Invasive aspergillosis in critically ill patients: An autopsy study

Abstract

Summary Autopsy studies show that IA is among the most commonly missed diagnoses in critically ill patients. And, because of lack of unequivocal diagnostic criteria, a timely diagnosis remains challenging. We investigate the epidemiology of and the clinical risk factors for IA in critically ill patients. We conducted a retrospective, observational study of all consecutive ICU patients with evidence of IA in the postmortem examination. During the period of the study (25 years), 893 postmortem examinations were performed in the ICU. Twenty‐five patients (2.8%) were diagnosed with IA in autopsy. Only ten (40%) were classified as IA ante‐mortem, based on the initiation of antifungal treatment. The most common comorbid conditions were corticosteroid treatment (n = 14, 56%), chronic obstructive pulmonary disease (COPD) (n = 11, 44%), immunosuppression (n = 6, 24%) and haematological malignancy (n = 5, 20%). Twenty‐three patients (92%) had three or more risk factors for IA. Critically ill patients with pulmonary infiltrates, treated with high doses intravenous corticosteroids (even for a short period of time), particularly COPD patients who developed worsening respiratory insufficiency despite appropriate treatment were at the highest risk of IA.

Invasive Aspergillosis in Transplant Recipients

“…Recent reports indicate that invasive aspergillosis is being increasingly diagnosed in patients without above-mentioned severe neutropenia-particularly in the lung transplant recipients, patients hospitalized in the intensive care unit or treated with corticosteroids [9,11,27]. Also, individuals with chronic obstructive pulmonary disease (COPD), liver failure, and other underlying diseases are listed in this group [8,11,20]. It has been reported that in ICU patients with invasive pulmonary aspergillosis 40-80% of them do not have any malignancy or other classical risk factors for this infection [8,20].…”

“…It has been reported that in ICU patients with invasive pulmonary aspergillosis 40-80% of them do not have any malignancy or other classical risk factors for this infection [8,20]. Moreover, in contrast to patients with neutropenia, in ICU patients the symptoms of aspergillosis are atypical; therefore the diagnosis of this infection may be delayed or omitted, according to the autopsy studies [11,15,28]. Tejerina et al showed that among 893 deceased patients, previously treated in ICU, only 40% (10 out of 25) had invasive aspergillosis diagnosed ante mortem [11].…”

“…Moreover, in contrast to patients with neutropenia, in ICU patients the symptoms of aspergillosis are atypical; therefore the diagnosis of this infection may be delayed or omitted, according to the autopsy studies [11,15,28]. Tejerina et al showed that among 893 deceased patients, previously treated in ICU, only 40% (10 out of 25) had invasive aspergillosis diagnosed ante mortem [11]. Problems with proper diagnosis of invasive asergillosis, and therefore a delay in administration of effective antifungal therapy, are undoubtfully linked to a high mortality rate in this group of patients (30-40%), which may even exceed 90% despite lack of severe immunosuppression in these individuals [15,27,29].…”

“…[5,6]. Factors predisposing to the invasive aspergillosis are prolonged neutropenia (<500/μl for >10 days) and lymphopenia (mainly affecting CD4+ cells) [5,[8][9][10][11][12]. Frequency of invasive infections caused by Aspergillus spp.…”

“…Surgical procedures, particularly thoracic or abdominal surgery and solid organ transplantation, and the use of central venous catheters or dialysis catheters are linked to endogenous and exogenous infections, including those caused by Aspergillus spp. [1,5,6,[8][9][10][11]. Underlying diseases, such as diabetes, kidney, and/or liver failure, and chronic obstructive pulmonary disease (COPD) also predispose to invasive fungal infections [1,8].…”