A recent study published in the Indian Journal of Critical Care Medicine presented a case series of patients with pulmonary aspergillosis associated with coronavirus disease 2019 (COVID-19) (CAPA). The aim of the study was to inform doctors and healthcare workers about this serious complication related to COVID-19.
Study: Pulmonary aspergillosis associated with COVID-19: a case series. Image credit: Kateryna Kon/Shutterstock
background
Many atypical radiological signs of COVID-19 and invasive pulmonary aspergillosis (IPA) are mimicked. Although IPA is more common in immunocompromised patients, influenza infection also increases its risk in non-neutropenic patients. Respiratory viruses damage the respiratory epithelium and paralyze the local immune system. This damage leads to secondary and opportunistic infections, including invasive fungal infections.
Thus, critically ill COVID-19 patients with acute respiratory distress syndrome (ARDS) admitted to intensive care units (ICUs) are prone to develop CAPA. Considering this and the occurrence of influenza-associated aspergillosis (IAA), the diagnosis of IPA is also imperative for patients with COVID-19. However, it is worth noting that radiology alone cannot always accurately diagnose CAPA in patients with COVID-19.
About the study
In the present study, researchers retrospectively reviewed the medical charts of all patients with COVID-19 who visited the Orchid Medical Center in Ranchi, India. These patients had COVID-19 confirmed by reverse transcription polymerase chain reaction (RT-PCR). First, doctors prescribed supportive home treatment. However, when the patient’s symptoms worsened, they advised hospital admission for further diagnosis and treatment.
Results of the study
High-resolution computed tomography (HRCT) showed cavitary lesions in the lungs of these patients. Although the HRCT findings pointed to the possibility of CAPA, they also performed a serum galactomannan test to improve the diagnosis. The serum galactomannan test was positive for all patients. Because of the risk of transmission and aerosolization of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), doctors avoided bronchoscopy. Instead, they prescribed an antifungal drug, voriconazole, at a dose of 6 mg/kg every 12 hours intravenously for the first two days, followed by 4 mg/kg every 12 hours (maintenance dose).
Other ICU patients did not develop IPA, and even these patients were not immunocompromised. In the absence of any other factors predisposing these patients to this infection, severe COVID-19 emerged as the sole reason for developing IPA.
Conclusions
In summary, it is difficult to differentiate between fungal colonization and invasive disease without bronchoscopic sampling and microscopic evaluation of fungal cultures. The antigen-based laboratory test galactomannan assay supports the diagnosis of IPA, but a more comprehensive approach is needed to define and diagnose IPA in patients with COVID-19. For example, tissue culture and tissue microscopy of primarily sterile specimens showing invasive growth of septate fungal hyphae could confirm the diagnosis of IPA. Furthermore, despite the risk of biopsies in patients with COVID-19, bronchoalveolar lavage fluid and lung biopsy are the best types of specimens to confirm the diagnosis of IPA in patients with COVID-19.
The present case series indicated an increased risk of developing PAH in critically ill patients with COVID-19, delayed diagnosis could result in increased mortality and unnecessary burden on healthcare systems. Therefore, clinicians should always seek CAPA in critically ill patients with COVID-19 who are unresponsive to treatment.