important because the therapeutic outcome depends on the prompt initiation of appropriate interventions. In this study, we present the feature of ultrasound of pulmonary fungal infection in six children with leukemia. Method and Patients: Between June and November 2020, this cross-sectional study was conducted in the radiology department at Dr. Sheikh Children’s Hospital, Mashhad, Iran. During this period, we reviewed imaging findings of fungal lung infections in six patients with leukemia (ages 5-11 years old) who were referred for chest ultrasound and CT-scan. High-resolution computed tomography (HRCT) of patients showed multiple nodular lesions with/without ground-glass opacity (halo sign or reverse halo sign), and wedge-shape consolidations. In some patients, there were thick wall cavitary lesions with intra-cavitary fungus ball and the air-crescent sign. Ultrasound findings of the lung included the target lesion, the cavitary lesion, wedge-shape consolidation, and extra-pulmonary invasion to the chest wall or sub-diaphragm. The galactomannan test or debridement of para-nasal sinuses confirmed fungal infections; Aspergillosis or Mucormycosis. Conclusion Four characteristic features of pulmonary invasive fungal disease on ultrasound can help in faster diagnosis and monitoring of treatment response in these patients.

Next-generation sequencing technology for detecting pulmonary fungal infection in bronchoalveolar lavage fluid of a patient with dermatomyositis: a case report and literature review

BackgroundInvasive fungal pneumonia is a severe infectious disease with high mortality in immunocompromised patients. However, the clinical diagnosis of the pathogen(s) remains difficult since microbiological evidence is difficult to acquire.Case presentationHere, we report a case of pulmonary fungal infection detected by next-generation sequencing (NGS) of bronchoalveolar lavage fluid (BALF) in a 61-year-old male with corticosteroid-treated dermatomyositis. Cytomegalovirus and influenza A virus infections were confirmed by nucleic acid detection and treated with antiviral medicine. The patient had been diagnosed with severe pneumonia and treated with empiric broad-spectrum antibacterial and antifungal drugs before bronchoscopy was performed. The patient responded poorly to those empiric treatments. Three fungi were found by NGS in the BALF, namely, Pneumocystis jirovecii, Aspergillus fumigatus and Rhizopus oryzae. After adjusting the patient’s treatment plan according to the NGS results, he improved significantly.ConclusionsThis case highlights the combined application of NGS and traditional tests in the clinical diagnosis of pulmonary invasive fungal disease. NGS is proposed as an important adjunctive diagnostic approach for identifying uncommon pathogens.

Dectin-1 rs3901533 and rs7309123 Polymorphisms Increase Susceptibility to Pulmonary Invasive Fungal Disease in Patients with Acute Myeloid Leukemia from a Chinese Han Population.

This study aimed to assess whether genetic variants of dendritic cell-associated C-type lectine-1 (Dectin-1), Toll-like receptor 2 (TLR2), Toll-like receptor 4 (TLR4), and myeloid differentiation primary response 88 (MyD88) influence the susceptibility to pulmonary invasive fungal disease (IFD) in patients with acute myeloid leukemia (AML) from a Chinese Han population. Eight single nucleotide polymorphisms (SNPs) of Dectin-1 (rs16910526, rs3901533, and rs7309123), TLR2 (rs5743708), TLR4 (rs4986790 and rs4986791) and MyD88 (rs4988453 and rs4988457) in the genomic DNA of 172 adult AML patients were genotyped. Pulmonary IFD was diagnosed as proven or probable according to the 2008 European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) consensus guidelines. SNPs that were significant in the univariate analysis were further analyzed using the multiple logistic regression analysis to determine their association with the occurrence of pulmonary IFD. The mRNA expression of Dectin-1 was detected according to the genotype by quantitative realtime PCR (qRT-PCR), and the correlation of this expression with the occurrence of pulmonary IFD in AML patients was analyzed. Two Dectin-1 intron SNPs (rs3901533 and rs7309123) were found to be significantly associated with the susceptibility to pulmonary IFD in AML patients in a Chinese Han population. Significant associations were noted between pulmonary IFD and Dectin-1 rs3901533 dominant model (G/T+G/G vs. T/T, OR: 2.158; 95% CI: 1.109-4.2, P=0.02), Dectin-1 rs3901533 G allele (OR: 2.201; 95% CI: 1.206-4.019, P=0.01), or Dectin-1 rs7309123 C allele (OR: 1.919; 95% CI: 1.047-3.518, P=0.03). There were no significant associations between pulmonary IFD and the remaining Dectin-1 SNPs (rs16910526), TLR2 (rs5743708), TLR4 (rs4986790 and rs4986791) or MyD88 (rs4988453 and rs4988457). In conclusion, two Dectin-1 SNPs (rs3901533 and rs7309123) are associated with increased susceptibility to pulmonary IFD in AML patients in a Chinese Han population.

