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Lamoth F, Prakash K, Beigelman-Aubry C, Baddley JW. Lung and sinus fungal infection imaging in immunocompromised patients. Clin Microbiol Infect 2024; 30:296-305. [PMID: 37604274 DOI: 10.1016/j.cmi.2023.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 08/06/2023] [Accepted: 08/13/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Imaging is a key diagnostic modality for suspected invasive pulmonary or sinus fungal disease and may help to direct testing and treatment. Fungal diagnostic guidelines have been developed and emphasize the role of imaging in this setting. We review and summarize evidence regarding imaging for fungal pulmonary and sinus disease (in particular invasive aspergillosis, mucormycosis and pneumocystosis) in immunocompromised patients. OBJECTIVES We reviewed data on imaging modalities and findings used for diagnosis of invasive fungal pulmonary and sinus disease. SOURCES References for this review were identified by searches of PubMed, Google Scholar, Embase and Web of Science through 1 April 1 2023. CONTENT Computed tomography imaging is the method of choice for the evaluation of suspected lung or sinus fungal disease. Although no computed tomography radiologic pattern is pathognomonic of pulmonary invasive fungal disease (IFD) the halo sign firstly suggests an angio-invasive pulmonary aspergillosis while the Reversed Halo Sign is more suggestive of pulmonary mucormycosis in an appropriate clinical setting. The air crescent sign is uncommon, occurring in the later stages of invasive aspergillosis in neutropenic patients. In contrast, new cavitary lesions should suggest IFD in moderately immunocompromised patients. Regarding sinus site, bony erosion, peri-antral fat or septal ulceration are reasonably predictive of IFD. IMPLICATIONS Imaging assessment of the lung and sinuses is an important component of the diagnostic work-up and management of IFD in immunocompromised patients. However, radiological features signs have sensitivity and specificity that often vary according to underlying disease states. Periodic review of imaging studies and diagnostic guidelines characterizing imaging findings may help clinicians to consider fungal infections in clinical care thereby leading to an earlier confirmation and treatment of IFD.
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Affiliation(s)
- Frederic Lamoth
- Service of Infectious Diseases, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; Institute of Microbiology, Department of Laboratory Medicine and Microbiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Katya Prakash
- Division of Infectious Diseases, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Catherine Beigelman-Aubry
- Radiodiagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - John W Baddley
- Division of Infectious Diseases, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA.
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Ankrah AO, Lawal IO, Dierckx RAJO, Sathekge MM, Glaudemans AWJM. Imaging of Invasive Fungal Infections- The Role of PET/CT. Semin Nucl Med 2023; 53:57-69. [PMID: 35933165 DOI: 10.1053/j.semnuclmed.2022.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/06/2022] [Accepted: 07/07/2022] [Indexed: 01/28/2023]
Abstract
Over the last decades, the population at risk for invasive fungal disease (IFD) has increased because of medical therapy advances and diseases compromising patients' immune systems. The high morbidity and mortality associated with invasive fungal disease in the immunocompromised present the challenge of early diagnosis of the IFD and the need to closely monitor the infection during treatment. The definitive diagnosis of invasive fungal disease based on culture or histopathological methods often has reduced diagnostic accuracy in the immunocompromised and may be very invasive. Less invasive and indirect evidence of the fungal infection by serology and imaging has been used for the early diagnosis of fungal infection before definitive results are available or when the definitive methods of diagnosis are suboptimal. Imaging in invasive fungal disease is a non-invasive biomarker that helps in the early diagnosis of invasive fungal disease but helps follow-up the infection during treatment. Different imaging modalities are used in the workup to evaluate fungal disease. The different imaging modalities have advantages and disadvantages at different sites in the body and may complement each other in the management of IFD. Positron emission tomography integrated with computed tomography with [18F]Fluorodeoxyglucose (FDG PET/CT) has helped manage IFD. The combined functional data from PET and anatomical data from the CT from almost the whole body allows noninvasive evaluation of IFD and provides a semiquantitative means of assessing therapy. FDG PET/CT adds value to anatomic-based only imaging modalities. The nonspecificity of FDG uptake has led to the evaluation of other tracers in the assessment of IFD. However, these are mainly still at the preclinical level and are yet to be translated to humans. FDG PET/CT remains the most widely evaluated radionuclide-based imaging modality in IFD management. The limitations of FDG PET/CT must be well understood, and more extensive prospective studies in uniform populations are needed to validate its role in the management of IFD that can be international guidelines.
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Affiliation(s)
- Alfred O Ankrah
- National Centre for Radiotherapy Oncology and Nuclear Medicine, Korle Bu Teaching Hospital, Accra GA, Ghana; Department of Nuclear Medicine, University of Pretoria, Steve Biko Academic Hospital, Pretoria, South Africa; Medical Imaging Center, University Medical Center Groningen, University of Groningen, RB Groningen, The Netherlands.
