COVID-19 associated Pulmonary Aspergillosis

Welcome to #IDFungiFriday!

This week by: @A_Spallonii @teena_xu

Let's get started with a real-world case…

65yoM in Brazil (+) fever, fatigue, myalgias. Dx: COVID-19 pneumonia (mild-mod). Tx: HCQ. 4 wk later found w "mold in the lungs." What is going on here?!

Answer: all choices are possible!

It’s not often that fungi headline the news. Let's take a few minutes to talk about CAPA today.

(References will be cited by the PMID… google or pubmed the # to find the paper)

What is CAPA?

🍄 COVID-19 associated pulmonary aspergillosis

🌎 Increasingly reported around the globe by physicians treating patients with COVID-19-related lung disease…

PMID:
🇫🇷 32445626
🇩🇪 32339350 (figure 1)
🇳🇱 32396381
🇵🇰 32585069
🇦🇺 32395423
🇪🇸 32749040
🇧🇪 32488446

Before we dive into CAPA, let’s review invasive pulmonary aspergillosis (IPA).

Who gets IPA?

✅ANC <500 for >10d
✅Hematologic malignancy
✅HSCT and SOT
✅Primary immunodeficiency
✅Prolonged corticosteroids
✅Other immunosuppression (see below)

PMID: 31802125 | 32566427

IPA (and invasive fungal diseases in general) are classified as

🍄 Proven
🍄 Probable
🍄 Possible

by the European Organization for Research and Treatment of Cancer/Mycosis Study Group Education and Research Consortium (EORTC/MSGERC)

Details below ⬇️⬇️⬇️

So does CAPA only develop in pts with predisposing host factors like in IPA?

Nope!

We’ve seen this illness script before: healthy patient + severe viral pneumonia ➡️ invasive fungal infection

🔹Influenza (IAPA)
🔹SARS
🔹MERS

PMID: 32572532 | 12890854 | 28101187

Patients w IAPA don’t always read the textbook (or EORTC/MSGERC guidelines).

Typical host factors and clinical/radiological features may be absent.

IAPA case definitions for ICU patients have been proposed ⬇️

PMID: 22895826 | 28387526 | 30076119

Flu = RF for IPA (aOR 5.19; P<0.0001)

Why?

Influenza virus➡️cell-mediated destruction of lung epithelium➡️impaired mucociliary clearance➡️Aspergillus colonization + invasion

Also implicated:
➕viral overload➡️aberrant immune response
➕steroids
➕neuram inh

PMID: 22895826

Okay, back to CAPA. What about RFs for CAPA?

Not clearly defined (yet) but possibly:

✅Chronic resp dz
✅Corticosteroids
✅Mech ventilation
✅Severe COVID-19, esp ARDS, "cytokine storm"

PMID: 32599813 | 32307254 | 32703771

/When should you worry about CAPA?

Netherlands: 11.5 days (8–42) after COVID-19 symptom onset and 5 days (3–28) after ICU admission.

Belgium: 16 days (11-23) after COVID-19 symptom onset.

PMID: 32396381 | 32488446

1How common is CAPA?

Reported incidence of CAPA:

France (ICU + vent): 9/27 (33.3%); 4/9 died

Germany (ICU + ARDS): 5/19 (26.3%); 3/5 died

PMID: 32445626 | 32339350

sad doctor who GIF

How we define CAPA matters!

(no consensus on case definition yet)

Like IAPA, CAPA pts tend to lack EORTC/MSGERC host factors & clinical features.

In ICU pts, diagnosis is especially challenging:
💠radiological findings often non-specific
💠colonization vs disease

Here is a proposed screening and diagnostic algorithm for CAPA. Use of BAL/serum galactomannan needs further study.

PMID: 32703771

Some unanswered questions…

-Are non-severe COVID-19 pts also at risk of CAPA?
-Are COVID-19 therapies (Dex, Toci) contributing to risk of CAPA?
-How good is GM in BAL/serum for dx’ing CAPA?
-Should we PPX COVID-19 pts for IPA?
-How does CAPA impact COVID-19 mortality?

Mindy Kaling The Office GIF

Our CAPA wishlist:

♦️Better understanding of incidence, CAPA-specific host factors, clinical characteristics, and mortality

♦️Dx algorithm (validated) to assist clin decisions

♦️Case definitions that factor in the fact that bronch/BAL not always possible in COVID-19 era

If You Can Dream It, You Can Do It. GIF

Originally tweeted by BCM ID Fellowship (@BCMIDFellowship) on 14 August, 2020.

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