Executive summary Aspergillosis Incidence: prevalence The incidence of COVID-19-associated pulmonary aspergillosis varies in the literature, mainly due to different diagnostic methods and definitions used, but is quite high. Risk factors: pathogenesis Most patients with CAPA lack the traditional host factors. The prolonged use of high doses of corticosteroids and anti-interleukin-6 agents may be implicated in the pathogenesis of CAPA. Diagnosis The diagnosis of CAPA is challenging as bronchocopy is in most cases necessary to discriminate infection from colonization. Serum biomarkers have low sensitivity and CT findings overlap with severe COVID-19 pneumonia. The newly defined diagnostic criteria for CAPA are based on compatible clinical symptoms, radiological findings and microbiology testing. Treatment First-line treatment for Aspergillus is voriconazole and isavuconazole, while triazole resistance is an emerging problem, which necessitates susceptibility testing. Prevention & prophylaxis CAPA prophylaxis with antifungals is not generally recommended, apart from patients with prolonged neutropenia, GVHD, secondary prophylaxis. Despite reports of effective application of systematic and/or inhaled antifungal CAPA prophylaxis in the critical care setting, further, larger studies are needed to clarify whether and which sub-groups might benefit from this approach. Outcomes Higher mortality has been reported in patients with CAPA, although the attributable mortality of the fungal coinfection has not yet been accurately assessed. Mucormycosis Incidence The presentation of COVID-19-associated mucormycosis differs between Western countries and areas like India. In India a much higher incidence has been reported, and rhino-orbital cerebral mucormycosis is the most common form. In Western countries, mucormycosis is a rare complication of severe COVID-19, and the pulmonary form is more common. Pathogenesis: risk factors In India, the main risk factor is uncontrolled diabetes mellitus, while in Western countries it is usually associated with underlying immunosuppression. Diagnosis Mycology testing is essential, as the visualization of the characteristic hyphae confirms the diagnosis. Regarding imaging, it is challenging to distinguish whether ground-glass opacities or consolidations are due to mucormycosis or due to COVID-19 pneumonia/ARDS itself in deteriorating severely ill patients with COVID-19. Nevertheless, several lung nodules or the presence of pulmonary cavities should prompt a thorough search for invasive fungal coinfection. CT and MRI imaging contribute to disease staging. Treatment CAM treatment includes the management of the underlying predisposing condition, empirical initiation of liposomal amphotericin-B and surgical resection of necrotic tissues. Prevention & prophylaxis Mucormycosis prophylaxis in COVID-19 patients is only recommended in neutropenic patients and GVHD. Outcomes Mortality is higher in the pulmonary form of CAM.
【저자키워드】 COVID-19, Critical illness, Mucormycosis, CAM, aspergillosis, CAPA, antifungals, Molds,