New category of probable invasive pulmonary aspergillosis in haematological patients

Abstract

The European Organization for Research and Treatment of Cancer and the Mycosis Study Group (EORTC-MSG) radiological definitions of invasive pulmonary aspergillosis (IPA) may lack diagnostic sensitivity. We evaluated applying less restrictive radiological criteria, when supported by specific microbiological findings, to define IPA in acute myeloid leukaemia (AML), lymphoproliferative diseases (LD) and allogeneic stem cell transplant (allo-SCT) patients. Overall, 109 consecutive episodes of proven/probable IPA in 56 AML, 31 LD and 22 allo-SCT patients diagnosed from February 2006 through to January 2011 were considered. IPA was diagnosed with EORTC-MSG criteria (control group, 76 patients) or without prespecified radiological criteria (study group, 33 patients). The latter differed from the former by the inclusion of patients with pulmonary infiltrates not fulfilling the three EORTC-MSG IPA specific findings of dense, well-circumscribed lesions with or without halo sign, air crescent sign or cavity. All the analysed clinical and mycological characteristics, 3-month response to antifungal therapy and 1- and 3-month cumulative survival were comparable in the control and study groups in AML, LD and allo-SCT patients. Seventeen of 33 (51.5%) patients of the study group fulfilled EORTC-MSG radiological criteria at subsequent imaging performed a median of 15 days (range, 6-40 days) after documentation of the pulmonary infection. Our study seems to confirm the possibility of revising the EORTC-MSG criteria by extending the radiological suspicion of IPA to less specific chest computerized tomography scan findings when supported by microbiological evidence of Aspergillus infection in high-risk haematological patients.

Diagnostic Accuracy of PCR Alone Compared to Galactomannan in Bronchoalveolar Lavage Fluid for Diagnosis of Invasive Pulmonary Aspergillosis: a Systematic Review

“…The main problem of studies on the diagnosis of IPA is the imperfect reference standard (4,16,17,39). Indeed, adherence to reference standard definitions was the main variable underlying heterogeneity in our analysis.…”

“…Early diagnosis of invasive pulmonary aspergillosis (IPA) is notoriously difficult, and few diagnostic tools are available (16). Between 1978 and 1992, the percentage of patients in whom postmortem-proven IPA was suspected or confirmed antemortem improved only from 9% to 32% (17).…”

Pulmonary fungal infections in patients with acute myeloid leukaemia: is it the time to revise the radiological diagnostic criteria?

“…Although the introduction of definitions for IFD has greatly facilitated the conduction of clinical trials on diagnostic and therapeutic modalities, their diagnostic performance in the clinical practice is low when compared with autopsy examination . The application of specific but not very sensitive diagnostic radiological criteria may determine an underestimation of these severe complications as shown in recently published retrospective studies in patients affected by various haematological diseases . As a consequence, the revision of the EORTC‐MSG definitions with the inclusion of less specific radiological images in addition to the three above findings in the diagnosis of PFI, when supported by proper microbiological exams, has been proposed .…”

Early diagnosis of invasive pulmonary aspergillosis in hematologic patients: an opportunity to improve the outcome

“…18 Seventy-six episodes were classified as proven or probable IPA, and 33 were probable aspergillosis without pre-specified radiological findings. All clinical and mycological criteria were similar between the two groups, with the exception of the radiological findings.…”