key: cord-1054197-dc7pzudb authors: Jiang, Zhaofang; Chen, Shuyan; Zhu, Qing; Xiao, Yanyu; Qu, Jiuxin title: COVID-19-associated pulmonary aspergillosis in a tertiary care center in Shenzhen City date: 2022-01-06 journal: J Infect Public Health DOI: 10.1016/j.jiph.2021.12.015 sha: cff47021d3f784689a7e2228859bec1f646fd723 doc_id: 1054197 cord_uid: dc7pzudb OBJECTIVES: The severe coronavirus disease 2019 (COVID-19) is characterized by acute respiratory distress syndrome (ARDS) and risk of fungal co-infection, pulmonary aspergillosis in particular. However, COVID-19 associated pulmonary aspergillosis (CAPA) cases remain limited due to the difficulty in diagnosis. METHODS: We describe presumptive invasive aspergillosis in eight patients diagnosed with COVID-19 in a single center in Shenzhen, China. Data collected include underlying conditions, mycological findings, immunodetection results, therapies and outcomes. RESULTS: Four of the eight patients had tested positive for Aspergillus by either culture or Next-generation sequencing analysis of sputum or bronchoalveolar lavage fluid (BALF), while the rest of patients had only positive results in antigen or antibody detection. Although all patients received antifungal therapies, six of these eight patients (66.7%) died. CONCLUSION: Due to the high mortality rate of CAPA, clinical care in patients with CAPA deserves more attention. The severe coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has become a global pandemic and caused a lot of deaths as a result of viral pneumonitis and its complications [1, 2] . The acute respiratory distress syndrome (ARDS) is one of the clinical characteristics of severe COVID-19, which is usually secondary to viral pneumonitis and invasive treatments, such as mechanical ventilation or extracorporeal membrane oxygenation (ECMO) [3] . Among critical COVID-19 patients, invasive pulmonary aspergillosis (IPA) has emerged as a complication with poor prognosis [4] . Association of IPA with high mortality rates is well-recognized. IPA typically occurs in the neutropenic hosts [5] ; however, it has also become increasingly recognized in the non-neutropenic patients, such as solid organ transplant recipients and critically ill patients who receive corticosteroids [4, 5] . Recent reports showed that 19-35% of those critically ill patients with COVID-19 have evidence of Aspergillus co-infection [4, [6] [7] [8] [9] [10] . However, because of the difficulty in the diagnosis of COVID-19 associated pulmonary aspergillosis (CAPA), the reported cases of CAPA are limited until now [11] . In the present study, we reported and described presumptive invasive pulmonary aspergillosis in eight COVID-19 patients admitted to the intensive care unit (ICU) in a single medical center in Shenzhen. From January to June 2020 (our hospital has been treating COVID-19 patients since January), fifty-nine critically ill patients were admitted to our ICU and nineteen of them admitted with COVID-19. Among these patients in ICU, eight COVID-19 cases and three non-COVID-19 cases were suspected to have pulmonary aspergillosis. Patient data collected include underlying conditions, mycological findings [culture or Next-generation sequencing (NGS) analysis of respiratory specimen], immunodetection results, therapies, and outcomes. The study was approved by the Institutional Review Board of The Third People's Hospital of Shenzhen. The presence of SARS-CoV-2 was confirmed by two repeated positive results from our hospital and local Chinese Centers for Disease Control and Prevention using two different commercial RT-PCR kits approved by the National Medical Products Administration [12] . Species identification of Aspergillus isolates were conducted using sequencing analysis. The fungal nuclear ribosomal internal transcribed spacer (ITS) sequences were amplified using universal primers "ITS1" and "ITS4", and the D1/D2 variable region of the 28S subunit of ribosomal DNA was amplified using universal primers "NL-1" and "NL-4" [13] . Galactomannan (GM) from J o u r n a l P r e -p r o o f serum (cutoff Index: 0.5) or BALF (cutoff Index: 1) (Bio-Rad), and anti-Aspergillus IgG from serum (cutoff Index: 1) (Beier) were tested using ELISA method [14, 15] . The anti-Aspergillus IgG Index = ODS/ (0.1+ODNC), where ODS is the optical density value of sample, and ODNC is the optical density value of negative control, respectively. The level of 1,3-β-D glucan in serum was detected by chromogenic assay with cutoff value of 60 pg/mL (Xinuo) [16] . The antifungal susceptibility was confirmed by the broth micro-dilution test and the result interpretation was performed according to the Clinical