Incidence, risk factors, and outcome of pulmonary invasive fungal disease after respiratory virus infection in allogeneic hematopoietic stem cell transplantation recipients.

BackgroundThere is growing evidence that community‐acquired respiratory virus (CARV) increases the risk of pulmonary invasive fungal disease (IFD) in the allogeneic hematopoietic stem cell transplantation (allo‐HSCT) setting. To date, there is a lack of knowledge regarding the risk factors (RFs), as well as the most critical period for subsequent onset of IFD after CARV infections in allo‐HSCT recipients.MethodsIn this prospective longitudinal observational CARV survey, we analyzed the effect of CARV on subsequent IFD development in 287 adult allo‐HSCT recipients diagnosed with 597 CARV episodes from December 2013 to December 2018. Multiplex PCR panel assays were used to test CARVs in respiratory specimens.FindingsTwenty‐nine out of 287 allo‐HSCT recipients (10%) developed IFD after a CARV episode. The median time of IFD onset was 21 days (range, 0‐158 days) from day of the first CARV detection. Generalized estimating equation model identified 4 risk factors for IFD: ATG‐based conditioning regimen [odds ratio (OR) 2.34, 95% confidence interval (CI) 1.05‐5.2, P = .038], CARV lower respiratory tract disease (OR 10.6, 95% CI 3.7‐30.8, P < .0001), CARV infection during the first year after transplant (OR 5.34, 95% CI 1.3‐21.8, P = .014), and corticosteroids during CARV (OR 2.6, 95% CI 1.1‐6.3, P = .03).ConclusionAllo‐HSCT recipients conditioned with ATG and under corticosteroid therapy at the time of CARV LRTD during the first year after transplant may require close monitoring for subsequent IFD.

Invasive mucormycosis during treatment for acute lymphoblastic leukaemia\u2014successful management of two life-threatening diseases

A 5-year-old patient treated for acute lymphoblastic leukaemia (ALL) developed proven pulmonary invasive fungal disease (IFD) due to Actinomucor elegans. While completing ALL treatment according to AIEOP ALL protocol 2009 for further 15 months, antifungal treatment with liposomal amphotericin B and intermittent additional posaconazole was continued until immune reconstitution 7 months after the end of ALL treatment. Repeated imaging guided treatment decisions. Twenty-six and 19 months after the end of ALL treatment and antifungal treatment, respectively, the patient is still in the first complete remission and shows no signs of active invasive fungal disease (IFD).

Reassessment of clinical implication of pretransplant surgical procedures for pulmonary invasive fungal lesions.

Dealing with the recent series of allogeneic hematopoietic stem cell transplantation (allo-SCT) performed this decade, we reassessed the clinical impact of pretransplant surgical procedures (SP) for pulmonary lesions of invasive fungal disease (IFD) on subsequent transplant outcome. We focused on the clinical outcomes of seven patients with pulmonary IFD who underwent segmentectomy (n=4), lobectomy (n=2) or abscess incision with drainage only (n=1), and compared results to those of 21 patients carrying pulmonary IFD who never underwent invasive SP before allo-SCT. The rate of exacerbation of pulmonary lesions by 180days after allo-SCT did not differ significantly between groups (32.2% vs 42.9%, P=0.69). Moreover, no significant differences in non-relapse mortality (46.4% vs 42.3%, P=0.93) or overall survival (53.6% vs 30.9%, P=0.45) at 1year were evident between groups. These results indicate that pretransplant SP for pulmonary lesions might have no survival benefit under the current antifungal prophylaxis or treatment modality.

