Invasive aspergillosis in patients with COVID-19 in intensive care units: results of a multicenter study.

Objective. To study risk factors, clinical and radiological features and effectiveness of the treatment of invasive aspergillosis (IA) in adult patients with COVID-19 (COVID-IA) in intensive care units (ICU). Materials and methods. A total of 60 patients with COVID-IA treated in ICU (median age 62 years, male - 58%) were included in this multicenter prospective study. The comparison group included 34 patients with COVID-IA outside the ICU (median age 62 years, male - 68%). ECMM/ISHAM 2020 criteria were used for diagnosis of CAPA, and EORTC/MSGERC 2020 criteria were used for evaluation of the treatment efficacy. A case-control study (one patient of the main group per two patients of the control group) was conducted to study risk factors for the development and features of CAPA. The control group included 120 adult COVID-19 patients without IA in the ICU, similar in demographic characteristics and background conditions. The median age of patients in the control group was 63 years, male - 67%. Results. 64% of patients with COVID-IA stayed in the ICU. Risk factors for the COVID-IA development in the ICU: chronic obstructive pulmonary disease (OR = 3.538 [1.104-11.337], p = 0.02), and prolonged (> 10 days) lymphopenia (OR = 8.770 [4.177-18.415], p = 0.00001). The main location of COVID-IA in the ICU was lungs (98%). Typical clinical signs were fever (97%), cough (92%), severe respiratory failure (72%), ARDS (64%) and haemoptysis (23%). Typical CT features were areas of consolidation (97%), hydrothorax (63%), and foci of destruction (53%). The effective methods of laboratory diagnosis of COVID-IA were test for galactomannan in BAL (62%), culture (33%) and microscopy (22%) of BAL. The main causative agents of COVID-IA are A. fumigatus (61%), A. niger (26%) and A. flavus (4%). The overall 12-week survival rate of patients with COVID-IA in the ICU was 42%, negative predictive factors were severe respiratory failure (27.5% vs 81%, p = 0.003), ARDS (14% vs 69%, p = 0.001), mechanical ventilation (25% vs 60%, p = 0.01), and foci of destruction in the lung tissue on CT scan (23% vs 59%, p = 0.01). Conclusions. IA affects predominantly ICU patients with COVID-19 who have concomitant medical conditions, such as diabetes mellitus, hematological malignancies, cancer, and COPD. Risk factors for COVID-IA in ICU patients are prolonged lymphopenia and COPD. The majority of patients with COVID-IA have their lungs affected, but clinical signs of IA are non-specific (fever, cough, progressive respiratory failure). The overall 12-week survival in ICU patients with COVID-IA is low. Prognostic factors of poor outcome in adult ICU patients are severe respiratory failure, ARDS, mechanical ventilation as well as CT signs of lung tissue destruction.Copyright © 2022, Interregional Association for Clinical Microbiology and Antimicrobial Chemotherapy. All rights reserved.

Aspergillosis: an Update on Clinical Spectrum, Diagnostic Schemes, and Management.

Purpose of Review: This review gives an overview of the diseases caused by Aspergillus, including a description of the species involved and the infected clinical systems. We provide insight into the various diagnostic methods available for diagnosing aspergillosis, particularly invasive aspergillosis (IA), including the role of radiology, bronchoscopy, culture, and non-culture-based microbiological methods. We also discuss the available diagnostic algorithms for the different disease conditions. This review also summarizes the main aspects of managing infections due to Aspergillus spp., such as antifungal resistance, choice of antifungals, therapeutic drug monitoring, and new antifungal alternatives. Recent Findings: The risk factors for this infection continue to evolve with the development of many biological agents that target the immune system and the increase of viral illnesses such as coronavirus disease. Due to the limitations of present mycological test methods, establishing a fast diagnosis is frequently difficult, and reports of developing antifungal resistance further complicate the management of aspergillosis. Many commercial assays, like AsperGenius®, MycAssay Aspergillus®, and MycoGENIE®, have the advantage of better species-level identification and concomitant resistance-associated mutations. Fosmanogepix, ibrexafungerp, rezafungin, and olorofim are newer antifungal agents in the pipeline exhibiting remarkable activity against Aspergillus spp. Summary: The fungus Aspergillus is found ubiquitously around the world and can cause various infections, from harmless saprophytic colonization to severe IA. Understanding the diagnostic criteria to be used in different patient groups and the local epidemiological data and antifungal susceptibility profile is critical for optimal patient management.

vasive aspergillosis in patients with COVID-19 in intensive care units: sults of a multicenter study.

