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Diagnosing invasive pulmonary aspergillosis in ICU patients

putting the puzzle together

Blot, Stijna,b; Rello, Jordic; Koulenti, Despoinad,e

Current Opinion in Critical Care: October 2019 - Volume 25 - Issue 5 - p 430–437
doi: 10.1097/MCC.0000000000000637
SEVERE INFECTIONS: Edited by Michael S. Niederman
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Purpose of review The approach to diagnose invasive pulmonary aspergillosis in the absence of lung biopsy in ICU patients is reviewed. This approach should be based on four pillars: mycology, medical imaging, underlying conditions, and acute disease expression.

Recent findings Diagnosing invasive pulmonary aspergillosis in the absence of histopathologic evidence is a matter of probability weighting. Initiating antifungal therapy in an early phase and with a lower likelihood of disease might outweigh further diagnostic workout with further delay in appropriate treatment. However, in ICU patients, a preemptive antifungal strategy has not been established yet.

Summary For mycology, a positive galactomannan test on serum or broncho-alveolar lavage fluid is highly indicative of invasive pulmonary aspergillosis. The meaning of positive culture results, lateral-flow device test, or PCR-assay is ambiguous. A negative galactomannan or PCR test has high negative predictive value. Clinical features suggestive for invasive fungal disease on CT-scan are highly indicative but rare in ventilated patients. An immunocompromised status indicates high-risk. chronic obstructive pulmonary disease, hepatic cirrhosis, and AIDS indicate moderate risk. Invasive pulmonary aspergillosis in the absence of underlying conditions is rare. Acute diseases frequently associated with invasive pulmonary aspergillosis include sepsis and/or respiratory insufficiency because of influenza, acute respiratory distress syndrome, or pneumonia.

aDepartment of Internal Medicine & Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium

bBurns, Trauma, and Critical Care Research Centre, Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Queensland, Australia

cCiberes & vall d’hebron institute of research, Barcelona, Spain

d2nd Critical Care Department, Attikon University Hospital, Athens, Greece

eUQCCR, Faculty of Medicine, The University of Queensland, Brisbane, Australia

Correspondence to Stijn Blot, Department of Internal Medicine & Pediatrics, Ghent University, Campus UZ Gent, Corneel Heymanslaan 10, 9000 Ghent, Belgium. Tel: +32 92326216; e-mail: stijn.blot@UGent.be

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