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Davies AA, Adekoya AO, Balogun OJ, Osaigbovo II, Nwosu A, Gbaja-biamila T, Osinupebi O, Gangneux JP, Oladele RO. Prevalence of Chronic Pulmonary Aspergillosis in Two (2) Tuberculosis Treatment Clinics in Lagos, Nigeria: A Prospective Longitudinal Study. Open Forum Infect Dis 2024; 11:ofae090. [PMID: 38567195 PMCID: PMC10986852 DOI: 10.1093/ofid/ofae090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 02/13/2024] [Indexed: 04/04/2024] Open
Abstract
Background Chronic pulmonary aspergillosis (CPA) is an underrecognized but common complication of pulmonary tuberculosis. In Nigeria, a tuberculosis-endemic country, there is currently no provision to monitor the development of CPA in patients treated for tuberculosis. This study determined the prevalence and incidence of CPA in Lagos, Nigeria. Methods A prospective longitudinal study of patients with previously managed tuberculosis was conducted between June 2021 and May 2022. The study cohorts were assessed at 3-month intervals, and the following were collected: sociodemographic data, chest radiographic findings, sputum samples for fungal culture, and venous blood samples for Aspergillus immunoglobulin G estimation. CPA cases were determined using the case definition for resource-constrained countries. Descriptive and inferential statistics were used, and significance was set at a probability of 5% (P < .05). Results Of the 141 patients recruited, 79 (56.0%) were in the retreatment and 62 (44.0%) in the posttreatment tuberculosis group. The median age (interquartile range) was 40 (30-52) years, with a male-to-female ratio of 1.1:1. Ninety-seven patients (69%) had a GeneXpert test done, of whom 63 (64.9%) were GeneXpert negative. Cough was the most common symptom, with 15 (11%) patients having hemoptysis. The rate of CPA increased steadily as the study progressed: 44 (31.2%) at commencement, 45 (34.9%) at 3 months, 49 (42.6%) at 6 months, and 51 (54.3%) at 9 months. Thus, the overall prevalence of CPA was 49.7%, and the incidence was 6.1%. Conclusions CPA is common in Nigeria and its true burden may still be underestimated. Increased awareness of CPA as a posttuberculosis lung disease is advocated. Evaluation for CPA should be incorporated in patients' work-up for tuberculosis.
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Affiliation(s)
- Adeyinka A Davies
- Department of Medical Microbiology and Parasitology, Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria
- Medical Mycology Society of Nigeria, Lagos, Nigeria
| | - Abiola O Adekoya
- Department of Radiology, Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria
| | | | - Iriagbonse I Osaigbovo
- Medical Mycology Society of Nigeria, Lagos, Nigeria
- Department of Medical Microbiology, School of Medicine, University of Benin, Benin City, Nigeria
| | - Augustina Nwosu
- Medical Mycology Society of Nigeria, Lagos, Nigeria
- Central Research Laboratory, College of Medicine University of Lagos, Lagos, Nigeria
| | - Titilola Gbaja-biamila
- Clinical Sciences Division, Nigeria Institute of Medical Research, Yaba, Lagos, Nigeria
- College of Public Health and Social Justice, Saint Louis University College of Public Health and Social Justice, Missouri, USA
| | - Olubunmi Osinupebi
- Department of Medical Microbiology and Parasitology, Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria
| | - Jean-Pierre Gangneux
- Laboratoire de Parasitologie et Mycologie, European Excellence Center in Medical Mycology, French National Reference Center for Chronic Aspergillosis, Centre Hospitalier Universitaire de Rennes, Rennes, France
- Université de Rennes, Centre Hospitalier Universitaire de Rennes, Inserm, EHESP, IRSET (Institut de Recherché en Santé, Environnement et Travail) (UMR_S 1085), Rennes, France
| | - Rita O Oladele
- Medical Mycology Society of Nigeria, Lagos, Nigeria
- Department of Medical Microbiology and Parasitology, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
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Palanivel J, Mohapatra MM, Rajaram M, Gochhait D, Chakkalakkoombil SV, Singh R. Prevalence and risk factors for chronic pulmonary aspergillosis in chronic obstructive pulmonary disease patients with acute exacerbations. Monaldi Arch Chest Dis 2024. [PMID: 38517152 DOI: 10.4081/monaldi.2024.2927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 03/13/2024] [Indexed: 03/23/2024] Open
Abstract
Chronic obstructive pulmonary disease (COPD) patients often experience acute exacerbations requiring hospitalization. Recently, attention has focused on Aspergillus sensitization in the airways of these COPD patients. This study aimed to assess the prevalence of chronic pulmonary aspergillosis (CPA) in COPD patients with acute exacerbations and identify associated risk factors. A cross-sectional descriptive study was conducted at the Jawaharlal Institute of Postgraduate Medical Education and Research from January 2021 to June 2022. Sixty-one COPD patients presenting with acute exacerbations were included. Demographic details, blood investigations, and sputum examinations were performed for all patients. A high-resolution computed tomography thorax was conducted for eligible patients. The prevalence of CPA among patients with an acute exacerbation of COPD was found to be 9.8%, with chronic cavitary pulmonary aspergillosis being the most common presentation (50%). Among post-tubercular COPD patients, the prevalence of CPA was significantly higher at 22.7%. Hemoptysis (p<0.001) and a previous history of tuberculosis (p=0.008) were associated with Aspergillus sensitization. This study highlights the substantial prevalence of CPA in COPD patients with acute exacerbations, particularly in those with a history of tuberculosis. Early recognition and targeted management of CPA in COPD patients may improve outcomes and reduce hospitalization rates. Further large-scale multi-center studies are needed to validate these findings and comprehensively address the impact of CPA on all COPD patients.
