Aspergillus complicating COVID-19
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The University of Sydney Page 1 Aspergillus complicating COVID-19 Presented by Dr Justin Beardsley Marie Bashir Institute, University of Sydney Oxford University Clinical Research Unit, HCMC Prince of Wales Hospital, SESLHD
Transcript of Aspergillus complicating COVID-19
The University of Sydney Page 1
Aspergillus complicating COVID-19
Presented byDr Justin Beardsley
Marie Bashir Institute, University of SydneyOxford University Clinical Research Unit, HCMCPrince of Wales Hospital, SESLHD
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Presenter
Presentation Notes
We perhaps inhale Aspergillus spores everyday, but don’t get illness. However, in those people with a weakened immune systems or damaged lungs, then disease can develop.
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– Allergic (SAFS / ABPA)
– Nodule / aspergilloma
– Chronic pulmonary aspergillosis (CPA)
– Invasive aspergillosis (IA)
Aspergillosis
Presenter
Presentation Notes
Here are 4 common Aspergillus infections, including Allergic Pulmonary Aspergillosis (ABPA), aspergilloma, CPA, and invasive aspergillosis. Some types are mild (ABPA), but some of them are very severe and aggressive fungal disease (CPA, IA)
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Diagnostic criteria Blot et al
Putative IA – requires all 41. Evidence of Aspergillus in lower respiratory tract
- Culture- ?PCR ?galactomannan
2. Consistent signs and symptoms - Fever refractory to 3d ABx- Recrudescent fever on Rx- Chest pain, rub, dyspnoea, haemoptysis- Worsening respiratory function
3. Abnormal radiology Xray or CT
4(a). Host factors OR Neutropenia, malignancy, steroid therapy, immunodeficiency
4(b). Smear Semiquant culture + or ++, and smear with branching hyphae
– Confirmed case - examination of tissue with hyphae + tissue damage seen OR Culture of a lung biopsy sample
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Aspergillosis in influenza
– Incidence rates reported vary widely, from very rare to surprisingly common– Sharma et al Chest 2020 0.17% (477,566 US hospital admissions with
influenza)– Schauwvlieghe et al Lancet Resp Med 2018 19% (14-32%) (432 Euro
ICU admission with influenza)
– Clear evidence of significant clinical impact– Sharma et al Mortality flu + IA 20.6% vs flu 1.4%, adjusted OR
mortality 2.08 (p 0.043)– Schauwvlieghe et al Mortality flu + IA 51% vs flu 28%, adjusted OR
mortality 5.19 (p<0.0001)– Develops after median 3 days in ICU
Presenter
Presentation Notes
Sharma paper relies on discharge codes from national de-identified database 2005-2014 Very likely there are significant under-diagnoses. Plus, not only ICU patient, but rather all –comers. Interesting to note that rates were higher in tertiary teaching sites, which may indicate higher index of clinical suspicion / access to investigations in these centres…. Schauwvlieghe pretty robust data 2009-2016. 14% was in totally health patients, 32% with immunocompromise. They had non-flu control with IA rates of just 5%.
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Aspergillus in COVID-19
– Rapidly emerging data. From March 6 until 14 July, 25 papers have appeared on PubMed. https://www.asid.net.au/eknowledge/area?command=record&id=1447
– Incidence range– Zhang et al J Clin Virol June 2020 3.2% (221 Wuhan hospital COVID-
19 admissions)– Arkel et al Am J Resp CCM 2020 19.4% (31 Dutch ICU COVID-19
admissions)– Nasir et al Mycoses 2020 21.7% (23 Pakistani ICU COVID-19
admissions)– Alanio et al Lancet Resp Med 2020 33.3% (27 French ICU COVID-19
admissions)– Koehler et al Mycoses 2020 26.3% (19 German ICU COVID-19
admissions)
Presenter
Presentation Notes
Most papers are case reports or case series. Zhang paper criticized because of a lack of detail: just says ‘co-infection with fungus’ in 7/221 patients, though it was higher in ‘severe’ 10.9% than ‘non-severe’ 0.6%. Rest of the papers look pretty consistent except Alanio … Putative IPA had a pretty wide inclusion: Aspergillus spp on BAL culture; or two of (ie, 1. Aspergillus spp in bronchial aspirate culture; 2. Aspergillus fumigatus PCR in BAL, BA, or serum;8 galactomannan index >0·8 in BAL;5galactomannan index >0·5 in serum; and β-D-glucan >80 pg/mL in serum). NB – serum galactomannan is generally not useful in COVID associated IA Zhang et al not clear from the paper how they were making diagnosis Arkel paper is pretty robust data, but lowish numbers Nasir paper is a little unclear But overall…. Appearances are quite similar to flu. Expert opinion places incidence in the range 26-33% of ICU patients (Verweij et al Lancet 2020) There is currently not good evidence for attributable mortality, and this was raised as research priority… any reason to assume it will be different from flu?
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CASE REMOVED AS NOT FOR DISTRIBUTION AT THIS STAGE
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Take home messages
– IA is likely to complicate COVID-19 frequently in critically ill patients
– There may be significant attributable mortality, based on evidence from influenza
– Frequent lower respiratory sampling is required for diagnosis, based on culture or galactomannan
– Treatment with voriconazole monotherapy
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Aspergillus complicating COVID-19
With thanksDr Nguyen Van Vinh Chau (director)Dr Lan Huong Nguyen (head micro)Dr Duong Bich Thuy (ICU doctor)Hospital for Tropical Diseases, HCMC
![[Micro] aspergillus](https://static.fdocuments.net/doc/165x107/55d6fc36bb61eb0d2b8b47a8/micro-aspergillus.jpg)