| | - Ismaheel O Lawal
- Department of Nuclear Medicine, University of Pretoria, Steve Biko Academic Hospital, Pretoria, South Africa; Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA
| | - Rudi A J O Dierckx
- Medical Imaging Center, University Medical Center Groningen, University of Groningen, RB Groningen, The Netherlands
| | - Mike M Sathekge
- Department of Nuclear Medicine, University of Pretoria, Steve Biko Academic Hospital, Pretoria, South Africa
| | - Andor W J M Glaudemans
- Medical Imaging Center, University Medical Center Groningen, University of Groningen, RB Groningen, The Netherlands
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3
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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] [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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Butler-Laporte G, Langevin MC, Lemieux C, Poirier C, Ferraro P, Théorêt Y, Luong ML. Voriconazole Therapeutic Drug Monitoring Among Lung Transplant Recipients Receiving Targeted Therapy for Invasive Aspergillosis. Clin Transplant 2022; 36:e14709. [PMID: 35575963 DOI: 10.1111/ctr.14709] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 04/09/2022] [Accepted: 05/10/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Voriconazole is the first line treatment for invasive aspergillosis (IA) Current guidelines suggest performing regular voriconazole therapeutic drug monitoring (TDM) to optimize treatment efficacy. We aimed to determine if TDM was predictive of clinical outcome in LTRs. METHODS Retrospective chart review was performed for all LTRs with probable or proven IA, treated with voriconazole monotherapy and who underwent TDM during therapy. Clinical outcome and toxicity were measured at 12 weeks. Classification and regression tree (CART) analysis was used to determine the most predictive voriconazole level thresholds for successful outcome. RESULTS 118 TDM samples from 30 LTRs with IA were analyzed. Three LTRs were excluded due to early treatment discontinuation. The median TDM level was 1.2 μg/mL (range 0.06-7.3). At 12 weeks, 62% (17/27) of patients had a successful outcome, while 37% (10/27) of patients failed therapy. CART analysis determined that the best predictor for successful outcome was a median TDM level > 0.72 μg/mL. Seventy percent (14/20) of patients with median TDM above 0.72 μg/mL had a successful outcome, compared to 42.9% (3/7) of patients with a median TDM below 0.72 μg/mL (OR 3.11; 95% CI: 0.53-20.4; P = 0.21). CART analysis determined that a TDM level greater than 2.13 μg/mL was predictive of hepatotoxicity. CONCLUSIONS Our data suggests that a voriconazole TDM range between 0.72 μg/mL and 2.13 μg/mL may be associated with improved outcomes. Our study is in line with current recommendations on the use of voriconazole TDM in improving outcome and minimizing toxicity in LTR with IA. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Guillaume Butler-Laporte
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Canada
| | - Marie-Claude Langevin
- Department of Pharmacy, Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - Claude Lemieux
- Department of Medical Microbiology, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - Charles Poirier
- Division of Respirology, Department of Medicine, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - Pasquale Ferraro
- Division of Thoracic Surgery, Department of Surgery, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - Yves Théorêt
- Department of Pharmacology, Centre de Recherche Pédiatrique, Hôpital Ste-Justine, Montréal, Canada
| | - Me-Linh Luong
- Department of Medical Microbiology, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Canada
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Siopi M, Karakatsanis S, Roumpakis C, Korantanis K, Eldeik E, Sambatakou H, Sipsas NV, Pagoni M, Stamouli M, Tsirigotis P, Meletiadis J. Evaluation of the Dynamiker® Fungus (1–3)-β-d-Glucan Assay for the Diagnosis of Invasive Aspergillosis in High-Risk Patients with Hematologic Malignancies. Infect Dis Ther 2022; 11:1161-1175. [PMID: 35404009 PMCID: PMC9124273 DOI: 10.1007/s40121-022-00627-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 03/17/2022] [Indexed: 11/25/2022] Open
Affiliation(s)
- Maria Siopi
- Clinical Microbiology Laboratory, Attikon University General Hospital, Medical School, National and Kapodistrian University of Athens, Rimini 1, Chaidari, 12462, Athens, Greece
| | - Stamatis Karakatsanis
- Department of Hematology and Lymphoma-Unit of Bone Marrow Transplantation, Evangelismos General Hospital, 10676, Athens, Greece
| | - Christoforos Roumpakis
- 2nd Department of Internal Medicine, Hematology Unit, Attikon University General Hospital, Medical School, National and Kapodistrian University of Athens, 12462, Athens, Greece
| | - Konstantinos Korantanis
- Pathophysiology Department, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527, Athens, Greece
| | - Elina Eldeik
- 2nd Department of Internal Medicine, Hippokration General Hospital, 11527, Athens, Greece
| | - Helen Sambatakou
- 2nd Department of Internal Medicine, Hippokration General Hospital, 11527, Athens, Greece
| | - Nikolaos V Sipsas
- Pathophysiology Department, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527, Athens, Greece
| | - Maria Pagoni
- Department of Hematology and Lymphoma-Unit of Bone Marrow Transplantation, Evangelismos General Hospital, 10676, Athens, Greece
| | - Maria Stamouli
- 2nd Department of Internal Medicine, Hematology Unit, Attikon University General Hospital, Medical School, National and Kapodistrian University of Athens, 12462, Athens, Greece
| | - Panagiotis Tsirigotis
- 2nd Department of Internal Medicine, Hematology Unit, Attikon University General Hospital, Medical School, National and Kapodistrian University of Athens, 12462, Athens, Greece
| | - Joseph Meletiadis
- Clinical Microbiology Laboratory, Attikon University General Hospital, Medical School, National and Kapodistrian University of Athens, Rimini 1, Chaidari, 12462, Athens, Greece.
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Obmann VC, Bickel F, Hosek N, Ebner L, Huber AT, Damonti L, Zimmerli S, Christe A. Radiological CT Patterns and Distribution of Invasive Pulmonary Aspergillus, Non-Aspergillus, Cryptococcus and Pneumocystis Jirovecii Mold Infections - A Multicenter Study. ROFO-FORTSCHR RONTG 2021; 193:1304-1314. [PMID: 34034346 DOI: 10.1055/a-1482-8336] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE Clinical signs and symptoms related to invasive fungal disease are nonspecific and need to be followed up by appropriate diagnostic procedures. The goal of this study was to analyze CT imaging patterns in invasive fungal infections and their correlation with the immune status and clinical outcome. MATERIALS AND METHODS We performed a retrospective multicenter study including 85 consecutive patients with invasive pulmonary fungal infection (2011-2014). Lung patterns on computed tomography (CT) scans were classified according to the Fleischner Society glossary. The patients were grouped according to immune status (neutropenia, steroid therapy, organ transplant recipient, and other cause) and outcome (positive outcome, progressive disease, and death). The Chi square test or Fisher exact test was used. Bonferroni correction was applied. RESULTS The total number of patients with invasive Aspergillus and non-Aspergillus infection (IANA), Pneumocystis jirovecii pneumonia (PCP), and Cryptococcus (CRY) was 60, 22, and 3, respectively. Patients with IANA demonstrated significantly more nodules (93 % vs. 59 %, p = 0.001), significantly fewer ground glass opacities (58 % vs. 96 %, p = 0.005), and significantly fewer positive lymph nodes (5 % vs. 41 %, p < 0.001) than patients with PCP. All patients with PCP and CRY had a favorable outcome. Patients with IANA and an adverse outcome demonstrated significantly more nodules with halo sign than patients with IANA and a favorable outcome (42.5 % vs. 15.9 %, p < 0.0001). Interestingly, patients with IANA and a favorable outcome had a higher prevalence of pulmonary infarction than patients with an adverse outcome (8 % vs. 1 %, p = 0.047). Patients with neutropenia showed significantly more consolidations (66 %) than organ transplant recipients (27 %, p = 0.045). CONCLUSION Patients with IANA showed a higher prevalence of nodules and a lower prevalence of ground glass opacities than patients with PCP. In patients with IANA, nodules with halo sign were associated with an adverse outcome. Patients with neutropenia showed generally more consolidations, but the consolidations were not associated with an adverse outcome. KEY POINTS · Nodules, ground glass opacities, and consolidations are common CT findings in all invasive pulmonary fungal infections.. · There is no pattern that is unique for one specific pathogen, although nodules are more predominant in IANA and Cryptococcus, and ground glass opacities are more predominant in PCP patients.. · Immune status had an impact on CT findings in fungal pneumonia with less consolidation in patients after organ transplantation compared to patients with neutropenia.. · Nodules with a halo sign are associated with a worse outcome.. CITATION FORMAT · Obmann VC, Bickel F, Hosek N et al. Radiological CT Patterns and Distribution of Invasive Pulmonary Aspergillus, Non-Aspergillus, Cryptococcus and Pneumocystis Jirovecii Mold Infections - A Multicenter Study. Fortschr Röntgenstr 2021; DOI: 10.1055/a-1482-8336.