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Affiliation(s)
- Jayabharathi Palanivel
- Department of Pulmonary Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry.
| | - Madhusmita Mohanty Mohapatra
- Department of Pulmonary Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry.
| | - Manju Rajaram
- Department of Pulmonary Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry.
| | - Debasis Gochhait
- Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry.
| | | | - Rakesh Singh
- Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry.
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Krishna A, Keche A, Tg R, Das P. Clinicomycological Study of the Spectrum of Pulmonary Aspergillosis at a Tertiary Care Hospital in Central India. Cureus 2024; 16:e56147. [PMID: 38618367 PMCID: PMC11015873 DOI: 10.7759/cureus.56147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2024] [Indexed: 04/16/2024] Open
Abstract
Knowing the spectrum, prevalence, and modes of diagnosis of pulmonary aspergillosis (PA) will be beneficial to clinicians for its early diagnosis and management. This study aims to estimate the prevalence, spectrum, and role of serological tests and radiological findings in the diagnosis of PA. A total of 150 patients were suspected of having PA after obtaining relevant clinical history and radiological imaging. The patients were grouped into each spectrum of PA as invasive PA (IPA), chronic necrotizing PA (CNPA), aspergilloma, allergic bronchopulmonary aspergillosis (ABPA) based on predisposing factors, clinical and radiological findings, and the guidelines of the 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). Samples (bronchoalveolar lavage (BAL), sputum, blood) were collected from these patients and processed in a microbiology lab. BAL and sputum were subjected to microscopy by potassium hydroxide mount, calcofluor white mount, and culture. The serum was separated from blood by centrifugation and subjected to specific serological tests based on the spectrum of PA that the patient was suspected to have. For IPA, serum and BAL galactomannan antigen enzyme-linked immunosorbent assay (ELISA) was performed. For CNPA and aspergilloma, the anti-Aspergillus IgG antibody ELISA was performed. For ABPA, the tests performed were total immunoglobulin E (IgE) ELISA, Aspergillus fumigatus-specific IgE ELISA, and anti-Aspergillus immunoglobulin G (IgG) antibody ELISA. After compiling the clinical, radiological, culture, and serological findings, patients were diagnosed to have a particular spectrum of PA. The prevalence of IPA was 1.4%, CNPA was 4%, ABPA was 3.2%, and aspergilloma was 2.9%. CNPA was the predominant spectrum of PA in our study. Culture positivity for Aspergillus species was seen the highest in aspergilloma patients, followed by IPA, ABPA, and CNPA patients. A. fumigatus was the most common causative agent of PA, except for IPA for which Aspergillus flavus was the most common causative. Aspergillus niger and Aspergillus terreus were less the frequent causes of PA. A combination of radiological, microbiological, and serological tests along with clinical correlation is needed to confirm the diagnosis of PA.
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Affiliation(s)
- Akshay Krishna
- Neuromicrobiology, National Institute of Mental Health and Neurosciences, Bengaluru, IND
| | - Archana Keche
- Microbiology, All India Institute of Medical Sciences, Raipur, Raipur, IND
| | - Ranganath Tg
- Pulmonary Medicine, All India Institute of Medical Sciences, Raipur, Raipur, IND
| | - Padma Das
- Microbiology, All India Institute of Medical Sciences, Raipur, Raipur, IND
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Tashiro M, Takazono T, Izumikawa K. Chronic pulmonary aspergillosis: comprehensive insights into epidemiology, treatment, and unresolved challenges. Ther Adv Infect Dis 2024; 11:20499361241253751. [PMID: 38899061 PMCID: PMC11186400 DOI: 10.1177/20499361241253751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 04/23/2024] [Indexed: 06/21/2024] Open
Abstract
Chronic pulmonary aspergillosis (CPA) is a challenging respiratory infection caused by the environmental fungus Aspergillus. CPA has a poor prognosis, with reported 1-year mortality rates ranging from 7% to 32% and 5-year mortality rates ranging from 38% to 52%. A comprehensive understanding of the pathogen, pathophysiology, risk factors, diagnosis, surgery, hemoptysis treatment, pharmacological therapy, and prognosis is essential to manage CPA effectively. In particular, Aspergillus drug resistance and cryptic species pose significant challenges. CPA lacks tissue invasion and has specific features such as aspergilloma. The most critical risk factor for the development of CPA is pulmonary cavitation. Diagnostic approaches vary by CPA subtype, with computed tomography (CT) imaging and Aspergillus IgG antibodies being key. Treatment strategies include surgery, hemoptysis management, and antifungal therapy. Surgery is the curative option. However, reported postoperative mortality rates range from 0% to 5% and complications range from 11% to 63%. Simple aspergilloma generally has a low postoperative mortality rate, making surgery the first choice. Hemoptysis, observed in 50% of CPA patients, is a significant symptom and can be life-threatening. Bronchial artery embolization achieves hemostasis in 64% to 100% of cases, but 50% experience recurrent hemoptysis. The efficacy of antifungal therapy for CPA varies, with itraconazole reported to be 43-76%, voriconazole 32-80%, posaconazole 44-61%, isavuconazole 82.7%, echinocandins 42-77%, and liposomal amphotericin B 52-73%. Combinatorial treatments such as bronchoscopic triazole administration, inhalation, or direct injection of amphotericin B at the site of infection also show efficacy. A treatment duration of more than 6 months is recommended, with better efficacy reported for periods of more than 1 year. In anticipation of improvements in CPA management, ongoing advances in basic and clinical research are expected to contribute to the future of CPA management.
