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Pulmonary fungal infections in immunocompromised patients: incidence and risk factors
M von Eiff1, N Roos, W Fegeler
1Department of Internal Medicine A, University of Münster, Germany.
Abstract:
In a prospective study, 178 patients with fever > 38.4 degrees C and newly diagnosed pulmonary infiltrates underwent bronchoscopy with bronchoalveolar lavage (BAL), aspiration of bronchial secretions (BS) and, in 71 cases, protected specimen brushing (PSB). In 42/143 immunocompromised patients (haematological malignancies, n = 92; AIDS, n = 22; immunosuppressant therapy, n = 29) and in 4/35 patients with no defined underlying disease fungal pneumonia was present (candidosis, n = 35; aspergillosis, n = 8 mixed fungal infection, n = 3). Candidosis was combined, in 17 cases, with Aspergillus (n = 3), bacterial (n = 15) or cytomegalovirus (n = 2) infection. Aspergillosis was combined in eight cases with infection with Candida (n = 3), Pneumocystis carinii (n = 1) or bacteria (n = 5). The sensitivity of BAL and PSB in Candida pneumonia was 48% and 50%, respectively; specificity was 75% and 74% respectively. Bronchial secretions were more sensitive in detecting Candida pneumonia, but specificity was only 55%. In aspergillosis, the specificity of BAL, BS and PSB in each case was 100%; the sensitivity of BAL, BS and PSB was 38%, 64% and 100%. Twenty-four fungal infections were fatal. Unfavourable prognostic factors were respiratory failure needing mechanical ventilation, diffuse bilateral pulmonary infiltrates, mixed fungal infections and start of i.v. antifungal treatment > 14 days after fever onset, which were associated with a mortality rate of 74%, 67%, 67% and 63% respectively.
Insights
Fungal pneumonia, including candidosis and aspergillosis, affects immunocompromised patients. Bronchoscopy methods like bronchoalveolar lavage (BAL) and protected specimen brushing (PSB) aid diagnosis, but prognosis is poor with delayed treatment or mixed infections.
Area of Science:
- Infectious Diseases
- Pulmonology
- Medical Microbiology
Background:
- Fungal pneumonia presents a significant challenge, particularly in immunocompromised individuals.
- Early and accurate diagnosis is crucial for effective management and improved patient outcomes.
- Pulmonary infiltrates in febrile patients warrant investigation for diverse etiologies, including fungal infections.
Purpose of the Study:
- To evaluate the diagnostic yield of bronchoscopy techniques for fungal pneumonia.
- To assess the sensitivity and specificity of bronchoalveolar lavage (BAL), bronchial secretions (BS), and protected specimen brushing (PSB).
- To identify prognostic factors associated with mortality in patients with fungal pneumonia.
Main Methods:
- A prospective study involving 178 patients with fever and pulmonary infiltrates.
- Bronchoscopy with BAL, BS, and PSB (in 71 cases) was performed.
- Microbiological analysis identified fungal pathogens like Candida and Aspergillus.
Main Results:
- Fungal pneumonia was diagnosed in 46/178 patients, predominantly immunocompromised individuals.
- BAL and PSB showed moderate sensitivity and good specificity for Candida pneumonia.
- PSB achieved 100% specificity and sensitivity for Aspergillus pneumonia; BAL and BS had 100% specificity but lower sensitivity.
- Mortality was high (63-74%) with delayed antifungal treatment, mechanical ventilation, diffuse infiltrates, or mixed infections.
Conclusions:
- Bronchoscopy techniques are valuable for diagnosing fungal pneumonia, with PSB being highly effective for Aspergillus.
- Prognosis is significantly influenced by the timing of treatment and disease severity.
- Aggressive management and prompt diagnosis are essential for reducing mortality in these vulnerable patients.