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Affiliation(s)
- Verena C Obmann
- Department of Interventional, Pediatric and Diagnostic Radiology, Inselspital, University of Bern, Switzerland
| | - Flurina Bickel
- Department of Interventional, Pediatric and Diagnostic Radiology, Inselspital, University of Bern, Switzerland
| | - Nicola Hosek
- Department of Interventional, Pediatric and Diagnostic Radiology, Inselspital, University of Bern, Switzerland
| | - Lukas Ebner
- Department of Interventional, Pediatric and Diagnostic Radiology, Inselspital, University of Bern, Switzerland
| | - Adrian T Huber
- Department of Interventional, Pediatric and Diagnostic Radiology, Inselspital, University of Bern, Switzerland
| | - Lauro Damonti
- Department of Infectious Diseases, Inselspital, University of Bern, Switzerland
| | - Stefan Zimmerli
- Department of Infectious Diseases, Inselspital, University of Bern, Switzerland
| | - Andreas Christe
- Department of Interventional, Pediatric and Diagnostic Radiology, Inselspital, University of Bern, Switzerland
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Alexander BD, Lamoth F, Heussel CP, Prokop CS, Desai SR, Morrissey CO, Baddley JW. Guidance on Imaging for Invasive Pulmonary Aspergillosis and Mucormycosis: From the Imaging Working Group for the Revision and Update of the Consensus Definitions of Fungal Disease from the EORTC/MSGERC. Clin Infect Dis 2021; 72:S79-S88. [PMID: 33709131 DOI: 10.1093/cid/ciaa1855] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Clinical imaging in suspected invasive fungal disease (IFD) has a significant role in early detection of disease and helps direct further testing and treatment. Revised definitions of IFD from the EORTC/MSGERC were recently published and provide clarity on the role of imaging for the definition of IFD. Here, we provide evidence to support these revised diagnostic guidelines. METHODS We reviewed data on imaging modalities and techniques used to characterize IFDs. RESULTS Volumetric high-resolution computed tomography (CT) is the method of choice for lung imaging. Although no CT radiologic pattern is pathognomonic of IFD, the halo sign, in the appropriate clinical setting, is highly suggestive of invasive pulmonary aspergillosis (IPA) and associated with specific stages of the disease. The ACS is not specific for IFD and occurs in the later stages of infection. By contrast, the reversed halo sign and the hypodense sign are typical of pulmonary mucormycosis but occur less frequently. In noncancer populations, both invasive pulmonary aspergillosis and mucormycosis are associated with "atypical" nonnodular presentations, including consolidation and ground-glass opacities. CONCLUSIONS A uniform definition of IFD could improve the quality of clinical studies and aid in differentiating IFD from other pathology in clinical practice. Radiologic assessment of the lung is an important component of the diagnostic work-up and management of IFD. Periodic review of imaging studies that characterize findings in patients with IFD will inform future diagnostic guidelines.
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Affiliation(s)
- Barbara D Alexander
- Department of Medicine, Division of Infectious Diseases, Duke University, Durham, North Carolina, USA
| | - Frédéric Lamoth
- Service of Infectious Diseases, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Institute of Microbiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Claus Peter Heussel
- Department of Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik gGmbH, Heidelberg, Germany.,Translational Lung Research Centre Heidelberg, Member of the German Centre for Lung Research.,Diagnostic and Interventional Radiology, Ruprecht-Karls-University, Heidelberg, Germany
| | | | - Sujal R Desai
- Department of Radiology, Royal Brompton and Harefield National Health Service Foundation Trust, London and National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - C Orla Morrissey
- Department of Infectious Diseases, Alfred Health and Monash University, Melbourne, Australia
| | - John W Baddley
- Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, Maryland, USA
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8
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Siopi M, Karakatsanis S, Roumpakis C, Korantanis K, Eldeik E, Sambatakou H, Sipsas NV, Tsirigotis P, Pagoni M, Meletiadis J. Performance, Correlation and Kinetic Profile of Circulating Serum Fungal Biomarkers of Invasive Aspergillosis in High-Risk Patients with Hematologic Malignancies. J Fungi (Basel) 2021; 7:jof7030211. [PMID: 33805751 PMCID: PMC7999040 DOI: 10.3390/jof7030211] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/01/2021] [Accepted: 03/08/2021] [Indexed: 12/15/2022] Open
Abstract
As conventional microbiological documentation of invasive aspergillosis (IA) is difficult to obtain, serum fungal biomarkers are important adjunctive diagnostic tools. Positivity rates and the kinetic profiles of galactomannan (GM), 1,3-β-D-glucan (BDG) and Aspergillus DNA (PCR) were studied in high-risk patients with hematologic malignancies. GM, BDG and PCR data from serial serum specimens (n = 240) from 93 adult hematology patients with probable (n = 8), possible (n = 25) and no (n = 60) IA were retrospectively analyzed. Positivity rates and sensitivity/specificity/positive/negative predictive values (NPV) of each fungal biomarker alone and in combination were estimated. The three markers were compared head-to-head and correlated with various biochemical, demographic and patient characteristics. The positivity rates for patients with probable/possible/no IA were 88%/8%/0% for GM (X2 = 55, p < 0.001), 62%/46%/35% for BDG (X2 = 2.5, p = 0.29), 62%/33%/27% for PCR (X2 = 3.9, p = 0.15), 50%/4%/0% for GM + BDG and GM + PCR (X2 = 31, p < 0.001), 50%/8%/22% for BDG + PCR (X2 = 6.5, p = 0.038) and 38%/4%/0% for GM + BDG + PCR (X2 = 21, p < 0.001). Higher agreement (76%) and negative correlation (rs = −0.47, p = 0.0017) was found between GM index and PCR Ct values. The sensitivity and NPV was 45–55% and 90–92% when biomarkers assessed alone and increased to 75–90% and 93–97%, respectively when combined. Weak significant correlations were found between GM, PCR and BDG results with renal/liver function markers (r = 0.11–0.57) with most GM+ and PCR+ samples found in the first and second week of clinical assessment, respectively and BDG later on. Different positivity rates, time profiles and performances were found for the three biomarkers advocating the combination of GM with PCR for the early diagnosis of IA, whereas the high NPV of combined biomarkerscould help excluding IA.