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Affiliation(s)
- Masato Tashiro
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
- Infection Control and Education Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Takahiro Takazono
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Koichi Izumikawa
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
- Infection Control and Education Center, Nagasaki University Hospital, Nagasaki, Japan
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Farooqi J, Bongomin F, Hasan R, Nasir N, Irfan M, Mahmood SF, Zafar A, Mir F, Nizamuddin S, Jabeen K. The Second International Collaborative Mycology Conference: evidence-informed fight against fungal diseases in Pakistan. Ther Adv Infect Dis 2024; 11:20499361241272510. [PMID: 39247871 PMCID: PMC11380120 DOI: 10.1177/20499361241272510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2024] [Accepted: 07/18/2024] [Indexed: 09/10/2024] Open
Affiliation(s)
- Joveria Farooqi
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Felix Bongomin
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
| | - Rumina Hasan
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Nosheen Nasir
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Muhammad Irfan
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | | | - Afia Zafar
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Fatima Mir
- Department of Pediatric and Child Health, Aga Khan University, Karachi, Pakistan
| | - Summiya Nizamuddin
- Department of Pathology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Kauser Jabeen
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi 74800, Pakistan
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Barac A, Vujovic A, Drazic A, Stevanovic G, Paglietti B, Lukic K, Stojanovic M, Stjepanovic M. Diagnosis of Chronic Pulmonary Aspergillosis: Clinical, Radiological or Laboratory? J Fungi (Basel) 2023; 9:1084. [PMID: 37998889 PMCID: PMC10672318 DOI: 10.3390/jof9111084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 10/27/2023] [Accepted: 11/03/2023] [Indexed: 11/25/2023] Open
Abstract
Chronic pulmonary aspergillosis (CPA) is a chronic progressive lung disease associated with a poor prognosis and a 5-year mortality rate of approximately 40-50%. The disease is characterized by slowly progressive destruction of the lung parenchyma, in the form of multiple cavities, nodules, infiltrates or fibrosis. CPA can be challenging to diagnose due to its non-specific symptoms and similarities with other respiratory conditions combined with the poor awareness of the medical community about the disease. This can result in delayed treatment even for years and worsening of the patient's condition. Serological tests certainly play a significant role in diagnosing CPA but cannot be interpreted without radiological confirmation of CPA. Although many data are published on this hot topic, there is yet no single definitive test for diagnosing CPA, and a multidisciplinary approach which involves a combination of clinical picture, radiological findings, microbiological results and exclusion of other mimicking diseases, is essential for the accurate diagnosis of CPA.
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Affiliation(s)
- Aleksandra Barac
- Clinic for Infectious and Tropical Diseases, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (A.V.); (G.S.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (A.D.); (M.S.); (M.S.)
| | - Ankica Vujovic
- Clinic for Infectious and Tropical Diseases, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (A.V.); (G.S.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (A.D.); (M.S.); (M.S.)
| | - Ana Drazic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (A.D.); (M.S.); (M.S.)
| | - Goran Stevanovic
- Clinic for Infectious and Tropical Diseases, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (A.V.); (G.S.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (A.D.); (M.S.); (M.S.)
| | - Bianca Paglietti
- Department of Biomedical Sciences, University of Sassari, 07100 Sassari, Italy;
| | - Katarina Lukic
- Center for Radiology and MRI, University Clinical Center of Serbia, 11000 Belgrade, Serbia;
| | - Maja Stojanovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (A.D.); (M.S.); (M.S.)
- Clinic of Allergy and Immunology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Mihailo Stjepanovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (A.D.); (M.S.); (M.S.)