Objective. To study risk factors, clinical and radiological features and effectiveness of the treatment of invasive aspergillosis (IA) in adult patients with COVID-19 (COVID-IA) in intensive care units (ICU). Materials and methods. A total of 60 patients with COVID-IA treated in ICU (median age 62 years, male - 58%) were included in this multicenter prospective study. The comparison group included 34 patients with COVID-IA outside the ICU (median age 62 years, male - 68%). ECMM/ISHAM 2020 criteria were used for diagnosis of CAPA, and EORTC/MSGERC 2020 criteria were used for evaluation of the treatment efficacy. A case-control study (one patient of the main group per two patients of the control group) was conducted to study risk factors for the development and features of CAPA. The control group included 120 adult COVID-19 patients without IA in the ICU, similar in demographic characteristics and background conditions. The median age of patients in the control group was 63 years, male - 67%. Results. 64% of patients with COVID-IA stayed in the ICU. Risk factors for the COVID-IA development in the ICU: chronic obstructive pulmonary disease (OR = 3.538 [1.104-11.337], p = 0.02), and prolonged (> 10 days) lymphopenia (OR = 8.770 [4.177-18.415], p = 0.00001). The main location of COVID-IA in the ICU was lungs (98%). Typical clinical signs were fever (97%), cough (92%), severe respiratory failure (72%), ARDS (64%) and haemoptysis (23%). Typical CT features were areas of consolidation (97%), hydrothorax (63%), and foci of destruction (53%). The effective methods of laboratory diagnosis of COVID-IA were test for galactomannan in BAL (62%), culture (33%) and microscopy (22%) of BAL. The main causative agents of COVID-IA are A. fumigatus (61%), A. niger (26%) and A. flavus (4%). The overall 12-week survival rate of patients with COVID-IA in the ICU was 42%, negative predictive factors were severe respiratory failure (27.5% vs 81%, p = 0.003), ARDS (14% vs 69%, p = 0.001), mechanical ventilation (25% vs 60%, p = 0.01), and foci of destruction in the lung tissue on CT scan (23% vs 59%, p = 0.01). Conclusions. IA affects predominantly ICU patients with COVID-19 who have concomitant medical conditions, such as diabetes mellitus, hematological malignancies, cancer, and COPD. Risk factors for COVID-IA in ICU patients are prolonged lymphopenia and COPD. The majority of patients with COVID-IA have their lungs affected, but clinical signs of IA are non-specific (fever, cough, progressive respiratory failure). The overall 12-week survival in ICU patients with COVID-IA is low. Prognostic factors of poor outcome in adult ICU patients are severe respiratory failure, ARDS, mechanical ventilation as well as CT signs of lung tissue destruction.Copyright © 2022, Interregional Association for Clinical Microbiology and Antimicrobial Chemotherapy. All rights reserved.

Aspergillus hip arthritis in COVID-19 era: Two case reports

Corticosteroids have been a mainstay in the treatment protocols and guidelines of COVID-19. However, its use in high dosage or for extended duration renders patients immunocompromised after COVID-19 recovery, and thus, susceptible to secondary opportunistic infections. We report the two cases of septic hip arthritis due to Aspergillus species in corticosteroid immunosuppressed post-COVID-19 patients. One patient recovered successfully from the arthritis and subsequently underwent total hip arthroplasty with good outcome. The second patient presented late to us in a critical condition and had two comorbid conditions along with, due to which, in spite of all measures, could not be revived and succumbed to death. We highlight the issue of the rare cause of fungal hip arthritis in immunosuppressed post-COVID-19 patients and stress the necessity to remain vigilant and identify the causative organisms correctly, especially fungal pathogens in such susceptible populations in the present COVID-19 era.

Azole resistance screening in Aspergillus species isolated from patients with COVID-associated pulmonary aspergillosis from Pakistan

Background: COVID-19 associated pulmonary aspergillosis (CAPA) complicates the course of critically ill COVID-19 patients. Delay in diagnosis and reports of azole resistance in CAPA patients lead to adverse outcome. We had previously reported CAPA rates of 21.7% from our center with high mortality. To detect azole resistance in Aspergillus species isolated from CAPA patients, we performed azole resistance screening. Material(s) and Method(s): Aspergillus species isolated from tracheal aspirates of CAPA patients admitted in Aga Khan University Hospital, Karachi, Pakistan during July 2020- January 2022, were screened for azole resistance as per CDC protocol. Minimum inhibitory concentration of screening positive strains were determined using YeastOne Sensititre plate. Result(s): 92 Aspergillus isolates were screened from 73 CAPA patients for azole resistance. Only 2 (2.17%) A. flavus isolates showed growth on voriconazole well, while other 90 (97%) isolates were screened negative for resistance (Table. 1). MICs of these two strains against posaconazole, voriconazole and itraconazole were 0.5 ug/mL, 1 ug/mL and 0.25ug/mL respectively. Table. 1: Aspergillus species distribution and growth on azole resistance screen agar Conclusion(s): We also did not find any azole resistance in this study. Periodic surveillance for the emergence of azole-resistant clinical isolates using molecular approaches is essential.