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Affiliation(s)
- Maria Siopi
- Clinical Microbiology Laboratory, “Attikon” University General Hospital, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece;
| | - Stamatis Karakatsanis
- Unit of Bone Marrow Transplantation, Department of Hematology and Lymphoma, “Evangelismos” General Hospital, 10676 Athens, Greece; (S.K.); (M.P.)
| | - Christoforos Roumpakis
- Hematology Unit, 2nd Department of Internal Medicine, “Attikon” University General Hospital, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece; (C.R.); (P.T.)
| | - Konstantinos Korantanis
- Pathophysiology Department, “Laiko” General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece; (K.K.); (N.V.S.)
| | - Elina Eldeik
- 2nd Department of Internal Medicine, “Hippokration” General Hospital, 11527 Athens, Greece; (E.E.); (H.S.)
| | - Helen Sambatakou
- 2nd Department of Internal Medicine, “Hippokration” General Hospital, 11527 Athens, Greece; (E.E.); (H.S.)
| | - Nikolaos V. Sipsas
- Pathophysiology Department, “Laiko” General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece; (K.K.); (N.V.S.)
| | - Panagiotis Tsirigotis
- Hematology Unit, 2nd Department of Internal Medicine, “Attikon” University General Hospital, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece; (C.R.); (P.T.)
| | - Maria Pagoni
- Unit of Bone Marrow Transplantation, Department of Hematology and Lymphoma, “Evangelismos” General Hospital, 10676 Athens, Greece; (S.K.); (M.P.)
| | - Joseph Meletiadis
- Clinical Microbiology Laboratory, “Attikon” University General Hospital, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece;
- Correspondence: ; Tel.: +30-210-583-1909; Fax: +30-210-532-6421
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9
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A Prospective Multicenter Cohort Surveillance Study of Invasive Aspergillosis in Patients with Hematologic Malignancies in Greece: Impact of the Revised EORTC/MSGERC 2020 Criteria. J Fungi (Basel) 2021; 7:jof7010027. [PMID: 33466525 PMCID: PMC7824879 DOI: 10.3390/jof7010027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/29/2020] [Accepted: 12/30/2020] [Indexed: 01/06/2023] Open
Abstract
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.
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Huang L, Zhai T, Hua L, Zhan Q. Early identification of patients with severe influenza-associated aspergillosis (IAA) in the intensive care unit--an IAA prediction score system (Asper-PreSS). J Infect 2020; 81:639-646. [PMID: 32739488 DOI: 10.1016/j.jinf.2020.07.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 07/21/2020] [Accepted: 07/22/2020] [Indexed: 01/01/2023]
Affiliation(s)
- Linna Huang
- Department of Pulmonary and Critical Care Medicine, Centre for Respiratory Diseases, China-Japan Friendship Hospital, Postal Address: No. 2 Yinghua East Road, Chaoyang District, Beijing 100029, PR China
| | - Tianshu Zhai
- Department of Pulmonary and Critical Care Medicine, Centre for Respiratory Diseases, China-Japan Friendship Hospital, Postal Address: No. 2 Yinghua East Road, Chaoyang District, Beijing 100029, PR China
| | - Lin Hua
- School of Biomedical Engineering, Capital Medical University, Beijing, PR China.
| | - Qingyuan Zhan
- Department of Pulmonary and Critical Care Medicine, Centre for Respiratory Diseases, China-Japan Friendship Hospital, Postal Address: No. 2 Yinghua East Road, Chaoyang District, Beijing 100029, PR China.
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11
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CT Halo sign: A systematic review. Eur J Radiol 2020; 124:108843. [PMID: 32007819 DOI: 10.1016/j.ejrad.2020.108843] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 01/12/2020] [Accepted: 01/14/2020] [Indexed: 12/18/2022]
Abstract
PURPOSE The CT Halo sign or Halo sign (HS) refers to ground-glass opacity surrounding a nodule or mass in the lung parenchyma. We conducted a systematic review to find the etiological associations of HS. We also evaluated the diagnostic performances of HS for invasive fungal infections (IFI) in immunosuppressed patients. METHOD The systematic review was conducted as per PRISMA guidelines. We searched the PubMed and EMBASE database till June 2018 without any restrictions. Only case reports, case series and original articles published in English language were included. A database created from the electronic searches was compiled and subsequent analysis was done. [PROSPERO registration: CRD42018094739] RESULTS: 168 studies were eligible, which included 51 case reports, 15 prospective studies, 102 retrospective studies. A total of 1977 patients (out of 6371) with HS were identified with age range between <1year-94years. The most common diagnosis in the immunosuppressed, mixed, immunocompetent and not specified groups were IFI (86.9 %, n = 1194), Cryptococcosis (51.6 %, n = 124), Cryptococcosis (40 %, n = 20) and lung neoplasms (81.8 %, n = 36) respectively. 14 studies (11 retrospective, 3 prospective) were included in quantitative analysis. The pooled sensitivity(sn), specificity(sp) and odd's ratio (OR) of HS for diagnosing IFI were 50.4 %, 91 % and 6.61 respectively. Also, HS could not reliably differentiate IPA from mucormycosis in the pooled analysis. CONCLUSIONS HS can be seen in a large number of diverse conditions both in immunosuppressed and immunocompetent population. In immunosuppressed patients HS is specific for IFI but cannot rule it out. Additionally, it cannot reliably distinguish between IPA and mucormycosis.