- Clinic for Pulmonology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
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Hatmaker EA, Rangel-Grimaldo M, Raja HA, Pourhadi H, Knowles SL, Fuller K, Adams EM, Lightfoot JD, Bastos RW, Goldman GH, Oberlies NH, Rokas A. Genomic and Phenotypic Trait Variation of the Opportunistic Human Pathogen Aspergillus flavus and Its Close Relatives. Microbiol Spectr 2022; 10:e0306922. [PMID: 36318036 PMCID: PMC9769809 DOI: 10.1128/spectrum.03069-22] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 10/10/2022] [Indexed: 11/16/2022] Open
Abstract
Fungal diseases affect millions of humans annually, yet fungal pathogens remain understudied. The mold Aspergillus flavus can cause both aspergillosis and fungal keratitis infections, but closely related species are not considered clinically relevant. To study the evolution of A. flavus pathogenicity, we examined genomic and phenotypic traits of two strains of A. flavus and three closely related species, Aspergillus arachidicola (two strains), Aspergillus parasiticus (two strains), and Aspergillus nomiae (one strain). We identified >3,000 orthologous proteins unique to A. flavus, including seven biosynthetic gene clusters present in A. flavus strains and absent in the three nonpathogens. We characterized secondary metabolite production for all seven strains under two clinically relevant conditions, temperature and salt concentration. Temperature impacted metabolite production in all species, whereas salinity did not affect production of any species. Strains of the same species produced different metabolites. Growth under stress conditions revealed additional heterogeneity within species. Using the invertebrate fungal disease model Galleria mellonella, we found virulence of strains of the same species varied widely; A. flavus strains were not more virulent than strains of the nonpathogens. In a murine model of fungal keratitis, we observed significantly lower disease severity and corneal thickness for A. arachidicola compared to other species at 48 h postinfection, but not at 72 h. Our work identifies variations in key phenotypic, chemical, and genomic attributes between A. flavus and its nonpathogenic relatives and reveals extensive strain heterogeneity in virulence that does not correspond to the currently established clinical relevance of these species. IMPORTANCE Aspergillus flavus is a filamentous fungus that causes opportunistic human infections, such as aspergillosis and fungal keratitis, but its close relatives are considered nonpathogenic. To begin understanding how this difference in pathogenicity evolved, we characterized variation in infection-relevant genomic, chemical, and phenotypic traits between strains of A. flavus and its relatives. We found extensive variation (or strain heterogeneity) within the pathogenic A. flavus as well as within its close relatives, suggesting that strain-level differences may play a major role in the ability of these fungi to cause disease. Surprisingly, we also found that the virulence of strains from species not considered to be pathogens was similar to that of A. flavus in both invertebrate and murine models of disease. These results contrast with previous studies on Aspergillus fumigatus, another major pathogen in the genus, for which significant differences in infection-relevant chemical and phenotypic traits are observed between closely related pathogenic and nonpathogenic species.
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Affiliation(s)
- E. Anne Hatmaker
- Department of Biological Sciences, Vanderbilt University, Nashville, Tennessee, USA
- Evolutionary Studies Initiative, Vanderbilt University, Nashville, Tennessee, USA
| | - Manuel Rangel-Grimaldo
- Department of Chemistry & Biochemistry, University of North Carolina at Greensboro, Greensboro, North Carolina, USA
| | - Huzefa A. Raja
- Department of Chemistry & Biochemistry, University of North Carolina at Greensboro, Greensboro, North Carolina, USA
| | - Hadi Pourhadi
- Department of Chemistry & Biochemistry, University of North Carolina at Greensboro, Greensboro, North Carolina, USA
| | - Sonja L. Knowles
- Department of Chemistry & Biochemistry, University of North Carolina at Greensboro, Greensboro, North Carolina, USA
| | - Kevin Fuller
- Department of Microbiology and Immunology, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma, USA
| | - Emily M. Adams
- Department of Microbiology and Immunology, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma, USA
| | - Jorge D. Lightfoot
- Department of Microbiology and Immunology, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma, USA
| | - Rafael W. Bastos
- Biosciences Center, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Gustavo H. Goldman
- Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brazil
| | - Nicholas H. Oberlies
- Department of Chemistry & Biochemistry, University of North Carolina at Greensboro, Greensboro, North Carolina, USA
| | - Antonis Rokas
- Department of Biological Sciences, Vanderbilt University, Nashville, Tennessee, USA
- Evolutionary Studies Initiative, Vanderbilt University, Nashville, Tennessee, USA
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Nasir N, Farooqi J, Zubair SM, Ayub M, Khan S, Wiqar MH, Mahmood SF, Jabeen K. Comparison of risk factors and outcome of patients with and without
COVID
‐19 associated pulmonary aspergillosis from Pakistan: A case‐control study. Mycoses 2022; 66:69-74. [PMID: 36111367 PMCID: PMC9537972 DOI: 10.1111/myc.13529] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 09/05/2022] [Accepted: 09/09/2022] [Indexed: 11/30/2022]
Abstract
Background Early identification of COVID‐19‐associated pulmonary aspergillosis (CAPA) is particularly challenging in low‐ middle‐income countries where diagnostic capabilities are limited, and risk factors for CAPA have not been identified. It is also essential to recognise CAPA patients who are likely to have a poorer outcome to decide on aggressive management approaches. Therefore, this study aimed to identify risk factors and outcomes for CAPA among admitted moderate to critical COVID‐19 patients at our centre in Pakistan. Methods An unmatched case–control study with ratio of 1:2 was conducted on hospitalised adult patients with COVID‐19 from March 2020–July 2021. Cases were defined according to European Confederation of Medical Mycology and the International Society for Human and Animal Mycology consensus criteria. Controls were defined as patients hospitalised with moderate, severe or critical COVID‐19 without CAPA. Results A total of 100 CAPA cases (27 probable CAPA; 73 possible CAPA) were compared with 237 controls. Critical disease at presentation (aOR 5.04; 95% CI 2.18–11.63), age ≥ 60 years (aOR 2.00; 95% CI 1.20–3.35) and underlying co‐morbid of chronic kidney disease (CKD) (aOR 3.78; 95% CI 1.57–9.08) were identified as risk factors for CAPA. Patients with CAPA had a significantly greater proportion of complications and longer length of hospital stay (p‐value < .001). Mortality was higher in patients with CAPA (48%) as compared to those without CAPA (13.5%) [OR = 6.36(95% CI 3.6–11)]. Conclusions CAPA was significantly associated with advanced age, CKD and critical illness at presentation, along with a greater frequency of complications and higher mortality.