Epidemiology of aspergillosis in Kuwait: A nationwide study

Objectives: Aspergillus is the most common filamentous fungi involved in human infections.It is characterized by causing various forms of clinical presentations, ie, invasive, chronic, and allergic forms. It is associated with considerable morbidity and mortality. In spite of this, the epidemiology of Aspergillus infections is scarce in Kuwait. This study aims to describe the epidemiology of aspergillosis in Kuwait on a national scale. Method(s): This is a 2-year retrospective observational study designed to analyze the demographic and mycological data on all Aspergillus isolates derived from clinical samples processed or submitted to the Mycology reference laboratory (MRL) by all government microbiology laboratories in Kuwait. Using the Mycology reference laboratory surveillance system, the required data was collected. It covers patients' age, gender, type of clinical samples, care settings (outpatient, wards, or ICU), the name of the Aspergillus species, and antifungal susceptibility for Aspergillus fumigatus.Species-level identification of Aspergillus was mostly based on morphological characteristics, except in a few cases where MALDI-T OF or PCR-sequencing of rDNA were performed. Antifungal susceptibility testing was done using Etest method according to manufacturer instructions. EUCAST clinical breakpoints were followed for the interpretation of antifungal susceptibility results for A. fumigatus species. Result(s): In total, 327 Aspergillus isolates from 277 patients were found.A total of 34/277 patients had 2 or more samples yielding either the same Aspergillus spp. (n = 17) or a different species (n = 17). The most prevalent type of clinical specimens was respiratorysample (n =196,60%), followed byear swabs (n= 64,19.6%), and nails (n= 24,7.3%). A.niger (n=147) was the most isolated species, involving 45% of aspergillosis cases followed by four other species including A. fumigatus (n = 64), A.flavus (n = 55), A.terreus (n = 38), and A.nidulans (n = 13).A total of 10 cases were caused by rare Aspergillus spp.All A. fumigatus isolates were susceptible to voriconazole. Itraconazole also exhibited excellent in vitro activity against nearly all A. fumigatus except 4 isolates that were resistant. Conclusion(s): This study reveals the epidemiology of aspergillosis from several perspectives. It gives some insights on the burden of Aspergillosis in Kuwait, especially during the COVID-19 pandemic. Respiratory samples were the predominant positive samples suggesting high rates of pulmonary aspergillosis. A. niger, not A. fumigatus or A. flavus, is the most prevalent agent of aspergillosis in Kuwait.Azole resistance is rare among A.fumigatus.Further studies are needed to explore the spectrum of clinical presentations with special emphasis on pulmonary aspergillosis.

Rapid Detection of Aspergillus flavus and Quantitative Determination of Aflatoxin B1 in Grain Crops Using a Portable Raman Spectrometer Combined with Colloidal Au Nanoparticles.

Aspergillus flavus and Aflatoxins in grain crops give rise to a serious threat to food security and cause huge economic losses. In particular, aflatoxin B1 has been identified as a Class I carcinogen to humans by the International Agency for Research on Cancer (IARC). Compared with conventional methods, Surface-Enhanced Raman Scattering (SERS) has paved the way for the detection of Aspergillus flavus and Aflatoxins in grain crops as it is a rapid, nondestructive, and sensitive analytical method. In this work, the rapid detection of Aspergillus flavus and quantification of Aflatoxin B1 in grain crops were performed by using a portable Raman spectrometer combined with colloidal Au nanoparticles (AuNPs). With the increase of the concentration of Aspergillus flavus spore suspension in the range of 102-108 CFU/mL, the better the combination of Aspergillus flavus spores and AuNPs, the better the enhancement effect of AuNPs solution on the Aspergillus flavus. A series of different concentrations of aflatoxin B1 methanol solution combined with AuNPs were determined based on SERS and their spectra were similar to that of solid powder. Moreover, the characteristic peak increased gradually with the increase of concentration in the range of 0.0005-0.01 mg/L and the determination limit was 0.0005 mg/L, which was verified by HPLC in ppM concentration. This rapid detection method can greatly shorten the detection time from several hours or even tens of hours to a few minutes, which can help to take effective measures to avoid causing large economic losses.

