The rising burden of invasive fungal infections in COVID-19, can structured CT thorax change the game

Background The occurrence of invasive fungal infections in COVID-19 patients is on surge in countries like India. Several reports related to rhino-nasal-sinus mucormycosis in COVID patients have been published in recent times; however, very less has been reported about invasive pulmonary fungal infections caused mainly by mucor, aspergillus or invasive candida species. We aimed to present 6 sputum culture proved cases of invasive pulmonary fungal infection (four mucormycosis and two invasive candidiasis) in COVID patients, the clues for the diagnosis of fungal invasion as well as difficulties in diagnosing it due to superimposed COVID imaging features. Case presentation The HRCT imaging features of the all 6 patients showed signs of fungal invasion in the form of cavities formation in the pre-existing reverse halo lesions or development of new irregular margined soft tissue attenuating growth within the pre-existing or in newly formed cavities. Five out of six patients were diabetics. Cavities in cases 1, 2, 3 and 4 of mucormycosis were aggressive and relatively larger and showed relatively faster progression into cavities in comparison with cases 5 and 6 of invasive candidiasis. Conclusion In poorly managed diabetics or with other immunosuppressed conditions, invasive fungal infection (mucormycosis, invasive aspergillosis and invasive candidiasis) should be considered in the differential diagnosis of cavitary lung lesions.

Prevalence of Fungal and Bacterial Co-Infection in Pulmonary Fungal Infections: A Metagenomic Next Generation Sequencing-Based Study

With the widespread use of antibacterial drugs and increasing number of immunocompromised patients, pulmonary fungal infections are becoming more common. However, the incidence of pulmonary fungal and bacterial co-infection is rarely reported. In this study, 119 patients definitively diagnosed with pulmonary fungal infections between July 2018 and March 2020 were assessed using metagenomic next-generation sequencing (mNGS) as well as traditional pathogen detection to gauge the incidence of fungal and bacterial co-infection and evaluate the associated risk factors. We found that of the 119 patients with fungal infections, 48 (40.3%) had pulmonary fungal and bacterial co-infection. We identified immunocompromised status and the presence of one or more pulmonary cavities as risk factors associated with fungal and bacterial co-infection. The most commonly isolated fungi species were Aspergillus, Pneumocystis, and Rhizopus. The most commonly isolated bacterial species were Pseudomonas aeruginosa, Acinetobacter baumannii, and Stenotrophomonas maltophilia. Seventy-nine (66.4%) patients had received empirical antibiotic treatment before their pathogenic test results became available, and 41.7% (fungal infection group) and 38.7% (fungal and bacterial co-infection group) of the patients had their antibacterial drug dosage changed accordingly. This mNGS-based study showed that the incidence of fungal and bacterial co-infection is significant. Our research outcomes can, thus, guide the use of antibacterial drugs in the treatment of clinical fungal infections.

Imaging Characteristics of Invasive Pulmonary Fungal Infection Secondary to Hematological Diseases and Comparison before and after Treatment

Fungal infections have become crucial factors that threaten the prognosis and survival of blood disease patients. Here, we aim to analyze the epidemiological characteristics and early and advanced CT (computed tomography) manifestations of patients with invasive pulmonary fungal infections secondary to blood system diseases. 65 hospitalized patients from October 2018 to October 2020 with invasive pulmonary fungal infections secondary to blood diseases were enrolled. Blood diseases were recorded according to clinical and imaging data, and the serum galactomannan test (GM test) was conducted. Two senior radiologists analyzed the CT data and recorded the distribution of the lesions and CT signs. We analyzed and counted the first chest CT scan images of patients with nodule/mass type secondary to hematological diseases and invasive pulmonary fungal infection. The first CT nodules or mass-type lesions were statistically significant in nodule size, the number of lesions, distribution, and accompanying signs. Pulmonary fungal infection was common in both lungs during 7-day, 14-day, and 30-day follow-up CT. We also found that the nodular mass type was the main manifestation in the positive group of the GM test. Both the positive group and the negative group had the highest incidence of nodules. The incidence of air crescent signs in nodules or mass lesions in the positive group was higher than in the negative group, and the difference was statistically significant. To conclude, follow-up CT signs after antifungal treatment were highly sensitive to the early diagnosis of hematological diseases and secondary invasive pulmonary Eumycetes infection, which could be used for clinical treatment to provide help. GM test results were also related to CT manifestations such as air crescent sign, cavity, and halo sign.