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Ramírez P, Garnacho-Montero J. [Invasive aspergillosis in critically ill patients]. Rev Iberoam Micol 2019; 35:210-216. [PMID: 30554674 DOI: 10.1016/j.riam.2018.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 07/11/2018] [Accepted: 07/24/2018] [Indexed: 01/06/2023] Open
Abstract
Critically ill patients without severe immunosuppression make up a population in which invasive aspergillosis (IA) has been identified as an emergent pathology. Chronic treatment with corticosteroids, chronic obstructive pulmonary disease, and liver cirrhosis are repeatedly identified risk factors. However, due to the non-specificity of the symptoms and signs in the critical patient, and the relative low diagnostic capacity of the complementary tests, the diagnosis of the IA is a challenge for the specialist in critical care medicine. The application of diagnostic algorithms adapted to critical patients, in whom activation will depend on the isolation of Aspergillus in a respiratory specimen, is the most efficient diagnostic methodology in this population. Among the diagnostic approaches, the determination of galactomannan in bronchoalveolar fluid is the most useful diagnostic test. Once the suspicion is established, treatment should be started as soon as possible. Voriconazole, amphotericin B, and isavuconazole are the most effective treatments. Although voriconazole and amphotericin B are the drugs with the most scientific evidence, they are related with adverse effects and pharmacokinetic difficulties. Therefore, isavuconazole, which has shown high efficacy and safety in other populations, is a potential alternative of great interest for critically ill patients.
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Affiliation(s)
- Paula Ramírez
- Servicio de Medicina Intensiva, Hospital Universitario y Politécnico La Fe, Valencia, España.
| | - José Garnacho-Montero
- Unidad Clínica de Cuidados Intensivos, Hospital Universitario Virgen de la Macarena, Sevilla, España
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Dumas G, Bigé N, Lemiale V, Azoulay E. Patients immunodéprimés, quel pathogène pour quel déficit immunitaire ? (en dehors de l’infection à VIH). MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Le nombre de patients immunodéprimés ne cesse d’augmenter en raison de l’amélioration du pronostic global du cancer et de l’utilisation croissante d’immunosuppresseurs tant en transplantation qu’au cours des maladies auto-immunes. Les infections sévères restent la première cause d’admission en réanimation dans cette population et sont dominées par les atteintes respiratoires. On distingue les déficits primitifs, volontiers révélés dans l’enfance, des déficits secondaires (médicamenteux ou non), les plus fréquents. Dans tous les cas, les sujets sont exposés à des infections inhabituelles de par leur fréquence, leur type et leur sévérité. À côté des pyogènes habituels, les infections opportunistes et la réactivation d’infections latentes font toute la complexité de la démarche diagnostique. Celle-ci doit être rigoureuse, orientée par le type de déficit, les antécédents, les prophylaxies éventuelles et la présentation clinicoradiologique. Elle permettra seule de guider le traitement probabiliste et les examens étiologiques, l’absence de diagnostic étant associée à une mortalité élevée.
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14
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Invasive pulmonary aspergillosis: current diagnostic methodologies and a new molecular approach. Eur J Clin Microbiol Infect Dis 2018; 37:1393-1403. [DOI: 10.1007/s10096-018-3251-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Accepted: 04/05/2018] [Indexed: 12/11/2022]
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15
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Bonnet S, Duléry R, Regany K, Bouketouche M, Magro L, Coiteux V, Alfandari S, Berthon C, Quesnel B, Yakoub-Agha I. Long-term follow up of invasive aspergillosis in allogeneic stem cell transplantation recipients and leukemia patients: Differences in risk factors and outcomes. Curr Res Transl Med 2017; 65:77-81. [PMID: 28689016 DOI: 10.1016/j.retram.2017.05.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 05/22/2017] [Accepted: 05/31/2017] [Indexed: 11/30/2022]
Abstract
Antifungal prophylaxis (AP) has dramatically changed the epidemiology of invasive aspergillosis (IA). To better understand the differences in terms of clinical significance of IA between allogeneic stem cell transplantation (allo-SCT) recipients and patients treated for leukemia, we report a single-center study of 735 unselected consecutive patients treated between 2000 and 2004, before the era of systematic AP. Probable or confirmed IA were observed in 29 patients (2008 EORTC/MSG criteria), including 7/235 undergoing allo-SCT (5.2%), 19/380 treated for acute leukemia (5.0%), 1/116 for chronic lymphocytic leukemia (0.9%) and 2/104 for myelodysplastic syndrome (1.9%). In allo-SCT recipients, IA occurred later than in leukemia patients, after the neutropenic period. The median time between the last treatment and the diagnosis of IA was 231 days (range, 68-341) in allo-SCT recipients and 17 days (6-57) in leukemia patients (P<0.001). Importantly, the 7 cases of IA after allo- SCT occurred only in patients treated with corticosteroids for graft-versus-host disease (GVHD). Mortality directly related to IA was 24%. The 100-day, 2-year and 10-year overall survival were 42.9%, 0%, 0% in allo-SCT recipients compared to 68.1%, 18.2%, 13.6% in leukemia patients, respectively (P≥0.05). These poor outcomes were mainly attributable to non-relapse mortality (NRM). In conclusion, our data allows distinguishing 2 types of IA occurring at different time in the treatment course. In both cases, the NRM is very high and treatment remains challenging. Thus, systematic broad-spectrum AP against Aspergillus should be considered in acute leukemia patients during the neutropenic phase and in all patients undergoing allo-SCT who develop GVHD.
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Affiliation(s)
- S Bonnet
- Department of Hematology, CHRU de Lille, 59037 Lille, France.
| | - R Duléry
- Department of Hematology, CHRU Saint-Antoine, AP-HP, 75012 Paris, France.
| | - K Regany
- Department of Hematology, CHRU de Lille, 59037 Lille, France.
| | - M Bouketouche
- Department of Hematology, CHRU de Lille, 59037 Lille, France.
| | - L Magro
- Department of Hematology, CHRU de Lille, 59037 Lille, France.
| | - V Coiteux
- Department of Hematology, CHRU de Lille, 59037 Lille, France.
| | - S Alfandari
- Department of infectious Diseases, Dron Hospital, 59200 Tourcoing, France.
| | - C Berthon
- Department of Hematology, CHRU de Lille, 59037 Lille, France.
| | - B Quesnel
- Department of Hematology, CHRU de Lille, 59037 Lille, France.
| | - I Yakoub-Agha
- Department of Hematology, CHRU de Lille, 59037 Lille, France.