Alternate Special Stains for the Detection of Mycotic Organisms in Oral Cyto-Smears-A Histomorphometric Study.

In the wake of the COVID-19 pandemic, fungal infections of the maxillofacial region have become prevalent, making their accurate diagnosis vital. Histopathological staining remains a simple, cost-effective technique for differentiation and diagnosis of the causative fungal organisms. The present study aims to evaluate the staining efficacy of Periodic Acid-Schiff (PAS), Alcian Blue, Safranin-O and Gomori's Methenamine Silver (GMS) on fungal smears. This research work also attempts to study the morphometric characteristics of Candida albicans, Aspergillus flavus, Rhizopus oryzae. Candida albicans, Aspergillus flavus and Rhizopus oryzae, 10 smears each, were stained using PAS, Alcian Blue, Safranin-O and GMS. The morphological characteristics and staining efficacy were examined, and semi-quantitative scoring was performed. Candida albicans, Aspergillus flavus and Rhizopus oryzae were stained for the first time with Safranin-O. The morphometric traits were then analyzed using an image analysis software. Safranin-O provided the most reliable staining efficacy amongst the stains and optimum morphological definition for all three organisms. Safranin-O was found to be superior to PAS and GMS, ensuring detection of even the most minute mycotic colonies. The hyphae of Aspergillus flavus to be the largest, and the spores and fruiting body of Rhizopus oryzae were found to be the largest amongst the three organisms compared. Early and accurate diagnosis of fungal infections can significantly reduce morbidity in orofacial fungal infections.

COVID-19 associated mixed mold infection: a rare case report of aspergillosis and mucormycosis

Background: Fungal epidemic was announced amid COVID pandemic with several cases of COVID-associated Mucormycosis and Aspergillosis being reported however there is not sufficient data regarding mixed fungal infection. Case Study: A 54-year-old male patient diagnosed with severe COVID 19 pneumonia and diabetes 1-month back presented to OPD with C/O of chest pain and breathlessness for two days associated with haemoptysis, heaviness and congestion of right nostril but no fever. O/E patient was tachypnoeic, hypoxic and in shock, Neutrophil count 87%, RBS-530 mg/dl, urine ketone body was absent. Chest x-ray showed opacity over the left upper and mid-zone, HRCTthorax showed a bird-nest-sign noted in the left upper lobe S/O invasive fungal infection. MRI PNS showed mucosal thickening S/O sinusitis, Fungal infection. Sino-nasal mucosa KHO-mount and fungal culture showed mixed infection of Rhizopus species and aspergillus flavus. Right nasal HP study showed mixed invasive moulds infection. Initially, the patient was treated conservatively later on inj. amphotericin-B was started. The patient's condition worsened on day-18 and succumbed a day later. Discussion: Uncontrolled diabetes-mellitus, and corticosteroids leading to hyperglycaemia, extensive use of broad-spectrum antibiotics increases the risk of invasive Moulds. In our case study, patients suffered from COVIDpneumonitis and had uncontrolled diabetes leading to damage of airway epithelium inviting an invasion of tissues by moulds. Conclusion: Mixed fungal infections as COVID-19 sequelae may be an emerging issue and seen particularly in post- COVID patients with uncontrolled diabetes, and on steroids. The focus should be on prompt management: hit hard approach with both medical and surgical treatment.

Mixed etiology COVID-19 associated acute rhinosinusitis caused by two Aspergillus species.

INTRODUCTION: Acute invasive fungal rhino-sinusitis (AIFR) is a life-threatening infection that is mostly found in immunocompromised patients with serious morbidity and mortality. Recently, reports of AIFR have also emerged among SARS-CoV-2 infected patients. CASE PRESENTATION: A 50-year-old diabetic woman, previously diagnosed with COVID-19 pneumonia, was presented to the hospital with left facial pain on day 12 after discharge. Paranasal sinuses computed tomography was performed and according to the mucosal thickening in both maxillary sinuses and ethmoidal air cells, the patient underwent functional endoscopic sinus surgery (FESS) and necrosis were observed. The histopathologic examination revealed mycelium with septation suspected to Aspergillus and the culture was consistent with Aspergillus flavus and also Aspergillus niger . We reported a case of COVID-19 associated AIFR with two combined Aspergillus species from Iran. The patient received liposomal amphotericin B, which then switched to voriconazole combined with aggressive surgical debridement of necrotic tissues with a clinically favorable outcome. CONCLUSION: Mixed etiology AIFR can influence the outcome. However, further investigation is required upon this new threat.