1/
First of 2 tweets! #GalactoMagic
55F w/ COPD has 3 days of fevers, SOB & cough. T 38.2C, HR 112, BP 100/75, RR 22, O2 93% on 100% non-rebreather. Exam- crackles b/l
CT chest- ground-glass opacities b/l
Rapid flu swab + for influenza A, sputum & blood cultures negative
First of 2 tweets! #GalactoMagic
55F w/ COPD has 3 days of fevers, SOB & cough. T 38.2C, HR 112, BP 100/75, RR 22, O2 93% on 100% non-rebreather. Exam- crackles b/l
CT chest- ground-glass opacities b/l
Rapid flu swab + for influenza A, sputum & blood cultures negative
2/
W/ oseltamivir, ceftriaxone & azithro, she defervesces. 3 wks later, has fevers & worsening SOB. Repeat CT chest- new 2cm RUL cavitary lesion. Resp viral panel +influenza A, blood & sputum cultures neg. Which of the following is the most likely cause of the cavitary lesion?
W/ oseltamivir, ceftriaxone & azithro, she defervesces. 3 wks later, has fevers & worsening SOB. Repeat CT chest- new 2cm RUL cavitary lesion. Resp viral panel +influenza A, blood & sputum cultures neg. Which of the following is the most likely cause of the cavitary lesion?
1/11
Answer: Pulmonary aspergillosis. Patient has several RF for pulm aspergillosis including COPD, critical illness, and severe influenza infection. As a refresher, here is a table with RF for aspergillosis
Answer: Pulmonary aspergillosis. Patient has several RF for pulm aspergillosis including COPD, critical illness, and severe influenza infection. As a refresher, here is a table with RF for aspergillosis
2/
Influenza-associated pulmonary aspergillosis (IAPA) is mostly described in ICU patients. The incidence of IAPA in ICU patients differs by region, with 20-40% in Europe and Asia compared to 7.2% in Canada
academic.oup.com/cid/article/71…
Influenza-associated pulmonary aspergillosis (IAPA) is mostly described in ICU patients. The incidence of IAPA in ICU patients differs by region, with 20-40% in Europe and Asia compared to 7.2% in Canada
academic.oup.com/cid/article/71…
3/
This difference in incidence globally can be 2/2 several reasons, such as genetic (SNPs in innate immunity), environmental (rural > urban, dry > wet), & differing flu vaccination rates (areas w/ lower vaccination rates can have more severe flu cases)
This difference in incidence globally can be 2/2 several reasons, such as genetic (SNPs in innate immunity), environmental (rural > urban, dry > wet), & differing flu vaccination rates (areas w/ lower vaccination rates can have more severe flu cases)
4/
It’s even been described that use of neuraminidase inhibitors (oseltamivir) may play a role
One study has shown that neuraminidase plays a role in the host immunity against Aspergillus
⭐️so blocking it could increase the risk for Aspergillus!
ncbi.nlm.nih.gov/pmc/articles/P…
It’s even been described that use of neuraminidase inhibitors (oseltamivir) may play a role
One study has shown that neuraminidase plays a role in the host immunity against Aspergillus
⭐️so blocking it could increase the risk for Aspergillus!
ncbi.nlm.nih.gov/pmc/articles/P…
5/
We can try to diagnose with sputum cultures...
🌞but their sensitivity in ICU pts for diagnosis of IPA does not exceed 50%
ncbi.nlm.nih.gov/pmc/articles/P…
We can try to diagnose with sputum cultures...
🌞but their sensitivity in ICU pts for diagnosis of IPA does not exceed 50%
ncbi.nlm.nih.gov/pmc/articles/P…
6/
But, how do you determine if culture is colonization or not? @emily_fri
Decision to treat is easier when culture is obtained from sterile site (tissue) & when there is histopath evidence of infection
💥More challenging is when organism is found from non-sterile site (sputum)
But, how do you determine if culture is colonization or not? @emily_fri
Decision to treat is easier when culture is obtained from sterile site (tissue) & when there is histopath evidence of infection
💥More challenging is when organism is found from non-sterile site (sputum)
7/
Cultures obtained from these sites do not necessarily indicate infection
Distinguishing b/w infection & colonization requires consideration of:
🍏host vulnerability
🍎clinical signs & symptoms
🍐results of non-culture techniques (e.g., BDG, GM, PCR)
🍊radiographic findings
Cultures obtained from these sites do not necessarily indicate infection
Distinguishing b/w infection & colonization requires consideration of:
🍏host vulnerability
🍎clinical signs & symptoms
🍐results of non-culture techniques (e.g., BDG, GM, PCR)
🍊radiographic findings
8/
What about serum and BAL GM? This study reviewed serum & BAL GM in ICU pts w/ high autopsy rate
🚗BAL GM had sens 88%/spec 87% (cut off 0.5)
🚙Serum GM sens 42% (cut off 0.5)
atsjournals.org/doi/pdf/10.116…
What about serum and BAL GM? This study reviewed serum & BAL GM in ICU pts w/ high autopsy rate
🚗BAL GM had sens 88%/spec 87% (cut off 0.5)
🚙Serum GM sens 42% (cut off 0.5)
atsjournals.org/doi/pdf/10.116…
9/
In 11 of 26 proven cases, BAL culture & serum GM were negative, whereas BAL GM was positive in 23/26!!
atsjournals.org/doi/pdf/10.116…
In 11 of 26 proven cases, BAL culture & serum GM were negative, whereas BAL GM was positive in 23/26!!
atsjournals.org/doi/pdf/10.116…
10/
Why should we care about diagnosing IAPA in the ICU?
A mortality analysis of a large cohort study included 83/432 patients (19%) w/ IAPA; their 90-day mortality was 51%, higher than mortality in 349 patients w/o IAPA (28%; P < .001)
academic.oup.com/cid/article/71…
Why should we care about diagnosing IAPA in the ICU?
A mortality analysis of a large cohort study included 83/432 patients (19%) w/ IAPA; their 90-day mortality was 51%, higher than mortality in 349 patients w/o IAPA (28%; P < .001)
academic.oup.com/cid/article/71…
11/
Finally, it’s been difficult to come up with case definitions for IAPA
29 authors from all over the world created an expert panel and developed case definitions for IAPA that can facilitate clinical studies. Their proposed case definition is below
pubmed.ncbi.nlm.nih.gov/32572532/
Finally, it’s been difficult to come up with case definitions for IAPA
29 authors from all over the world created an expert panel and developed case definitions for IAPA that can facilitate clinical studies. Their proposed case definition is below
pubmed.ncbi.nlm.nih.gov/32572532/
Hope you all enjoyed another tweetorial on #FungalFriday!
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