Prevalence and predictors of pulmonary fungal infections in patients with acute leukemia and aggressive lymphomas: Implications for cancer care in developing countries

Objectives: Among patients receiving cancer therapy, pulmonary fungal infections (PFIs) are an important cause of morbidity and mortality. Identifying predictors of PFI can direct targeted prophylaxis to improve outcomes, especially in low- and middle-income countries (LMIC) with limited resources. The objectives of the study were to evaluate the predictors of PFI in hospitalized patients with hematological malignancies in the United States and implications for prioritizing anti-fungal care in LMIC. Materials and Methods: Using the 2018 National Inpatient Sample, we conducted a retrospective study of patients ≥18 years, with acute leukemia or aggressive lymphoma. Demographics and outcomes were compared between patients with and without PFI. Predictors of PFI were evaluated by regression analysis. Results: PFI was diagnosed in 1635 (0.8%) of 205,525 eligible hospitalizations and aspergillosis was noted in 1315 (80.4%) of PFI cases. Patients with acute myeloid leukemia (AML) accounted for 64.2% of cases of PFI. Patients with PFI, when compared with those without PFI, were younger, had higher Charlson comorbidity index, were more likely to be non-Caucasian, and to have AML. Patients with PFI had higher odds of respiratory failure, sepsis, and in-hospital mortality. Variables associated with PFI were Hispanic or native American origin (OR = 1.71; 95% CI: 1.21–2.42), Charlson comorbidity index ≥3 (OR = 1.52; 95% CI: 1.16–2.00), neutropenia (OR = 1.97; 95% CI: 1.58–2.46), malnutrition (OR = 2.30; 95% CI: 1.75–3.01), bone marrow transplant status (OR = 2.28, 95% CI: 1.53–3.39), and AML diagnosis (OR = 3.12; 95% CI: 2.40–4.05). Conclusions: This study identified variables associated with PFI in patients diagnosed with acute leukemia and aggressive lymphomas. In LMIC, where resources are scarce, patients with cancer who have the identified high-risk characteristics should be given priority for antifungal prophylaxis.

Risk Factors of Invasive Pulmonary Fungal Infections in Patients with Hepatitis B Virus Related Acute-on-Chronic Liver Failure

To analyze the risk factors of invasive pulmonary fungal infections in patients with HBV-ACL, the clinical data and risk factors of 60 patients with HBV-ACLF complicated IPFI were analyzed retrospectively including clinical parameters, broad-spectrum antibiotics usage, neutropenia, invasive medical manipulations, serum total bilirubin, international normalized ratio (INR), and MELD scores were compared with non-IPFI. Risk factors were analyzed using mathematical tools. Candida species and Aspergillus were detected as the most prominent fungal strains (61.11% and 33.33%, respectively). The risk factors included prolong broad-spectrum antibiotic usage OR = 4.362 , P = 0.008 , neutropenia OR = 3.288 , P = 0.007 , invasive procedures OR = 3.263 , P = 0.010 , serum total bilirubin OR = 1.006 , P = 0.011 , INR OR = 2.101 , P = 0.007 , and MELD scores OR = 1.074 , P = 0.008 . Candida is the main IPFI strains in patients with HBV-ACLF. Broad-spectrum antibiotics usage, neutropenia, invasive manipulations, and the severity of ACLF might be risk factors for IPFI in patients with HBV-ACLF.

