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