Invasive fungal disease in patients with severe COVID-19 infection at a midwestern academic medical center

ABSTRACT

Background. Invasive fungal diseases (IFD) have been described in patients (pts) with severe coronavirus disease 2019 (COVID), albeit with geographic variability in rates. Methods. We performed a retrospective study to determine rates of & risk factors for IFD occurring within 30 days (d) of COVID diagnosis (dx) in adults requiring critical care for severe COVID between 5/11/20 & 2/7/21. Mortality was assessed at 90 d following COVID dx and at 84 d after IFD dx, if applicable. ECMM/ISHAM criteria were used for COVID-associated pulmonary aspergillosis (CAPA) and EORTC/ MSGERC criteria were used for other IFD and treatment response. Results. 218 pts were included;median age was 62 (19 - 91) & 63% were men. Underlying conditions included solid organ transplant (Tx) (16;7%), allogenic stem cell Tx (3;1%), malignancy (21;10%), & exposure to either high-dose steroids (HDS) (11;5%) or T- or B-cell suppressants (29;13%) within 90 d prior to COVID dx. 209 (96%) pts had respiratory failure & 127 (58%) required mechanical ventilation. 15 (7%) required extracorporeal membrane oxygenation. COVID treatment consisted of corticosteroids in 205 (96%) & tocilizumab in 10 (5%). 12 (6%) pts developed IFD. 6 pts had CAPA (2 probable, 4 possible);50% were men, median age 64.5 (48 - 83). Mean time to CAPA dx from COVID dx was 17 d (+/- 14d). All pts had received corticosteroids for COVID but only 1 pt received > 30d of HDS by the time of IFD dx. Mortality at 84 d from CAPA dx was 67%. 5 (2%) pts had central venous catheter associated candidemia;80% were men & median age 61 (55 - 77). Mean time from COVID to candidemia dx was 29 d (+/-12 d). All pts with Candida infection had received steroids for COVID. Mortality at 84 d from candidemia dx was 60%. A 35-year-old man with prolonged exposure to HDS had Paecilomyces pneumonia;he was alive at 84 d after IFD dx. No cases of mucormycosis were identified. All-cause mortality in the entire cohort was 38% at 90 d after COVID dx. Mortality among pts who developed IFD was 58% at the same time point. Conclusion. Rates of IFD in pts with severe COVID were low and most pts with IFD after COVID had CAPA or catheter-associated candidemia. All but one pt with CAPA had no risk factors for IFD. In pts with severe COVID, mortality was higher among pts who developed IFD than those who did not.