COVID-19-Associated Pulmonary Aspergillosis, March-August 2020

Abstract

Pneumonia caused by severe acute respiratory syndrome coronavirus 2 emerged in China at the end of 2019. Because of the severe immunomodulation and lymphocyte depletion caused by this virus and the subsequent administration of drugs directed at the immune system, we anticipated that patients might experience fungal superinfection. We collected data from 186 patients who had coronavirus disease-associated pulmonary aspergillosis (CAPA) worldwide during March-August 2020. Overall, 182 patients were admitted to the intensive care unit (ICU), including 180 with acute respiratory distress syndrome and 175 who received mechanical ventilation. CAPA was diagnosed a median of 10 days after coronavirus disease diagnosis. Aspergillus fumigatus was identified in 80.3% of patient cultures, 4 of which were azole-resistant. Most (52.7%) patients received voriconazole. In total, 52.2% of patients died; of the deaths, 33.0% were attributed to CAPA. We found that the cumulative incidence of CAPA in the ICU ranged from 1.0% to 39.1%.

Keywords: Aspergillus; COVID-19; SARS-CoV-2; aspergillosis; coronavirus disease; coronaviruses; fungi; intensive care unit; respiratory infections; severe acute respiratory syndrome coronavirus 2; viruses; voriconazole; zoonoses.

Figure 1

Enrollment process in study of patients with CAPA, March–August 2020. Patients were identified in the FungiScope registry and academic literature using the search string “(Aspergill*) AND (invasive OR putative OR probable OR infection OR case OR patient OR report) AND (COVID* OR corona* OR SARS-CoV-2) (Appendix Table 1). The initial 288 COVID-19 patients suspected to have IA were revised in a deduplication process; 59 double entries were identified. Only 1 report per patient was maintained. Thus, 221 individual COVID-19 patients suspected to have IA were assessed for CAPA. CAPA, COVID-19–associated pulmonary aspergillosis; COVID-19, coronavirus disease; EORTC/MSG, European Organization for Research and Treatment of Cancer/Mycoses Study Group; IA, invasive aspergillosis.

Figure 2

Global distribution of the 186 CAPA patients reported in the literature and FungiScope registry, March–August 2020. In total, 39 patients were from France, 36 from Italy, 26 from Spain, 23 from Germany, 14 from the Netherlands, 11 from the United Kingdom, 9 from Pakistan, 8 from Belgium, 6 from Mexico, 3 from Brazil, 3 from Switzerland, 2 from Denmark, 2 from Qatar, 1 from Argentina, 1 from Australia, 1 from Austria, and 1 from Ireland (Appendix Table 8). CAPA, COVID-19–associated pulmonary aspergillosis; COVID-19, coronavirus disease.