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Affiliation(s)
- Nosheen Nasir
- Department of Medicine Aga Khan University Karachi Pakistan
| | - Joveria Farooqi
- Department of Pathology & Laboratory Medicine Aga Khan University Karachi Pakistan
| | | | - Maaha Ayub
- Medical College Aga Khan University Karachi Pakistan
| | - Shahmeer Khan
- Medical College Aga Khan University Karachi Pakistan
| | | | | | - Kauser Jabeen
- Department of Pathology & Laboratory Medicine Aga Khan University Karachi Pakistan
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Zarif A, Thomas A, Vayro A. Chronic Pulmonary Aspergillosis: A Brief Review. THE YALE JOURNAL OF BIOLOGY AND MEDICINE 2021; 94:673-679. [PMID: 34970105 PMCID: PMC8686779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Chronic Pulmonary Aspergillosis (CPA) is a destructive pulmonary disease caused by a fungal infection, affecting mainly individuals with prior or concurrent pulmonary conditions. It has a global prevalence of 42 per 100,000 population, but in the US and Europe, prevalence is less than 1 per 100,000. The clinical definition of CPA is based on various factors accounting for comorbidities, clinical presentation, and duration. It may be categorized into five subtypes that the disease may evolve between over time. Based on global consensus covering the spectrum of low-resource to high-resource settings, diagnosis is a multi-factorial process that involves a combination of clinical presentation persisting over 3 months, radiological findings, positive culture growth, and serological tests. CPA remains underdiagnosed due to a lack of awareness and is often misdiagnosed due to the comorbidities present. Treatment options are limited due to a lack of research. Furthermore, associated comorbidities and drug interactions further complicate treatment plans. Follow-up throughout treatment should be based on understanding the predictors of mortality. Identification of potential relapse or resistance to antifungal therapy is crucial to limit the low long-term survival rate. Awareness surrounding this devastating disease needs to be raised further to enable earlier identification, improve understanding of patient factors associated with prognosis, and the future potential for targeted therapies. This review aims to raise awareness of this rare condition among practitioners, by providing an overview of common risk factors influencing the prevalence and incidence of the disease. We further discuss current approaches and recent advancements in CPA diagnosis and treatment.
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Affiliation(s)
- Azmaeen Zarif
- Cambridge Judge Business School, University of
Cambridge, Cambridge, UK
- School of Biological Sciences, University of Cambridge,
Cambridge, UK
- Gonville & Caius College, University of Cambridge,
Cambridge, UK
| | - Adith Thomas
- Cambridge Judge Business School, University of
Cambridge, Cambridge, UK
- School of Biological Sciences, University of Cambridge,
Cambridge, UK
- Queens’ College, University of Cambridge, Cambridge,
UK
| | - Alex Vayro
- Cambridge Judge Business School, University of
Cambridge, Cambridge, UK
- School of Biological Sciences, University of Cambridge,
Cambridge, UK
- Emmanuel College, University of Cambridge, Cambridge,
UK
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Clinical manifestations, associated risk factors and treatment outcomes of Chronic Pulmonary Aspergillosis (CPA): Experiences from a tertiary care hospital in Lahore, Pakistan. PLoS One 2021; 16:e0259766. [PMID: 34767589 PMCID: PMC8589179 DOI: 10.1371/journal.pone.0259766] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 10/26/2021] [Indexed: 11/19/2022] Open
Abstract
Background Chronic pulmonary aspergillosis (CPA) has a wide spectrum of illnesses depending on the progression of the disease and comorbid conditions. However, there is an inadequacy of investigations regarding clinical, laboratory, risk factor and prognostic data on CPA. The current study is aimed to consider the clinical manifestations, risk factors and outcomes of CPA. Methodology Retrospective records of all patients with a confirmed diagnosis of CPA who sought treatment at Gulab Devi Chest Hospital Lahore, Pakistan from January 2017 to December 2019 were evaluated. Data regarding demographics, clinical manifestations, comorbidities, radiographic and microbiological findings, length of hospital stay (LOS) and intensive care unit (ICU) admission was collected and analyzed to identify the factors associated with mortality. The independent factors associated with mortality were also identified by appropriate analyses. Results A total of 218 CPA patients were included in this study. The mean age was 45.75 ± 6.26 years. Of these, 160 (73.4%) were male, and 65 (29.8%) had diabetes. The mean LOS was 18.5 ± 10.9 days. The most common type of CPA was simple aspergilloma (56%) followed by chronic cavitary pulmonary aspergillosis (CCPA) (31.2%). About one half of the patients had a history of pulmonary tuberculosis (TB) and treatment response rates were low in patients with active TB. The overall mortality rate was 27.1%. ICU admission was required for 78 (35.8%) patients. Diabetes mellitus (DM), hematological malignancies and chronic kidney disease (CKD) were the common underlying conditions predicting a poor outcome. Mean LOS, hematological malignancies, consolidation and ICU admission were identified as the independent factors leading to mortality. Conclusions CPA had a significant association with TB in the majority of cases. Treatment response rates in cases with active TB were comparatively low. Cases with high mean LOS, hematological malignancies, consolidation, ICU admission, CKD and DM experienced poor outcomes. High mean LOS, hematological malignancies, consolidation and ICU stay were identified as independent risk factors for mortality. Future large prospective studies, involving aspergillus specific immunoglobulin G (IgG) antibody testing, are required for a better understanding of CPA in Pakistan.
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Understanding the fundamental role of virulence determinants to combat Aspergillus fumigatus infections: exploring beyond cell wall. Mycol Prog 2021. [DOI: 10.1007/s11557-021-01677-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Rozaliyani A, Rosianawati H, Handayani D, Agustin H, Zaini J, Syam R, Adawiyah R, Tugiran M, Setianingrum F, Burhan E, Kosmidis C, Wahyuningsih R. Chronic Pulmonary Aspergillosis in Post Tuberculosis Patients in Indonesia and the Role of LDBio Aspergillus ICT as Part of the Diagnosis Scheme. J Fungi (Basel) 2020; 6:jof6040318. [PMID: 33260909 PMCID: PMC7712371 DOI: 10.3390/jof6040318] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 10/27/2020] [Accepted: 11/18/2020] [Indexed: 12/24/2022] Open
Abstract
Chronic pulmonary aspergillosis (CPA) is a common sequela of pulmonary tuberculosis (TB). The diagnosis of CPA is difficult and often misdiagnosed as smear-negative TB in endemic settings. Aspergillus IgG detection is the cornerstone of CPA diagnosis. There are a lack of studies on the prevalence of CPA in GeneXpert/smear-negative TB patients in Indonesia, despite a high number of TB cases. This study aims to determine the CPA rate in HIV-negative, GeneXpert-negative patients presenting with symptoms following completion of TB therapy and to evaluate the performance of LDBio Aspergillus immunochromatographic technology (ICT) lateral flow assay in the diagnosis of CPA. CPA was diagnosed on the basis of symptoms for ≥3 months, characteristic chest imaging and positive Aspergillus culture. Twenty (22%) out of 90 patients met the criteria for CPA. The LDBio test was positive in 16 (80%) CPA patients and in 21 (30%) non-CPA patients (p < 0.001) with 80% sensitivity and 70% specificity. Logistic regression revealed a positive LDBio Aspergillus ICT result, smoking history and diabetes to be important predictors of CPA diagnosis. Although CPA is an unrecognised disease in Indonesia, this study suggests that more than one in five GeneXpert negative patients with persistent symptoms following completion of TB therapy may have CPA.
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Affiliation(s)
- Anna Rozaliyani
- Department of Parasitology, Faculty of Medicine, Universitas Indonesia, Jakarta 10430, Indonesia; (R.S.); (R.A.); (M.T.); (F.S.); (R.W.)
- Pulmonary Mycosis Centre, Jakarta 10430, Indonesia; (H.R.); (D.H.); (H.A.); (J.Z.); (E.B.)
- Grha Permata Ibu Hospital, Depok 16425, Indonesia
- Correspondence: ; Tel.: +62-213-102-135; Fax: +62-21-3983-2018
| | - Harmi Rosianawati
- Pulmonary Mycosis Centre, Jakarta 10430, Indonesia; (H.R.); (D.H.); (H.A.); (J.Z.); (E.B.)
- Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Universitas Indonesia, Persahabatan National Respiratory Referral Hospital, Jakarta 13230, Indonesia
| | - Diah Handayani
- Pulmonary Mycosis Centre, Jakarta 10430, Indonesia; (H.R.); (D.H.); (H.A.); (J.Z.); (E.B.)
- Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Universitas Indonesia, Persahabatan National Respiratory Referral Hospital, Jakarta 13230, Indonesia
| | - Heidy Agustin
- Pulmonary Mycosis Centre, Jakarta 10430, Indonesia; (H.R.); (D.H.); (H.A.); (J.Z.); (E.B.)
- Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Universitas Indonesia, Persahabatan National Respiratory Referral Hospital, Jakarta 13230, Indonesia
| | - Jamal Zaini
- Pulmonary Mycosis Centre, Jakarta 10430, Indonesia; (H.R.); (D.H.); (H.A.); (J.Z.); (E.B.)
- Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Universitas Indonesia, Persahabatan National Respiratory Referral Hospital, Jakarta 13230, Indonesia
| | - Ridhawati Syam
- Department of Parasitology, Faculty of Medicine, Universitas Indonesia, Jakarta 10430, Indonesia; (R.S.); (R.A.); (M.T.); (F.S.); (R.W.)
- Pulmonary Mycosis Centre, Jakarta 10430, Indonesia; (H.R.); (D.H.); (H.A.); (J.Z.); (E.B.)
| | - Robiatul Adawiyah
- Department of Parasitology, Faculty of Medicine, Universitas Indonesia, Jakarta 10430, Indonesia; (R.S.); (R.A.); (M.T.); (F.S.); (R.W.)
- Pulmonary Mycosis Centre, Jakarta 10430, Indonesia; (H.R.); (D.H.); (H.A.); (J.Z.); (E.B.)
| | - Mulyati Tugiran
- Department of Parasitology, Faculty of Medicine, Universitas Indonesia, Jakarta 10430, Indonesia; (R.S.); (R.A.); (M.T.); (F.S.); (R.W.)
- Pulmonary Mycosis Centre, Jakarta 10430, Indonesia; (H.R.); (D.H.); (H.A.); (J.Z.); (E.B.)
| | - Findra Setianingrum
- Department of Parasitology, Faculty of Medicine, Universitas Indonesia, Jakarta 10430, Indonesia; (R.S.); (R.A.); (M.T.); (F.S.); (R.W.)
- Pulmonary Mycosis Centre, Jakarta 10430, Indonesia; (H.R.); (D.H.); (H.A.); (J.Z.); (E.B.)
| | - Erlina Burhan
- Pulmonary Mycosis Centre, Jakarta 10430, Indonesia; (H.R.); (D.H.); (H.A.); (J.Z.); (E.B.)
- Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Universitas Indonesia, Persahabatan National Respiratory Referral Hospital, Jakarta 13230, Indonesia
| | - Chris Kosmidis
- Manchester Academic Health Science Centre, Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M23 9LT, UK;
| | - Retno Wahyuningsih
- Department of Parasitology, Faculty of Medicine, Universitas Indonesia, Jakarta 10430, Indonesia; (R.S.); (R.A.); (M.T.); (F.S.); (R.W.)
- Pulmonary Mycosis Centre, Jakarta 10430, Indonesia; (H.R.); (D.H.); (H.A.); (J.Z.); (E.B.)
- Department of Parasitology, Faculty of Medicine, Universitas Kristen, Jakarta 13530, Indonesia
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Duong TMN, Nguyen PT, Le TV, Nguyen HLP, Nguyen BNT, Nguyen BPT, Nguyen TA, Chen SCA, Barrs VR, Halliday CL, Sorrell TC, Day JN, Beardsley J. Drug-Resistant Aspergillus flavus Is Highly Prevalent in the Environment of Vietnam: A New Challenge for the Management of Aspergillosis? J Fungi (Basel) 2020; 6:jof6040296. [PMID: 33217930 PMCID: PMC7711995 DOI: 10.3390/jof6040296] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/04/2020] [Accepted: 11/12/2020] [Indexed: 01/10/2023] Open
Abstract
The burden of aspergillosis, especially Chronic Pulmonary Aspergillosis, is increasingly recognized, and the increasing presence of azole-resistant environmental Aspergillus fumigatus has been highlighted as a health risk. However, a sizable minority of aspergillosis is caused by Aspergillus flavus, which is assumed to be sensitive to azoles but is infrequently included in surveillance. We conducted environmental sampling at 150 locations in a rural province of southern Vietnam. A. flavus isolates were identified morphologically, their identity was confirmed by sequencing of the beta-tubulin gene, and then they were tested for susceptibility to azoles and amphotericin B according to EUCAST methodologies. We found that over 85% of A. flavus isolates were resistant to at least one azole, and half of them were resistant to itraconazole. This unexpectedly high prevalence of resistance demands further investigation to determine whether it is linked to agricultural azole use, as has been described for A. fumigatus. Clinical correlation is required, so that guidelines can be adjusted to take this information into account.
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Affiliation(s)
- Tra My N. Duong
- Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney 2145, Australia; (T.M.N.D.); (T.A.N.); (S.C.-A.C.); (V.R.B.); (C.L.H.); (T.C.S.)
- Oxford University Clinical Research Unit, Ho Chi Minh City 70000, Vietnam; (P.T.N.); (T.V.L.); (J.N.D.)
| | - Phuong Tuyen Nguyen
- Oxford University Clinical Research Unit, Ho Chi Minh City 70000, Vietnam; (P.T.N.); (T.V.L.); (J.N.D.)
| | - Thanh Van Le
- Oxford University Clinical Research Unit, Ho Chi Minh City 70000, Vietnam; (P.T.N.); (T.V.L.); (J.N.D.)
| | | | - Bich Ngoc T. Nguyen
- National Lung Hospital, Hanoi 10000, Vietnam;
- Tuberculosis and Lung Diseases Department, Hanoi Medical University, Hanoi 10000, Vietnam
| | | | - Thu Anh Nguyen
- Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney 2145, Australia; (T.M.N.D.); (T.A.N.); (S.C.-A.C.); (V.R.B.); (C.L.H.); (T.C.S.)
- Woolcock Institute of Medical Research, Hanoi 10000, Vietnam;
| | - Sharon C.-A. Chen
- Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney 2145, Australia; (T.M.N.D.); (T.A.N.); (S.C.-A.C.); (V.R.B.); (C.L.H.); (T.C.S.)
- Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Westmead Hospital, Sydney 2145, Australia
| | - Vanessa R. Barrs
- Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney 2145, Australia; (T.M.N.D.); (T.A.N.); (S.C.-A.C.); (V.R.B.); (C.L.H.); (T.C.S.)
- Department of Veterinary Clinical Sciences, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Kowloon Tong, Hong Kong, China
| | - Catriona L. Halliday
- Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney 2145, Australia; (T.M.N.D.); (T.A.N.); (S.C.-A.C.); (V.R.B.); (C.L.H.); (T.C.S.)
- Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Westmead Hospital, Sydney 2145, Australia
| | - Tania C. Sorrell
- Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney 2145, Australia; (T.M.N.D.); (T.A.N.); (S.C.-A.C.); (V.R.B.); (C.L.H.); (T.C.S.)
- Westmead Institute for Medical Research, Westmead, Sydney 2145, Australia
| | - Jeremy N. Day
- Oxford University Clinical Research Unit, Ho Chi Minh City 70000, Vietnam; (P.T.N.); (T.V.L.); (J.N.D.)
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7FZ, UK
| | - Justin Beardsley
- Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney 2145, Australia; (T.M.N.D.); (T.A.N.); (S.C.-A.C.); (V.R.B.); (C.L.H.); (T.C.S.)
- Oxford University Clinical Research Unit, Ho Chi Minh City 70000, Vietnam; (P.T.N.); (T.V.L.); (J.N.D.)
- Westmead Institute for Medical Research, Westmead, Sydney 2145, Australia
- Correspondence: ; Tel.: +61-8627-3402
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Jabeen K, Farooqi J, Iqbal N, Wahab K, Irfan M. Aspergillus fumigatus and Aspergillus flavus-Specific IgG Cut-Offs for the Diagnosis of Chronic Pulmonary Aspergillosis in Pakistan. J Fungi (Basel) 2020; 6:jof6040249. [PMID: 33114653 PMCID: PMC7711809 DOI: 10.3390/jof6040249] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 10/19/2020] [Accepted: 10/23/2020] [Indexed: 12/14/2022] Open
Abstract
Despite a high burden of chronic pulmonary aspergillosis (CPA) in Pakistan, Aspergillus-specific IgG testing is currently not available. Establishing cut-offs for Aspergillus-specific IgG for CPA diagnosis is crucial due to geographical variation. In settings such as Pakistan, where non-Aspergillus fumigatus (mainly A. flavus) Aspergillus species account for the majority of CPA cases, there is a need to explore additional benefit of Aspergillus flavus-specific IgG detection along with A. fumigatus-specific IgG detection. This study was conducted at the Aga Khan University, Karachi, Pakistan after ethical approval. Serum for IgG detection were collected after informed consent from healthy controls (n = 21), diseased controls (patients with lung diseases, n = 18), and CPA patients (n = 21). A. fumigatus and A. flavus IgG were detected using Siemens immulite assay. The sensitivity and specificity of A. fumigatus-specific IgG were 80.95% and 82.05%, respectively at a cut-off of 20 mg/L. The sensitivity and specificity of A. flavus-specific IgG were 80.95% and 79.49% at a cut-off of 30 mg/L. We report, for the first time, performance of A. flavus-specific IgG for CPA diagnosis. Although there was no statistically significant difference between the performance of both antigens, it seems contextually relevant to include A. flavus IgG in the CPA diagnostic algorithm in regions with higher non-A. fumigatus CPA infections.
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Affiliation(s)
- Kauser Jabeen
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi 74800, Pakistan; (J.F.); (K.W.)
- Correspondence: ; Tel.: +92-21-34930051
| | - Joveria Farooqi
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi 74800, Pakistan; (J.F.); (K.W.)
| | - Nousheen Iqbal
- Section of Pulmonary Medicine, Department of Medicine, Aga Khan University, Karachi 74800, Pakistan; (N.I.); (M.I.)
- Department of Medicine, Jinnah Medical and Dental College, Karachi 75400, Pakistan
| | - Khalid Wahab
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi 74800, Pakistan; (J.F.); (K.W.)
| | - Muhammad Irfan
- Section of Pulmonary Medicine, Department of Medicine, Aga Khan University, Karachi 74800, Pakistan; (N.I.); (M.I.)
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