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Ikari T, Nagai K, Ohe M, Harada T, Akiyama Y. Multiple cavities with halo sign in a case of invasive pulmonary aspergillosis during therapy for drug-induced hypersensitivity syndrome. Respir Med Case Rep 2017; 21:124-128. [PMID: 28480161 PMCID: PMC5407638 DOI: 10.1016/j.rmcr.2017.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 04/10/2017] [Accepted: 04/18/2017] [Indexed: 11/02/2022] Open
Abstract
A 67-year-old female with rheumatoid arthritis and asthma-chronic obstructive pulmonary disease overlap syndrome was admitted for drug-induced hypersensitivity syndrome (DIHS) caused by salazosulfapyridine. Human herpes virus 6 (HHV-6) variant B was strongly positive on peripheral blood. Multiple cavities with ground grass opacities rapidly emerged predominantly in the upper and middle lobes. She was diagnosed with invasive pulmonary aspergillosis (IPA), and was treated successfully with antifungal agents. Therapeutic systemic corticosteroids, emphysematous change in the lungs, and the worsening of the patient's general condition due to DIHS were considered major contributing factor leading to IPA. HHV-6 reactivation could have an effect on clinical course of IPA. Cavities with halo sign would provide an early clue to IPA in non-neutropenic and immunosuppressive patients.
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Key Words
- BAL, bronchoalveolar lavage
- BG, 1,3-β-glucan
- CMV, cytomegalovirus
- COPD, chronic obstructive pulmonary disease
- CT, computed tomography
- Chronic obstructive pulmonary disease (COPD)
- DIHS, drug-induced hypersensitivity syndrome
- DRESS, drug reaction with eosinophilia and systemic syndrome
- Drug-induced hypersensitivity syndrome
- GGO, ground grass opacity
- GM, galactomannan antigenemia
- HHV-6, Human herpes virus 6
- Halo sign
- Human herpes virus 6 (HHV-6)
- IPA, invasive pulmonary aspergillosis
- Invasive pulmonary aspergillosis
- LAA, low attenuation area
- MCFG, micafungin
- VRCZ, voriconazole
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Affiliation(s)
- Tomoo Ikari
- Department of Respiratory Medicine, Center for Respiratory Diseases, JCHO Hokkaido Hospital, Japan
| | - Katsura Nagai
- Department of Respiratory Medicine, Center for Respiratory Diseases, JCHO Hokkaido Hospital, Japan
| | - Masashi Ohe
- Department of Connective Tissue Disease, JCHO Hokkaido Hospital, Japan
| | - Toshiyuki Harada
- Department of Respiratory Medicine, Center for Respiratory Diseases, JCHO Hokkaido Hospital, Japan
| | - Yasushi Akiyama
- Department of Respiratory Medicine, Center for Respiratory Diseases, JCHO Hokkaido Hospital, Japan
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Huang L, He H, Ding Y, Jin J, Zhan Q. Values of radiological examinations for the diagnosis and prognosis of invasive bronchial-pulmonary aspergillosis in critically ill patients with chronic obstructive pulmonary diseases. CLINICAL RESPIRATORY JOURNAL 2016; 12:499-509. [PMID: 27614086 DOI: 10.1111/crj.12551] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 07/31/2016] [Accepted: 08/29/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Linna Huang
- Department of Respiratory and Critical Care Medicine; Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University; Beijing P.R. China
- Department of Respiratory and Critical Care Medicine, China-Japan Friendship Hospital; Beijing P.R. China
| | - Hangyong He
- Department of Respiratory and Critical Care Medicine; Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University; Beijing P.R. China
| | - Yi Ding
- Department of Radiology, Beijing Chao-Yang Hospital, Capital Medical University; Beijing P.R. China
| | - Jingjing Jin
- Department of Respiratory and Critical Care Medicine; Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University; Beijing P.R. China
| | - Qingyuan Zhan
- Department of Respiratory and Critical Care Medicine, China-Japan Friendship Hospital; Beijing P.R. China
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18
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Cohn SM, Pokala HR, Siegel JD, McClay JE, Leonard D, Kwon J, Timmons CF, Winick NJ. Application of a standardized screening protocol for diagnosis of invasive mold infections in children with hematologic malignancies. Support Care Cancer 2016; 24:5025-5033. [DOI: 10.1007/s00520-016-3367-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 07/28/2016] [Indexed: 11/30/2022]
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19
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Radiologic Imaging Techniques for the Diagnosis and Management of Invasive Fungal Disease. CURRENT FUNGAL INFECTION REPORTS 2015. [DOI: 10.1007/s12281-015-0227-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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20
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Muñoz P, Vena A, Cerón I, Valerio M, Palomo J, Guinea J, Escribano P, Martínez-Sellés M, Bouza E. Invasive pulmonary aspergillosis in heart transplant recipients: Two radiologic patterns with a different prognosis. J Heart Lung Transplant 2014; 33:1034-40. [DOI: 10.1016/j.healun.2014.05.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Revised: 05/20/2014] [Accepted: 05/28/2014] [Indexed: 01/15/2023] Open
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21
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Kropshofer G, Kneer A, Edlinger M, Meister B, Salvador C, Lass-Flörl C, Freund M, Crazzolara R. Computed tomography guided percutaneous lung biopsies and suspected fungal infections in pediatric cancer patients. Pediatr Blood Cancer 2014; 61:1620-4. [PMID: 24803392 DOI: 10.1002/pbc.25091] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Accepted: 04/14/2014] [Indexed: 11/09/2022]
Abstract
BACKGROUND The spectrum of potential fungal pathogens known to cause invasive pulmonary infections has grown as a result of intensified immunosuppressive therapy and the emergence of antifungal resistance. PROCEDURE In a retrospective single center study, we investigated computed tomography guided percutaneous lung biopsies in 16 childhood patients with suspected fungal infections. Microbiological analysis consisted of microscopic examination, culture, and a broad-range fungal polymerase chain reaction for detection of either Aspergillus or Mucorales species. RESULTS In 14 patients (88%), invasive fungal infection with Aspergillus species including A. terreus, Mucormycetes, and Saccharomyces cerevisiae being the main pathogens was confirmed, including patients with a double infection (19%). In two cases, the most likely diagnosis of primary bronchiolitis obliterans organizing pneumonia was established based on the results of typical histopathologic features, negative culture results, and symptoms resolved after treatment with high-dose cortisone. Diagnosis of invasive fungal pneumonia led to an immediate interruption of antineoplastic treatment in 100%, reduction of antibiotic drugs in 76%, and change of empirical to targeted antifungal therapy in 63%. The safety of lung biopsy was guaranteed by lack of any complications, such as bleeding or pneumothorax. CONCLUSIONS The increased detection of rare fungal infections by computed tomography guided biopsy supports the need for a rapid and precise diagnosis, as most of the fungal pathogens are at least partially resistant to available antifungal therapy and proper treatment is essential for best practice in patient management.