Pulmonary fungal infections in acute leukemias and aggressive lymphomas: Analysis of the United States National Inpatient Database.

e19042 Background: For patients undergoing intensive chemotherapy, pulmonary fungal infections (PFI) represent a major cause of morbidity and mortality. Our study examined predictors and outcomes of PFI in hospitalized patients (pts) with hematological malignancies in the current era of antifungal prophylaxis for high-risk patients. Methods: Using the 2018 National Inpatient Sample (NIS) database, we conducted a retrospective study of hospitalized pts aged ≥ 18 years, with acute leukemias or aggressive lymphomas. Hospitalizations were selected using International Classification of Disease, Tenth Revision (ICD-10) codes for leukemias, lymphomas and PFI (candidiasis, aspergillosis, cryptococcus, and mucormycosis). Demographics, comorbidities, and outcomes were compared between pts with and without PFI using Chi-squared test. Multivariable logistic regression was performed to explore predictors associated with PFI. Results: Of 205,525 hospitalizations that met the inclusion criteria, PFI was diagnosed in 1635 (0.8%). Frequent infections were aspergillosis (80%) and candidiasis (11%). Pts with acute myeloid leukemia (AML) accounted for 64% of all PFI. The PFI group, compared to non-PFI, were more likely to be non-Caucasian (39% vs 32%, p<0.05), have higher Charlson comorbidity index (CI) [64% vs 55%, p<0.01], longer mean length of stay (23 vs 9 days, p<0.001), and more likely to have AML (64% vs 33%, p<0.001). Pts with PFI had higher odds of acute respiratory failure, severe sepsis, and in-hospital mortality. Mortality rates for PFI and non-PFI group were 17% and 6% respectively (p<0.001). Predictors associated with PFI were Hispanic or Native American race, Charlson CI ≥ 3, neutropenia, malnutrition, bone marrow transplant status and diagnosis of AML (Table). Conclusions: Our study identified clinical variables that predicted for PFI in patients with acute leukemias and aggressive lymphomas. Pts with these high-risk characteristics should get priority for close surveillance, mold-specific prophylaxis, and antifungal therapeutic drug monitoring. Selected predictors associated with pulmonary fungal infections. Adjusted Odds ratio (OR).[Table: see text]

Status of pulmonary fungal infections among individuals with clinical signs of pulmonary tuberculosis at a University Teaching Hospital in Southwestern Uganda.

Background: Pulmonary mycoses are very important diseases of the respiratory tract and are responsible for significant morbidity and mortality rates worldwide. However less attention has been paid to them. In this study we determined the prevalence of pulmonary mycoses and their aetiological agents among individuals with clinical signs of pulmonary tuberculosis at Mbarara Regional Referral Hospital (MRRH). Method: This was a Laboratory based cross sectional survey in which 113 participants were recruited. Sputum samples were corrected from each study participant. To each sample the following tests were done; Sabouraud Dextrose Agar (SDA) Culture, GeneXpert and Potassium hydroxide (KOH). Fungal growth of filamentous fungi and yeasts were further examined with LPCB and Germ tube respectively. Generated data was analysed using R studio. Results: Out of 113 participants, 80 (70.8%) had pulmonary mycoses whilst those with pulmonary tuberculosis were 5 (4.4%). C. albicans 22.58% and Aspergillus species 17.20%) were the most aetiological agents for pulmonary mycoses identified among others. Of those who were TB GeneXpert positive, 2 (1.77%) of them were co-infected with pulmonary mycoses. We established a prevalence of 57 (71.3%) for PFI, 3 (60.0%) for MTB in HIV sero positive patients and 18 (22.5%) for PFI, 0 (0.00%) for MTB in HIV sero negative patients. On the other hand, 2 (100%) sero positive patients were co-infected with both PFI and MTB.Conclusion: Our findings highlight the medical importance of pulmonary fungal infections among patients suspected for TB. Importantly, the aetiological diversity established here is rich enough to suggest precise examination using different methods. Established scope of aetiological agents is predominated by opportunistic fungi which when superimposed on to certain underlying conditions such as TB, their effects can be fatal. Therefore this possibility presents a need to employ appropriate strategies for prevention, diagnosis, and management in TB suspects.