Immunoparalysis as a cause for invasive aspergillosis?

Abstract

Aspergillus infections are among the most feared opportunistic infections in humans. These organisms are ubiquitous in nature; protection against infection is usually provided by anatomical barriers and by the immune system. Tissue invasion by Aspergillus is uncommon, occurring primarily in the setting of immunosuppression. The prognosis of invasive aspergillosis is very poor. Although it is widely recognised that critically ill patients in the Intensive Care Unit (ICU) are at risk for nosocomial infections, it is not generally appreciated that such patients may also be at risk for opportunistic infections usually seen only in immunocompromised patients. This might be explained by a biphasic immunological pattern during sepsis: an early hyperinflammatory phase followed by an anti-inflammatory response, leading to a hypo-inflammatory state, the so-called compensatory anti-inflammatory response syndrome (CARS or immunoparalysis). We describe four patients admitted to our ICU for various reasons, without a history of abnormal immune function, who developed invasive pulmonary aspergillosis. We hypothesise that the occurrence of these opportunistic infections in our patients may have been due to immunoparalysis, and that perhaps all ICU patients with sepsis and multiple organ dysfunction syndrome (MODS) may be at risk for opportunistic infections such as aspergillosis as a result of this syndrome. Physicians treating critically ill patients in the ICU should be aware of the CARS/immunoparalysis syndrome and its potential to cause opportunistic infections, even in patients with normal immune function prior to ICU admission.

Evaluation of Risk Factors for Invasive Pulmonary Aspergillosis and Detection of Diagnostic Values of Galactomannan and PCR Methods in Bronchoalveolar Lavage Samples From Non-Neutropenic Intensive Care Unit Patients

“…He ve arkadaşları 17 da, kü-mülatif 350 mg ve üzerinde prednizolon kullanımının İPA riskini 8.6 kat artırdığını bildirmişledir. Çalışmamızda da, literatür 21 bilgileri ile paralel olarak, steroid kullanımının doza bağımlı olarak İPA gelişiminde etkili olduğu saptanmış ve yüksek olası İPA olgularında kümülatif steroid dozu 460 mg olarak belirlenmiştir.…”

Aspergillus Infections in Transplant and Non-Transplant Surgical Patients

“…A recent review of invasive fungal infections in critically ill patients with similar Simplified Acute Physiology Scores showed that aspergillosis was responsible for the highest crude mortality, of 63% [14]. Conditions associated with aspergillosis in these ''nonimmunosuppressed patients'' include chronic obstructive pulmonary disease (COPD), immunoparalysis secondary to sepsis, diabetes mellitus, chronic kidney disease, surgery, and steroid treatment [7,8,[15][16][17]. Our study population was characterized by diabetes, acute kidney injury requiring dialysis, ventilator dependency, malignant disease, trauma, underlying lung disease, and blood transfusion.…”

Invasive pulmonary aspergillosis in patients with chronic obstructive pulmonary disease

“…When the latter reaction is excessive, it may lead to an immunoparalysis, also known as compensatory anti-inflammatory response syndrome. Consequently, the patient should be considered as temporarily immunocompromised and may be at risk of developing opportunistic infections, such as IPA [72].…”