Early treatment of invasive pulmonary aspergillosis (IPA) is essential, but the clinical cues that trigger treatment are non-specific. Here, we asked whether patient characteristics affect the clinical presentation and performance of diagnostic assays of IPA.
We reviewed adult patients with hematological malignancies who met the EORTC/MSG criteria for probable or proven IPA (2007-2014). The radiographic pattern was defined according to established CT criteria as angioinvasive, airway-invasive or a mixed pattern. Serum galactomannan was monitored weekly in susceptible patients. Patients with new pulmonary infiltrates underwent flexible bronchoscopy. Bronchoalveolar lavage fluid (BALF) was analyzed using standard mycological culture and galactomannan testing.
33 patients met criteria for IPA. 23 (76%) had an elevated temperature at presentation. Respiratory symptoms were significantly more frequent in patients with lymphoma (71% vs 8%) and concomitant sinusitis was more frequent in patients with acute leukemia (22% vs 4%). Radiographic patterns were angioinvasive (n=10), airway-invasive (n=12) and mixed (n=11). The predominant radiographic pattern differed among patient groups: angioinvasive disease was frequent in patients with acute leukemia (45% vs 22%) whereas stem cell transplant recipients had a mixed pattern (50% vs 25%). The frequency of airway-invasive disease was similar among patient groups. Serum galactomannan was elevated in 54% and BALF galactomannan was detected in 61%. Serum GM sensitivity was highest in patients with angioinvasive disease (80% vs 44%), multiple nodules (66% vs 28%) and CMV coinfection (83% vs 48%). The sensitivity of BAL galactomannan was highest in patients with relapsed malignancy (100% vs 46%). Risk factors for 30-day mortality were stem cell transplantation and treatment with amphotericin B.
Patient characteristics predispose to different patterns of lung involvement and affect the yield of biomarker testing. This information should be useful in designing a rational diagnostic strategy for high-risk patient populations.
I. Avivi, None
R. Ben-Ami, Pfizer: Scientific Advisor , Consulting fee
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