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22
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Singh N, Suarez JF, Avery R, Lass-Flörl C, Geltner C, Pasqualotto AC, Marshall Lyon G, Barron M, Husain S, Wagener MM, Montoya JG. Risk factors and outcomes in lung transplant recipients with nodular invasive pulmonary aspergillosis. J Infect 2013; 67:72-8. [DOI: 10.1016/j.jinf.2013.03.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Revised: 03/21/2013] [Accepted: 03/25/2013] [Indexed: 12/30/2022]
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Qin J, Xu J, Dong Y, Tang W, Wu B, An Y, Shan H. High-resolution CT findings of pulmonary infections after orthotopic liver transplantation in 453 patients. Br J Radiol 2012; 85:e959-65. [PMID: 22993384 DOI: 10.1259/bjr/26230943] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES The objective of this study was to review the high-resolution CT (HRCT) findings in patients with pulmonary infection after orthotopic liver transplantation (OLT) and to determine distinguishing findings among the various types of infection. METHODS This study included 453 consecutive liver transplant recipients with pulmonary infection, on whom HRCT of the chest was performed within 24 h of the beginning of symptoms and for whom proven diagnosis had taken place within 1 week of the onset of symptoms. Two radiologists analysed the CT images; final decisions regarding the findings were reached by consensus. RESULTS Bacterial and viral pneumonia made up the bulk of infections (63.4% and 29.4%, respectively), followed by fungal infiltrates (24.5%). Large nodules were most common in patients with fungal pneumonia, having been seen in 38 (54%) of the 70 patients with fungal pneumonia, 22 (10%) of 220 with bacterial pneumonia (p=0.0059) and 6 (8%) of 78 with viral pneumonia (p=0.0011). The halo sign was also more frequent in patients with fungal pneumonia, having been seen in 38 (54%) of the 70 patients with fungal pneumonia, 17 (8%) of 220 with bacterial pneumonia (p=0.0026) and 7 (9%) of 78 with viral pneumonia (p=0.0015). There was no statistically significant difference in the prevalence of the other HRCT patterns including air-space consolidation, ground-glass attenuation and small nodules among bacterial, viral and fungal infections (all p>0.05). CONCLUSION The presence of large nodules with the halo sign is most suggestive of fungal infection after OLT. Other HRCT patterns are not helpful in distinguishing among the various types of infection seen in liver transplant recipients.
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Affiliation(s)
- J Qin
- Department of Radiology, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
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24
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How I manage pulmonary nodular lesions and nodular infiltrates in patients with hematologic malignancies or undergoing hematopoietic cell transplantation. Blood 2012; 120:1791-800. [DOI: 10.1182/blood-2012-02-378976] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Abstract
Pulmonary nodules and nodular infiltrates occur frequently during treatment of hematologic malignancies and after hematopoietic cell transplantation. In patients not receiving active immunosuppressive therapy, the most likely culprits are primary lung cancer, chronic infectious or inactive granulomata, or even the underlying hematologic disease itself (especially in patients with lymphoma). In patients receiving active therapy or who are otherwise highly immunosuppressed, there is a wider spectrum of etiologies with infection being most likely, especially by bacteria and fungi. Characterization of the pulmonary lesion by high-resolution CT imaging is a crucial first diagnostic step. Other noninvasive tests can often be useful, but invasive testing by bronchoscopic evaluation or acquisition of tissue by one of several biopsy techniques should be performed for those at risk for malignancy or invasive infection unless contraindicated. The choice of the optimal biopsy technique should be individualized, guided by location of the lesion, suspected etiology, skill and experience of the diagnostic team, procedural risk of complications, and patient status. Although presumptive therapy targeting the most likely etiology is justified in patients suspected of serious infection while evaluation proceeds, a structured evaluation to determine the specific etiology is recommended. Interdisciplinary teamwork is highly desirable to optimize diagnosis and therapy.
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The strategy for the diagnosis of invasive pulmonary aspergillosis should depend on both the underlying condition and the leukocyte count of patients with hematologic malignancies. Blood 2012; 119:1831-7; quiz 1956. [DOI: 10.1182/blood-2011-04-351601] [Citation(s) in RCA: 101] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Abstract
The identification of the causative organism in invasive pulmonary aspergillosis (IPA) is recommended. We investigated whether a mycologic diagnostic strategy could be optimized based on patient characteristics. Fifty-five patients were enrolled in a prospective study. The presence of Aspergillus in respiratory samples occurred more frequently in non-acute leukemia (AL) patients than in AL patients (P = .0003), and in patients with leukocyte counts more than 100/mm3 (P = .002). In a logistic regression model, these 2 factors appeared to be independent, with an adjusted odds ratio of 7.14 (95% confidence interval, 1.40-36.5) for non-AL patients and an adjusted odds ratio of 6.97 (95% confidence interval, 1.33-36.5) for patients with leukocyte counts more than 100/mm3. A positive mycologic result was also more frequent among patients with lung CT scan signs of airway-invasive disease than among other patients (P = .043). Airway-invasive signs were more frequent among non-AL patients (P = .049), whereas angioinvasive disease was more frequent among both AL patients (P = .01) and patients with leukocyte counts less than 100/mm3 (P = .001). A concomitant pulmonary infection was identified more frequently among non-AL patients (P = .005 vs allogeneic hematopoietic stem cell transplant and P = .048 vs others). Our results suggest that different strategies for diagnosing IPA should be considered based on the underlying condition.
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26
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Herbrecht R, Roedlich MN. Earlier Diagnosis of Angioinvasive Pulmonary Mold Disease: Is Computed Tomography Pulmonary Angiography a New Step? Clin Infect Dis 2011; 54:617-20. [DOI: 10.1093/cid/cir894] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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Computed tomography findings in invasive pulmonary aspergillosis in non-neutropenic transplant recipients and neutropenic patients, and their prognostic value. J Infect 2011; 63:447-56. [DOI: 10.1016/j.jinf.2011.08.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2011] [Revised: 08/08/2011] [Accepted: 08/10/2011] [Indexed: 01/12/2023]
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28
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Imaging studies for diagnosing invasive fungal pneumonia in immunocompromised patients. Curr Opin Infect Dis 2011; 24:309-14. [PMID: 21673574 DOI: 10.1097/qco.0b013e328348b2e1] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The aim is to review imaging advances in invasive fungal pneumonia in cancer and transplant recipients and how their use can help guide treatment. RECENT FINDINGS Early chest computed tomographic (CT) imaging of immunocompromised patients with neutropenic fever leads to improved survival. Some of the typical CT findings of invasive fungal pneumonia are transitory and are most common during the first week of symptoms. The reversed halo sign, an early sign of disease, is more common in mucormycosis. During the first 10 days of infection, invasive fungal pneumonia nodules may grow on follow-up CT scans, but this does not necessarily equate to worsening disease. Because of the excessive radiation of chest CT and because pulmonary nodule size typically expands during the first few weeks of treatment, follow-up CT scans should be ordered only when therapy changes are dependent on imaging findings. SUMMARY Early chest CT imaging in immunocompromised patients suspected of having invasive fungal pneumonia can help identify disease early, leading to improved outcome.