Laboratory Standards Institute (CLSI) guidelines [17, 18] . IPA is difficult to diagnose, especially in non-immunosuppressed hosts, because they usually lack specific radiological presentation, such as halo sign or air-crescent sign [19] . The authoritative European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium (EORTC/MSGERC) criteria categorized invasive fungal diseases (IFDs) into 'proven', 'probable' and 'possible' IFD. Except for 'proven' IFD that needs culture or microscopic results from sterile material, 'probable' and 'possible' categories were proposed for immunocompromised patients [20] . Because of these limitations, a modified AspICU algorithm for classification of IFD patients without an EORTC host factor in the ICU was proposed [21] . Modified AspICU criteria essentially rely on mycological evidence of No histopathological examination or autopsies were performed for these CAPA cases in this J o u r n a l P r e -p r o o f study. All the eight patients should be classified into 'putative' according to modified AspICU criteria. While, in EORTC/MSGERC criteria, these cases don't belong to 'proven' , 'probable' , or 'possible' category without histological evidence or host factor (e.g. recent history of neutropenia, hematological malignancy, or receipt of an allogeneic stem cell transplant). Details in patients' characteristics were provided in Table 1 . Patients with SARS-CoV-2 infection develop ARDS due to viral replication or the exacerbated inflammatory responses [22] . These ARDS patients are reported to be co-infected with Aspergillus even in the absence of prior immunodeficiency [23] . In Spain [24] , from a total of 215 COVID-19 patients, seven patients (3.3%) had an infection caused by Aspergillus spp. In Netherlands [4] , an incidence (19.4%) of presumed aspergillosis in a cohort of 31 ICU COVID-19 patients was observed. In Pakistan [25] , Aspergillus species were isolated from tracheal aspirates of five (21.7%) patients among a total of 23 patients admitted to ICU. In Germany [6] , among nineteen COVID-19 patients with moderate to severe ARDS, five "putative" IPA cases (26.3%) were reported. In Italy [26] , 30 out of 108 COVID-19 patients (27.7%) were identified as probable CAPA cases. In Alanio's report [27] , eight patients from 27 continuous mechanically ventilated patients with COVID-19 (30%) were diagnosed with 'putative' IPA. In Belgium [7] , 34 COVID-19 patients were admitted to ICU, of whom 20 patients (59%) required invasive mechanical ventilation. Seven of these ventilated patients (35%) were suspected of IPA. In our study, from January to June of 2020, fifty-nine critically ill patients were admitted to our ICU and nineteen patients were confirmed with COVID-19. Among them, eight COVID-19 cases (8/19) and three non-COVID-19 cases (3/40) were suspected to have pulmonary aspergillosis and met the 'putative' aspergillosis criteria as defined by modified AspICU algorithm. The incidence of presumed aspergillosis in COVID-19 patients (42.1%) was higher than other published reports. Part of the reason was that all eight patients received tracheal intubation or tracheostomy, corticosteroid therapies, and long ICU durations, which are considered as high-risk factors for IPA [28] [29] [30] . Definitive diagnosis of CAPA is challenging. Based on EORTC/MSGERC consensus criteria [20] , 'proven' IPA needs autopsies or histopathological results, which were difficult to perform due to the infectivity of the virus. While 'probable' and 'possible' IPA categories are proposed for patients with specific host factors (inappropriate for flu or SARS-CoV-2 infections), which limits the clinical application of these criteria. For the modified AspICU algorithm [21] , 'putative' IPA doesn't need an EORTC host factor and mainly depends on shreds of evidence from mycological findings of BALF and GM presence in serum/BALF. This criterion might have led to some chronic pulmonary aspergillosis(CAP) patients or Aspergillus colonization to be misdiagnosed as putative IPA [22] . It's indicated that a standardized diagnostic procedure and more applicable definition criteria are needed to serve as a basis for optimizing the clinical management of IPA. In the present study, all eight patients were classified into 'putative' cohort according to modified In addition, positive results were obtained from anti-Aspergillus IgG detections of the eight CAPA patients. The published study confirmed that newly raised Aspergillus-specific IgG antibodies could provide evidence for acute Aspergillus infection [31] . Serial measurement of Aspergillus-specific IgG antibodies after commencing treatment may be used for