Invasive Respiratory Fungal Infections in COVID-19 Critically Ill Patients

Abstract

Patients with coronavirus disease 19 (COVID-19) admitted to the intensive care unit (ICU) often develop respiratory fungal infections. The most frequent diseases are the COVID-19 associated pulmonary aspergillosis (CAPA), COVID-19 associated pulmonary mucormycosis (CAPM) and the Pneumocystis jirovecii pneumonia (PCP), the latter mostly found in patients with both COVID-19 and underlying HIV infection. Furthermore, co-infections due to less common mold pathogens have been also described. Respiratory fungal infections in critically ill patients are promoted by multiple risk factors, including epithelial damage caused by COVID-19 infection, mechanical ventilation and immunosuppression, mainly induced by corticosteroids and immunomodulators. In COVID-19 patients, a correct discrimination between fungal colonization and infection is challenging, further hampered by sampling difficulties and by the low reliability of diagnostic approaches, frequently needing an integration of clinical, radiological and microbiological features. Several antifungal drugs are currently available, but the development of new molecules with reduced toxicity, less drug-interactions and potentially active on difficult to treat strains, is highly warranted. Finally, the role of prophylaxis in certain COVID-19 populations is still controversial and must be further investigated.

Keywords: CAM; CAPA; COVID-19; SARS-CoV-2; pneumocystosis; respiratory fungal infection.

Figure 1

Aspergillus niger co-infection in COVID-19 ARDS. Bronchoalveolar lavage, soon after endotracheal intubation, showed galactomannan positivity (OI = 5) and direct identification of the mold. The patient already received IL-6 inhibitors and was ongoing dexamethasone. The clinical picture healed after four weeks of voriconazole.