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Georgiadou SP, Sipsas NV, Marom EM, Kontoyiannis DP. The diagnostic value of halo and reversed halo signs for invasive mold infections in compromised hosts. Clin Infect Dis 2011; 52:1144-55. [PMID: 21467021 DOI: 10.1093/cid/cir122] [Citation(s) in RCA: 174] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The halo sign is a CT finding of ground-glass opacity surrounding a pulmonary nodule or mass. The reversed halo sign is a focal rounded area of ground-glass opacity surrounded by a crescent or complete ring of consolidation. In severely immunocompromised patients, these signs are highly suggestive of early infection by an angioinvasive fungus. The halo sign and reversed halo sign are most commonly associated with invasive pulmonary aspergillosis and pulmonary mucormycosis, respectively. Many other infections and noninfectious conditions, such as neoplastic and inflammatory processes, may also manifest with pulmonary nodules associated with either sign. Although nonspecific, both signs can be useful for preemptive initiation of antifungal therapy in the appropriate clinical setting. This review aims to evaluate the diagnostic value of the halo sign and reversed halo sign in immunocompromised hosts and describes the wide spectrum of diseases associated with them.
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Affiliation(s)
- Sarah P Georgiadou
- Infectious Diseases Unit, Pathophysiology Department, Laikon General Hospital and Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Abstract
PURPOSE OF REVIEW This review highlights the most important and salient recent developments with regards to invasive pulmonary aspergillosis (IPA), currently the most common opportunistic fungal pneumonia in patients with hematological malignancies. RECENT FINDINGS Besides patients in hematology units, other immunosuppressed and critically ill patients are also at risk of IPA. Identification of patients who possess specific polymorphisms of Toll-like receptor 4 and dectin-1, both of which are involved in the immune sensing of Aspergillus spp., may facilitate risk-stratification. The use of the galactomannan assay in bronchoalveolar fluid to improve diagnosis of IPA is undergoing validation. Trending galactomannan and other biomarker results may prognosticate clinical outcomes. During intensive chemotherapy for leukemia, posaconazole and aerosolized liposomal amphotericin B (L-AMB) have demonstrated efficacy as prophylaxis against invasive fungal infection. However, fluconazole remains an effective prophylactic agent in the setting of hematopoietic stem cell transplantation despite availability of newer antifungal agents. Although voriconazole is still the drug of choice for IPA, both caspofungin and L-AMB are viable alternatives. SUMMARY Despite increasing knowledge of IPA and availability of newer antifungal agents, clinical management remains a challenge in the setting of a compromised host defense system that is unable to mount an appropriate immune response against the pathogen.
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Evaluation of lysine biosynthesis as an antifungal drug target: biochemical characterization of Aspergillus fumigatus homocitrate synthase and virulence studies. EUKARYOTIC CELL 2010; 9:878-93. [PMID: 20363898 DOI: 10.1128/ec.00020-10] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Aspergillus fumigatus is the main cause of severe invasive aspergillosis. To combat this life-threatening infection, only limited numbers of antifungals are available. The fungal alpha-aminoadipate pathway, which is essential for lysine biosynthesis, has been suggested as a potential antifungal drug target. Here we reanalyzed the role of this pathway for establishment of invasive aspergillosis in murine models. We selected the first pathway-specific enzyme, homocitrate synthase (HcsA), for biochemical characterization and for study of its role in virulence. A. fumigatus HcsA was specific for the substrates acetyl-coenzyme A (acetyl-CoA) and alpha-ketoglutarate, and its activity was independent of any metal ions. In contrast to the case for other homocitrate synthases, enzymatic activity was hardly affected by lysine and gene expression increased under conditions of lysine supplementation. An hcsA deletion mutant was lysine auxotrophic and unable to germinate on unhydrolyzed proteins given as a sole nutrient source. However, the addition of partially purified A. fumigatus proteases restored growth, confirming the importance of free lysine to complement auxotrophy. In contrast to lysine-auxotrophic mutants from other fungal species, the mutant grew on blood and serum, indicating the existence of high-affinity lysine uptake systems. In agreement, although the virulence of the mutant was strongly attenuated in murine models of bronchopulmonary aspergillosis, virulence was partially restored by lysine supplementation via the drinking water. Additionally, in contrast to the case for attenuated pulmonary infections, the mutant retained full virulence when injected intravenously. Therefore, we concluded that inhibition of fungal lysine biosynthesis, at least for disseminating invasive aspergillosis, does not appear to provide a suitable target for new antifungals.
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Kim SH, Choi SM, Lee DG, Park JK, Kwon JC, Park SH, Kim HJ, Lee S, Eom KS, Choi JH, Yoo JH, Min WS. Outcome of Surgical Resection for Invasive Pulmonary Fungal Diseases in Patients with Acute Leukemia. Infect Chemother 2010. [DOI: 10.3947/ic.2010.42.6.383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Si-Hyun Kim
- Department of Internal Medicine, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Su-Mi Choi
- Department of Internal Medicine, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Dong-Gun Lee
- Department of Internal Medicine, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Jae Kil Park
- Department of Thoracic and Cardiovascular Surgery, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Jae-Cheol Kwon
- Department of Internal Medicine, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Sun Hee Park
- Department of Internal Medicine, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Hee-Je Kim
- Department of Internal Medicine, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Seok Lee
- Department of Internal Medicine, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Ki-Seong Eom
- Department of Internal Medicine, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Jung-Hyun Choi
- Department of Internal Medicine, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Jin-Hong Yoo
- Department of Internal Medicine, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Woo-Sung Min
- Department of Internal Medicine, The Catholic University of Korea, College of Medicine, Seoul, Korea
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