evaluating presumed invasive aspergillosis [32] . In this situation, a fall in Aspergillus-specific IgG levels is a unfavorable prognostic marker [33, 34] . This most likely relates to failure of the immune system to mount a response to the infection [32] . A rise in anti-Aspergillus IgG can retrospectively confirm the diagnosis in those who recover following empirical treatment for suspected invasive aspergillosis [35] . In this article, all these eight CAPA patients received single antifungal therapy upon the appearance of the first positive evidence (not including anti-Aspergillus IgG). In the later period, some patients received antifungal combination treatment due to the poor antifungal effect of single drug. By the end of the study, six of these eight patients (66.7%) died. Thus, the grave prognosis of CAPA patients is indicated and more attention should be paid to CAPA in clinical care. None declared Risk Factors Associated With Acute Respiratory Distress Syndrome and Death in Patients With Coronavirus Disease Confronting and mitigating the risk of COVID-19 associated pulmonary aspergillosis Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study COVID-19-associated Pulmonary Aspergillosis The clinical spectrum of pulmonary aspergillosis COVID-19 associated pulmonary aspergillosis COVID-19-associated invasive pulmonary aspergillosis Azole-Resistant COVID-19-Associated Pulmonary Aspergillosis in an Immunocompetent Host: A Case Report Fatal invasive aspergillosis and coronavirus disease in an immunocompetent patient COVID-19 associated pulmonary aspergillosis in ICU patients: Report of five cases from Argentina COVID-19 Associated Pulmonary Aspergillosis (CAPA)-From Immunology to Treatment Profile of Immunoglobulin G and IgM Antibodies Against Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Evaluation of nucleic acid sequencing of the D1/D2 region of the large subunit of the 28S rDNA and the internal transcribed spacer region using SmartGene IDNS software for identification of filamentous fungi in a clinical laboratory Galactomannan and Computed Tomography-Based Preemptive Antifungal Therapy in Neutropenic Patients at High Risk for Invasive Fungal Infection: A Evaluation of antibody against Aspergillus fumigatus thioredoxin reductase GliT for diagnosis of invasive aspergillosis Contribution of (1-3)-beta-D-glucan chromogenic assay to diagnosis and therapeutic monitoring of invasive aspergillosis in neutropenic adult patients: a comparison with serial screening for circulating galactomannan Method for Broth Dilution Antifungal Susceptibility Testing of Filamentous Fungi 950 West Valley Road, Suite 2500 Epidemiological Cutoff Values for Antifungal Susceptibility Testing Clinical and Laboratory Standards Institute, 950 West Valley Road, Suite 2500 A clinical algorithm to diagnose invasive pulmonary aspergillosis in critically ill patients Revision and Update of the Consensus Definitions of Invasive Fungal Disease From the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium Invasive aspergillosis in patients admitted to the intensive care unit with severe influenza: a retrospective cohort study Diagnosing COVID-19-associated pulmonary aspergillosis Pulmonary aspergillosis in critically ill patients with Coronavirus Disease 2019 (COVID-19) Prevalence of opportunistic invasive aspergillosis in COVID-19 patients with severe pneumonia COVID-19-associated pulmonary aspergillosis (CAPA) in patients admitted with severe COVID-19 pneumonia: An observational study from Pakistan COVID-19 intubated patients: a prospective study Prevalence of putative invasive pulmonary aspergillosis in critically ill patients with COVID-19 Ventilator-associated pneumonia in critically ill patients with COVID-19 Glucocorticoids and invasive fungal infections Risk factors associated with COVID-19-associated pulmonary aspergillosis in ICU patients: a French multicentric retrospective cohort Evaluation of eight antibody tests and one antigen test for the diagnosis of invasive aspergillosis Antibody testing in aspergillosis--quo vadis? Aspergillus fumigatus and aspergillosis Follow-up of anti-Aspergillus IgG and IgA antibodies in bone marrow transplanted patients with invasive aspergillosis Laboratory diagnosis of invasive aspergillosis II: a severity of disease classification system Profile of IgG and IgM antibodies against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Invasive aspergillosis in patients admitted to the intensive care unit with severe influenza: a retrospective cohort study Revision and Update of the Consensus Definitions of Invasive Fungal Disease From the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium