Invasive pulmonary aspergillosis after influenza a infection in an immunocompetent patient

Severe Influenza With Invasive Pulmonary Aspergillosis in Immunocompetent Hosts: A Retrospective Cohort Study

Background: Influenza was an independent risk factor for invasive pulmonary aspergillosis (IPA). In light of increasing incidence and mortality of influenza associated aspergillosis, our study summarized risk factors, clinical characteristics, and prognostic factors of developing aspergillosis in immunocompetent hosts with influenza to further screen high-risk population and improve outcome.

Methods: We reviewed the patient characteristics, laboratory examinations, radiological imaging, and microbiology data of 72 influenza patients with IPA and 84 influenza patients without IPA admitted to West China Hospital.

Result: Our study shown that aspergillosis co-infection increased overall mortality of severe influenza from 22.6 to 52.8%, along with higher white blood count (WBC) (10.9 ± 5.0 vs. 8.4 ± 3.3, P = 0.016), Neutrophiles (9.5 ± 5.0 vs. 7.0 ± 3.8, P = 0.023), procalcitonin (PCT) (8.6 ± 15.9 vs. 1.2 ± 2.1, P = 0.009), and a lower CD4⁺ T cell count (189.2 ± 135.3 vs. 367.1 ± 280.0, P = 0.022) in death group. No impact of age, gender, underlying diseases, immunosuppressive agents and steroids use, CD4⁺ T cell count on incidence of influenza associated aspergillosis was observed. But influenza associated aspergillosis cases mostly accompanied with more H1N1 subtype (91.7 vs. 79.8%, P = 0.037) and higher level of C-reactive protein (CRP) (117.6 ± 88.1 vs. 78.5 ± 75.2, P = 0.017) and interleukin 6 (IL-6) (133.5 ± 149.2 vs. 69.9 ± 100.0, P = 0.021) than those without aspergillosis.

Conclusion: Aspergillosis co-infection in severe influenza patients can lead to a significant increased mortality, which was associated with severe respiratory failure due to mixed infection and immunosuppression. Pulmonary excessive inflammatory response was related with IPA co-infection.

Aspergillosis Complicating Severe Coronavirus Disease

Aspergillosis complicating severe influenza infection has been increasingly detected worldwide. Recently, coronavirus disease-associated pulmonary aspergillosis (CAPA) has been detected through rapid reports, primarily from centers in Europe. We provide a case series of CAPA, adding 20 cases to the literature, with review of pathophysiology, diagnosis, and outcomes. The syndromes of pulmonary aspergillosis complicating severe viral infections are distinct from classic invasive aspergillosis, which is recognized most frequently in persons with neutropenia and in other immunocompromised persons. Combined with severe viral infection, aspergillosis comprises a constellation of airway-invasive and angio-invasive disease and results in risks associated with poor airway fungus clearance and killing, including virus- or inflammation-associated epithelial damage, systemic immunosuppression, and underlying lung disease. Radiologic abnormalities can vary, reflecting different pathologies. Prospective studies reporting poor outcomes in CAPA patients underscore the urgent need for strategies to improve diagnosis, prevention, and therapy.

Invasive Tracheobronchial Aspergillosis with Bronchial Ulcers Complicated by Nontuberculous Mycobacterial Disease

Invasive tracheobronchial aspergillosis (ITBA) complicated by nontuberculous mycobacteria (NTM) is rare. An 88-year-old man was admitted for hemoptysis. Bronchoscopy revealed bronchial ulcers, and a tissue biopsy showed Aspergillus fumigatus. He was diagnosed with ITBA, which improved with voriconazole. During treatment, infiltrative shadows appeared in his lungs, and bronchoscopy was performed once again. A non-necrotic epithelioid granuloma and Mycobacterium intracellulare were detected in the biopsy specimen. He was diagnosed with NTM disease. It is important to note that tracheobronchial ulcers may cause hemoptysis and to identify the etiology and treat it appropriately when multiple bacteria are found.

Invasive pulmonary aspergillosis complicating severe influenza: epidemiology, diagnosis and treatment

PURPOSE OF REVIEW

Bacterial super-infection of critically ill influenza patients is well known, but in recent years, more and more reports describe invasive aspergillosis as a frequent complication as well. This review summarizes the available literature on the association of invasive pulmonary aspergillosis (IPA) with severe influenza [influenza-associated aspergillosis (IAA)], including epidemiology, diagnostic approaches and treatment options.

RECENT FINDINGS

Though IPA typically develops in immunodeficient patients, non-classically immunocompromised patients such as critically ill influenza patients are at high-risk for IPA as well. The morbidity and mortality of IPA in these patients is high, and in the majority of them, the onset occurs early after ICU admission. At present, standard of care (SOC) consists of close follow-up of these critically ill influenza patients with high diagnostic awareness for IPA. As soon as there is clinical, mycological or radiological suspicion for IAA, antifungal azole-based therapy (e.g. voriconazole) is initiated, in combination with therapeutic drug monitoring (TDM). Antifungal treatment regimens should reflect local epidemiology of azole-resistant Aspergillus species and should be adjusted to clinical evolution. TDM is necessary as azoles like voriconazole are characterized by nonlinear pharmacokinetics, especially in critically ill patients.

SUMMARY

In light of the frequency, morbidity and mortality associated with influenza-associated aspergillosis in the ICU, a high awareness of the diagnosis and prompt initiation of antifungal therapy is required. Further studies are needed to evaluate the incidence of IAA in a prospective multicentric manner, to elucidate contributing host-derived factors to the pathogenesis of this super-infection, to further delineate the population at risk, and to identify the preferred diagnostic and management strategy, and also the role of prophylaxis.

Invasive pulmonary aspergillosis in patients with influenza infection: A retrospective study and review of the literature

INTRODUCTION

There has been a rapid increase in the number of influenza and invasive pulmonary aspergillosis (IPA) co-infection.

OBJECTIVES

To explore the risk factors and predictors of a poor prognosis in influenza and IPA co-infection.

METHODS

We included patients with confirmed influenza during the 2017-2018 influenza season and cases of influenza and IPA co-infection in the literature.

RESULTS

A total of 64 patients with influenza infection were admitted to ICU. Of these patients, 18 were co-infected with IPA. Others were assigned to the control group (n = 46). A total of 45 patients from the literature were added to the IPA group (n = 63). A multivariate logistic regression suggested that influenza patients who were given steroids after ICU admission, who had a white blood count (WBC) of more than 10*10⁹ /L on ICU admission and whose CT findings manifested as multiple nodules and cavities might have a higher risk of developing IPA. Compared to survivors, non-survivors had higher sequential organ failure assessment (SOFA) scores (16 ± 4 points vs 8 ± 4 points, P < 0.001), lower CD4⁺ T cell counts on ICU admission [315 (83-466) cells/μL vs 152 (50-220) cells/μL, P = 0.031] and more requirement extracorporeal membrane oxygenation (ECMO) support [13 (50%) vs 7 (18.9%), P = 0.015].

CONCLUSIONS

Influenza patients who are given steroids after ICU admission, who have WBCs of greater than 10*10⁹ /L on ICU admission, and whose CT imaging shows multiple nodules and cavities might have a high risk of IPA. Higher SOFA scores, CD4⁺ T cell counts lower than 200 cells/μL on ICU admission and more ECMO requirement might be predictors of a poor prognosis.

Invasive fungal infection by Aspergillus flavus in immunocompetent hosts: A case series and literature review

Invasive aspergillosis usually affects immunocompromised hosts with variable manifestations depending on the site of infection. In this article, we present two cases of invasive Aspergillosis in two non-immunocompromised patients; both cases had a paranasal sinuses infection, with intraorbital and intracranial extension, requiring surgery and antifungal treatment with Voriconazole. These cases were initially diagnosed as paranasal sinus neoplasms. However, the pathology and microbiology studies revealed invasive fungal infection by Aspergillus flavus.

TR34/L98H Mutation in CYP51A Gene in Aspergillus fumigatus Clinical Isolates During Posaconazole Prophylaxis: First Case in Korea

Azole resistance in Aspergillus fumigatus is an emerging problem, especially in immunocompromised patients. It has been reported worldwide, including in Asia, but has not yet been reported in Korea. Here, we report a case of invasive pulmonary aspergillosis (IPA) caused by azole-resistant A. fumigatus that developed in a hematopoietic stem cell transplantation recipient during posaconazole prophylaxis for immunosuppressive therapy of graft-versus-host diseases. We identified TR34/L98H/S297T/F495L mutation in the CYP51A gene of A. fumigatus clinical isolate obtained from bronchial washing fluid. Minimal inhibitory concentrations for itraconazole, voriconazole, and posaconazole were > 16, 1, and 4 μg/mL, respectively. While IPA improved partially under voriconazole treatment, the patient died from carbapenemase-producing Klebsiella pneumoniae bacteremia. Further epidemiological surveillance studies are warranted.

