COVID‐19‐associated pulmonary aspergillosis (CAPA) in patients admitted with severe COVID‐19 pneumonia: An observational study from Pakistan

Abstract

Background Invasive aspergillosis is a well‐known complication of severe influenza pneumonia with acute respiratory distress syndrome (ARDS). However, recent studies are reporting emergence of aspergillosis in severe COVID‐19 pneumonia, named as COVID‐19 associated aspergillosis (CAPA). Methods A retrospective observational study was conducted in patients with severe COVID‐19 pneumonia from February 2020‐ April 2020. Patients’ ≥18 years of age with clinical features and abnormal chest imaging with confirmed COVID‐19 by RT‐PCR for SARS‐Cov‐2 were included. CAPA was diagnosed based on clinical parameters, radiological findings and mycological data. Data were recorded on a structured proforma and descriptive analysis was performed using Stata ver 12.1. Results A total of 147 patients with confirmed COVID‐19 and 23 (15.6%) patients requiring ICU admission were identified. Aspergillus species were isolated from tracheal aspirates of nine (39.1%) patients and of these five patients (21.7%) were diagnosed with CAPA and four (17.4%) had Aspergillus colonization. The mean age of patients with CAPA was 69 years (Median age: 71, IQR: 24, Range: 51 – 85) and 3/5 patients were male. The most frequent co‐morbid was diabetes mellitus (4/5). The overall fatality rate of COVID‐19 patients with aspergillosis was 44% (4/9). The cause of death was ARDS in all 3 patients with CAPA and the median length of stay was 16 days (IQR: 10; Range 6‐35 days). Conclusion This study highlights the need for comparative studies to establish whether there is an association of aspergillosis and COVID‐19 and the need for screening for fungal infections in severe COVID‐19 patients with certain risk factors.

Fatal Coronavirus Disease 2019-associated Pulmonary Aspergillosis; A Report of Two Cases and Review of the Literature

“…For example, CAPA was reported in 8 (29.6%) out of 27 consecutive critical COVID-19 cases from France, 5 (26.3%) out of 19 critical COVID-19 from Germany, 7 (20.6%) out of 34 cases from the Netherlands, and 5 (21.7%) out of 23 cases in Pakistan. [ [8] , [9] , [10] , [11] ] Similar to the cases described here, patients reported with CAPA were mostly immune competent, had radiological abnormalities typical of COVID-19, and many received systemic steroids as part of their COVID-19 care. [ [8] , [9] , [10] , [11] , [12] , [13] , [14] , [15] ] However, whereas bronchoscopy was not performed in our patients due to their critical status and for infection control considerations, many reported cases were diagnosed on the basis of cultures, galactomannan detection or PCR on BAL samples.…”

“…[ [8] , [9] , [10] , [11] ] Similar to the cases described here, patients reported with CAPA were mostly immune competent, had radiological abnormalities typical of COVID-19, and many received systemic steroids as part of their COVID-19 care. [ [8] , [9] , [10] , [11] , [12] , [13] , [14] , [15] ] However, whereas bronchoscopy was not performed in our patients due to their critical status and for infection control considerations, many reported cases were diagnosed on the basis of cultures, galactomannan detection or PCR on BAL samples. [ [8] , [9] , [10] , 12 , 14 , 15 ] Lung biopsy is generally considered risky in ventilated patients, though this has occasionally been performed in patients with suspected CAPA.…”

“…Out of 40 CAPA cases thus far reported in the literature, 25 (62.5%) have died ( Table 1 ). [ 5 , [8] , [9] , [10] , [11] , [12] , [13] , [14] , [16] , [17] , [18] , [19] , [20] ] Such high mortality is not surprising given that CAPA has been almost exclusively reported in critically ill COVID-19 requiring mechanical ventilation, who were mostly of older age and had significant co-existing chronic medical conditions. Delayed recognition and commencement of appropriate antifungal therapy may have also contributed to the poor outcomes associated with CAPA.…”

Rhino-Orbital Mucormycosis Associated With COVID-19

“…Corticosteroid therapy and a past history of chronic pulmonary disease were associated with a higher risk of invasive fungal disease [ 9 ]. Similarly, high incidences have been seen in Pakistan (23/147, 15.6%) and Italy (30/108, 27.7%), with the authors suggesting that the development of invasive fungal infections alters the natural history of the disease [ 10 - 11 ]. Song et al have suggested an algorithm for the early diagnosis and management of common invasive fungal infections (aspergillus, candidiasis, cryptococcosis, and mucormycosis) [ 12 ].…”

Putative invasive pulmonary aspergillosis in critically ill patients with COVID‐19: An observational study from New York City

“…Serum galactomannan is more specific for invasive aspergillosis than beta‐D‐glucan but has poor sensitivity in non‐neutropenic patients 12 . Combining three case series of CAPA, only three (13%) out of 23 patients had positive serum galactomannan level 5,6,13 . The less frequently elevated serum galactomannan levels might simply reflect colonisation rather than infection or suggest that angioinvasive pulmonary infection is a rare phenomenon in CAPA.…”