A clinical analysis of micafungin treatment of pulmonary invasive fungal infection in pediatric patients with acute leukemia or post hematopoietic stem cells transplantation

Objective: To investigate the efficacy and safety of micafungin (MCF) for pulmonary invasive fungal disease (PIFD) in pediatric patients with acute leukemia or post hematopoietic stem cells transplantation. Method: Twenty-five neutropenic PIFD children with acute leukemia or post hematopoietic stem cells transplantation in Sun Yat-sen Memorial Hospital of Sun Yat-sen University were selected from January 2012 to June 2015, including 12 males and 13 females, age range 2-15 (average 6.2±2.0) years. There were 12 cases of acute leukemia (AL) after chemotherapy, 4 cases of acute leukemia (AL) after allogeneic hematopoietic stem cell transplantation (allo-HSCT) and 9 cases of β-thalassemia major after allo-HSCT. All children received MCM for the treatment of PIFD, the dosage of MCM was 3-4 mg/ (kg·d) , once a day. The children received 2 to 6 courses of treatment, individually with a course of 7 days. 1, 3-β-D glucan assay (G test), galactomannan antigen test (GM test), high-resolution CT and the biochemical indexes for organ functions were closely monitored. Result: Twenty-five cases were diagnosed as PIFD, including 2 patients diagnosed as proven, 6 as probable and 17 as possible. Of the 25 cases, 1 was confirmed aspergillus by biopsy pathology and 1 was candida albicans by blood culture. The G and GM test with positive results was 5 and 2 respectively. Chest CT scans of the 25 cases had obvious lesions: air crescent sign and cavitation in 4 cases, diffuse ground glass change in 9 cases, double lung scattered patchy, small nodules and cord like high density shadow in 7 cases, unilateral or bilateral chest wall wedge-shaped consolidation edge in 5 cases and pleural effusion in 5 patients. The effective rate of MCF in treatment of PIFD was 68% (17/25), including 13 cases cured, 4 cases improved, 4 cases were improved clinically and in 4 cases the treatment was ineffective. Eight cases were effective in MCF monotherapy group (12 cases) and nine were effective in MCF combined therapy group(13 cases), respectively. Side-effects including allergies, gastrointestinal side effects, electrolyte disturbances, impairment of liver and kidney function, and myelosuppression were not found in those children treated with MCF. Conclusion: Micafungin is effective and safe in the treatment of pulmonary invasive fungal disease in pediatric patients with acute leukemia or post hematopoietic stem cell transplantation.

Caspofungin Treatment for Pulmonary Invasive Fungal Disease in Hematology Patients: A Retrospective Study in a Clinical Practice Setting in China

PurposeInvasive fungal disease (IFD) is a serious complication in patients with hematologic malignancies. Caspofungin is the first approved inhibitor of fungal β-1,3-glucan synthesis. The aim of the present study was to evaluate the effectiveness of caspofungin in the treatment of IFD in patients with hematologic malignancies. MethodsIn this retrospective study, data from the electronic medical records of 1118 inpatients who were admitted to 10 hospitals in China between 2013 and 2014 were analyzed. Inclusion criteria were hematologic disorder and IFD diagnosed during the hospitalization, based on clinical manifestations or evidence of pulmonary invasion, as well as caspofungin treatment for at least 7 days. The primary end point was the favorable response rate at the end of caspofungin as initial therapy for proven/probable/possible pulmonary IFD. The secondary end point was the survival rate after the completion of the caspofungin treatments. FindingsA total of 704 patients were included, of whom 122 had IFD classified as probable/possible and 582 had unclassified IFD. The most frequent hematologic diseases were acute myeloid leukemia (42.8%), followed by acute lymphatic leukemia (18.8%), non-Hodgkin lymphoma (8.8%), aplastic anemia (7.1%), and others (22.5%). The rates of favorable caspofungin response were 57.2% in all patients, 58.2% in the probable/possible IFD group, and 57.0% in the unclassified IFD group. Caspofungin as initial monotherapy led to a favorable response rate of 62.2% in the probable/possible IFD group. Uni- and multivariate analyses revealed that not recovering from neutropenia during antifungal treatment, and advanced age, were significant factors for unfavorable outcomes. The overall IFD-related mortality rate was 4.1%. ImplicationsThe results of our study show that caspofungin treatment of IFD in hematology patients was reasonable, with an overall rate of favorable response of 57.2% with each caspofungin treatment strategy.

A Retrospective Study of Central Nervous System Invasive Fungal Disease after Allogeneic Stem Cell Transplantation: Risk Factors, Clinical Characteristics, and Outcomes

There are limited reports of central nervous system (CNS) invasive fungal disease (IFD) in allogeneic stem cell transplantation (HSCT) recipients. We aimed to describe the clinical characteristics of and the risk factors for CNS-IFD. We retrospectively reviewed consecutive HSCT patients at Peking University Institute of Hematology during a 10-year period. A total of 29 patients were diagnosed with CNS-IFD. The median onset of CNS-IFD was 173 (range, 24 to 972) days after HSCT. The most frequent pathogen was Aspergillus, and the most common clinical symptoms and signs were space-occupying presentations. We found that prior pulmonary IFD (P < .001; hazard ratio, 62.746; 95% confidence interval, 14.28 to 275.27) was the only risk factor associated with occurrence of CNS-IFD. Poor response at 6 weeks after treatment (P = .045; hazard ratio, 2.574; 95% confidence interval, 1.021 to 6.487) was the only risk factor predicting the involvement of the CNS in pulmonary IFD. Overall survival was 24.2% at the last follow-up, with a median of 289 (range, 27 to 3341) days after transplantation. We conclude that patients with pulmonary IFD had higher risk of CNS-IFD, especially in those with poor response after 6 weeks of treatment. The prognosis of CNS-IFD was very poor after HSCT.

Invasive pulmonary aspergillosis in a child with acute myeloid leukaemia: pharmacotherapy and surgical management

This paper reports on diagnostic and therapeutic management of pulmonary invasive fungal disease (IFD) in a child with relapsed acute myeloid leukaemia, undergoing chemotherapy followed by hematopoietic stem cell transplantation. Surgical management with resection of the involved lung tissue was based on the location of fungal infiltrates close to large circulatory vessels. After examination of resected pulmonary tissue, a diagnosis of proven IFD was done. This case report is an example that aspergillosis is usually the cause for pulmonary IFD. Pharmacotherapy of pulmonary IFD should be based on compounds with good penetration to lung tissue: amphotericin B lipid form or voriconazole.

Applicability of the EORTC/MSG criteria for IFD in clinical practice.

Invasive fungal disease (IFD) is a feared complication in patients with hematological malignancies. In 2008, the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycosis Study Group (EORTC/MSG) published updated criteria for the diagnostic workup within clinical studies for immunosuppressed patients with suspected fungal infection. We applied these criteria in a routine clinical setting with regard to their feasibility for bedside practice at our institution in a 1-year period. One hundred seventy consecutive patients with a recent history of chemotherapy-induced neutropenia (n = 100) or allogeneic stem cell recipients (n = 70) who had received a CT scan of the chest in search of pulmonary IFD were examined. We analyzed all available radiological and microbiological data according to the EORTC/MSG criteria. The quality of images was good in 94.7%, microbiological diagnostics performed in 94.1% patients. Five patients had histopathologic-proven IFD, 18 patients were classified as "probable," 55 patients as "possible" IFD, and 92 patients did not fulfill any criteria ("no IFD"). Microbiology revealed suggestive findings in 29 patients. These were either galactomannan antigen (Gm-AG) in serum (n = 18) and/or broncho-alveolar lavage (BAL) (n = 5). CT scan showed pulmonary infiltrates in 106 patients; 78 were classified as typical for IPA, further discriminated by morphology and number of nodules, as well as additional signs (halo, air crescent, cavity). We observed a better overall survival in patients without infiltrates compared to those with any type of infiltrate (p = 0.042) and a trend toward favorable survival in patients who had micronodular lesions (p = 0.058). We also found a higher probability of Gm-AG positivity in the group of allogeneic stem cell transplantation (allo-SCT) patients (p = 0.001) and a trend toward an association of Gm-AG positivity and positive findings on CT (p = 0.054). The applicability of criteria was good, both with regard to radiological and mycological evidence and sufficient for the categorization of IFD according to EORTC/MSG in the clinical setting. However, our findings suggest that feasibility improves with stringency of mycological workup, which is reflected in the two subgroups. Radiology harvests by far more suggestive findings which can only partly be correlated with mycological evidence. Although feasible, whether the EORTC/MSG criteria are the appropriate tool for early identification of IFD remains open for discussion.