Invasive pulmonary aspergillosis and influenza co-infection in immunocompetent hosts: case reports and review of the literature

Invasive pulmonary aspergillosis (IPA) is classically considered an illness of severely immunocompromised patients with limited host defenses. However, IPA has been reported in immunocompetent but critically ill patients. This report describes two fatal cases of pathologically confirmed IPA in patients with influenza in the intensive care unit. One patient had influenza B infection, whereas the other had influenza A H1N1. Both patients died despite broad-spectrum antimicrobials, mechanical ventilation, and vasopressor support. Microscopic and histologic postmortem examination confirmed IPA. Review of the English language and foreign literature indicates that galactomannan antigen testing and classic radiologic findings for IPA may not be reliable in immunocompetent patients. Respiratory cultures which grow Aspergillus species in critically ill patients, particularly those with underlying influenza infection, should not necessarily be disregarded as contaminants or colonizers. Further research is needed to better understand the immunological relationship between influenza and IPA for improved prevention and treatment of influenza and Aspergillus co-infections.

Influenza A Virus as a Predisposing Factor for Cryptococcosis

Influenza A virus (IAV) infects millions of people annually and predisposes to secondary bacterial infections. Inhalation of fungi within the Cryptococcus complex causes pulmonary disease with secondary meningo-encephalitis. Underlying pulmonary disease is a strong risk factor for development of C. gattii cryptococcosis though the effect of concurrent infection with IAV has not been studied. We developed an in vivo model of Influenza A H1N1 and C. gattii co-infection. Co-infection resulted in a major increase in morbidity and mortality, with severe lung damage and a high brain fungal burden when mice were infected in the acute phase of influenza multiplication. Furthermore, IAV alters the host response to C. gattii, leading to recruitment of significantly more neutrophils and macrophages into the lungs. Moreover, IAV induced the production of type 1 interferons (IFN-α4/β) and the levels of IFN-γ were significantly reduced, which can be associated with impairment of the immune response to Cryptococcus during co-infection. Phagocytosis, killing of cryptococci and production of reactive oxygen species (ROS) by IAV-infected macrophages were reduced, independent of previous IFN-γ stimulation, leading to increased proliferation of the fungus within macrophages. In conclusion, IAV infection is a predisposing factor for severe disease and adverse outcomes in mice co-infected with C. gattii.

Invasive Aspergillosis Associated With Severe Influenza Infections

Background. Invasive aspergillosis may occur in the setting of severe influenza infections due to viral-induced respiratory epithelium disruption and impaired immune effects, but data are limited.

Methods. A retrospective study was conducted among severe influenza cases requiring medical intensive care unit (ICU) admission at an academic center during the 2015–2016 season. Data collected included respiratory cultures, medical conditions and immunosuppressants, laboratory and radiographic data, and outcomes. A systematic literature review of published cases in the English language of aspergillosis complicating influenza was conducted.

Results. Six (75%) of 8 ICU influenza cases had Aspergillus isolated; 5 were classified as invasive disease. No ICU patient testing negative for influenza infection developed aspergillosis during the study period. Among cases with invasive aspergillosis, influenza infection was type A (H1N1) (n = 2) and influenza B (n = 3). Published and current cases yielded n = 57 (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 criteria: 37% proven, 25% probable, and 39% possible cases). An increasing number of cases were reported since 2010. Sixty-five percent of cases lacked classic underlying conditions at admission for aspergillosis, 86% had lymphopenia, and 46% died.

Conclusions. Aspergillosis may occur in the setting of severe influenza infections even among immunocompetent hosts. Risks may include influenza A (H1N1) or B infections and viral-induced lymphopenia, although further studies are needed. Prompt diagnosis and antifungal therapy are recommended given high mortality rates.

Fatal clinical course of probable invasive pulmonary aspergillosis with influenza B infection in an immunocompetent patient

Invasive pulmonary aspergillosis (IPA) is rarely reported in patients who have normal immune function. Recently, IPA risk was reported in nonimmunocompromised hosts, such as patients with chronic obstructive pulmonary disease and critically ill patients in intensive care units. Moreover, influenza infection is also believed to be associated with IPA among immunocompetent patients. However, most reports on IPA with influenza A infection, including pandemic influenza H1N1, and IPA associated with influenza B infection were scarcely reported. Here, we report probable IPA with a fatal clinical course in an immunocompetent patient with influenza B infection. We demonstrate IPA as a possible complication in immunocompetent patients with influenza B infection. Early clinical suspicion of IPA and timely antifungal therapy are required for better outcomes in such cases.