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PURPOSE: Patients with hematologic malignancies (HM) are at high risk of invasive lung fungal infections (ILFI). To describe the main characteristics, treatment, and outcomes for five years in adult patients with HM and fungal pneumonia. METHODS: We conducted a retrospective study at Instituto Nacional de Cancerología (INCan), a referral tertiary care oncology hospital with 135 beds in Mexico City, Mexico. We included all cases of fungal pneumonia in patients with HM from January 1, 2017, to December 31, 2022. Cases were classified as proven, probable, and possible according to EORTC/MSG criteria 2021. RESULTS: Two hundred ten patients were included; the mean age was 40 years. The most frequent HM was acute lymphoblastic leukemia (n = 74) and acute myeloid leukemia (n = 68). One hundred forty patients (66.7%) had severe neutropenia for a median of 16 days. All patients had a CT thorax scan; in 132 (62.9%), multiple nodules were documented. Serum galactomannan (GM) was positive in 21/192 (10.9%) and bronchoalveolar lavage in 9/36 (25%). Fifty-three patients (25.2%) died in the first month. In the multivariate analysis for mortality in the first 30 days, hypoalbuminemia, shock, possible ILFI, and inappropriate antifungal treatment were statistically associated. CONCLUSIONS: In high-risk HM patients, CT thorax scan and GM help diagnose ILFI. An appropriate antifungal improves mortality.

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The impact of invasive pulmonary aspergillosis (IPA) on non-neutropenic critically ill patients in intensive care units (ICU) has been demonstrated in recent decades. Furthermore, after the start of the COVID-19 pandemic, COVID-19 associated with pulmonary aspergillosis (CAPA) has become a major concern in ICUs. However, epidemiological data from different regions are scarce. We evaluated the prevalence and clinical-epidemiological data of IPA in patients with COVID-19 requiring mechanical ventilation (MV) in the ICU ("severe COVID-19") and non-COVID ICU patients in MV of a tertiary hospital in the southern region of Brazil. Eighty-seven patients admitted between June 2020 and August 2022 were included; 31 with severe COVID-19. For the diagnosis of IPA or CAPA, algorithms including host factors and mycological criteria (positive culture for Aspergillus spp., immunoassay for galactomannan detection, and/or qPCR) were utilized. The overall incidence of IPA and CAPA in our ICU was 73 cases/1000 ICU hospitalizations. Aspergillosis occurred in 13% (4/31) of the COVID-19 patients, and in 16% (9/56) of the critically ill patients without COVID-19, with mortality rates of 75% (3/4) and 67% (6/9), respectively. Our results highlight the need for physicians enrolled in ICU care to be aware of aspergillosis and for more access of the patients to sensitive and robust diagnostic tests by biomarkers detection.

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La aspergilosis es una infección fúngica causada por el microorganismo Aspergillus spp. Las manifestaciones clínicas dependen del estado inmunológico del paciente y de las alteraciones estructurales del parénquima pulmonar. Pese a su baja incidencia, siempre se debe considerar como diagnóstico diferencial en el contexto de pacientes con enfermedades pulmonares de base. Se presenta un caso de hombre de 66 años, agricultor, con antecedente de tuberculosis pulmonar y enfermedad pulmonar obstructiva crónica, quien consultó por cuadro de 5 meses de disnea progresiva, fiebre, tos, hemoptisis y pérdida de peso. Los hallazgos imagenológicos fueron sugestivos de tuberculosis pulmonar asociado a aspergiloma, lo que fue confirmado por tinción de hidróxido de potasio (KOH) y cultivo de hongos positivo para Aspergillus fumigatus. El Gene Xpert fue positivo para Mycobacterium tuberculosis demostrando coinfección activa.

Aspergillosis is a fungal infection caused by the microorganism Aspergillus spp. Clinical manifestations depend on the patient's immune status and structural alterations of the lung parenchyma. Despite its low incidence, it should always be considered as a differential diagnosis in the context of patients with underlying lung diseases. We present the case of a 66-year-old male farmer, with a history of pulmonary tuberculosis and chronic obstructive pulmonary disease, who presented with progressive dyspnea months, fever, cough, hemoptysis and weight loss for 5 months. Imaging findings were suggestive of aspergiloma- associated pulmonary tuberculosis, which was confirmed by potassium hydroxide (KOH) staining and positive fungal culture for Aspergillus fumigatus. Gene Xpert was positive for Mycobacterium tuberculosis showing active co-infection.

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BACKGROUND: In regions where there is only itraconazole capsule as a therapeutic option for treatment of chronic pulmonary aspergillosis (CPA), measuring the serum concentrations becomes even more important for therapeutic success. OBJECTIVE: Evaluate the initial itraconazole serum trough concentrations after the administration of oral capsule of itraconazole for the treatment of CPA. METHODS: The measurement was performed at least 7-days after initiation of therapy. The standard treatment at our institution was a 200 mg capsule every 12 h. We defined that an adequate serum trough concentration of itraconazole during treatment was 1-4 mg/L. RESULTS: This study recruited 28 patients. The median value was 0.30 mg/L (IQR 0.01-0.70). Only 11% (n = 3) had adequate serum concentrations based on guideline recommendation. All patients with clinical deterioration had itraconazole serum levels ≤ 0.8 mg/L. CONCLUSION: The initial serum concentrations of itraconazole after capsule formulation administration were low. Increasing the dose should be considered when the itraconazole concentration is low, especially if it is ≤ 0.8 mg/L, and the patient presents with clinical deterioration. Larger studies are needed to evaluate the adequate concentrations recommended for CPA.

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BACKGROUND: A clear cutoff value of galactomannan (GM) has not been established for chronic pulmonary aspergillosis (CPA) and is frequently extrapolated from invasive pulmonary aspergillosis. We performed a systematic review and meta-analysis to evaluate the diagnostic performance of serum and bronchoalveolar lavage (BAL) GM, and to propose a cutoff. METHODS: We extracted from the studies the cutoff of serum or/and BAL GM associated with true positives, false positives, true negatives, and false negatives. We performed a multi-cutoff model and a non-parametric random effect model. We estimated the optimal cutoff and the area under the curve (AUC) for GM in serum and BAL samples. RESULTS: Nine studies from 1999 to 2021 were included. Overall, the optimal cutoff of serum GM was 0.96 with a sensitivity of 0.29 (95%CI: 0.14-0.51); specificity of 0.88 (95%CI: 0.73-0.95); and AUC of 0.529 (with a CI: [0.415-0.682] [0.307-0.713]). The AUC for the non-parametric ROC model was 0.631. For BAL GM the cutoff was 0.67 with a sensitivity of 0.68 (95%CI: 0.51-0.82), specificity of 0.84 (95%CI: 0.70-0.92), and AUC of 0.814 (with a CI: [0.696-0.895] [0.733-0.881]). The AUC for the non-parametric model was 0.789. CONCLUSION: The diagnosis of CPA requires the assessment of a combination of mycological and serological factors, as no single serum and/or BAL GM antigen test is adequate. BAL GM performed better than serum, with better sensitivity and excellent accuracy.

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BACKGROUND: Untreated HIV infection can lead to profound immunosuppression and increase susceptibility of people living with HIV/AIDS (PLHA) to aspergillosis. OBJECTIVES: Reporting the burden and natural history of aspergillosis documented in PLHA admitted in five medical centres in Brazil. PATIENTS AND METHODS: Clinical, epidemiological and laboratory data were collected in all sequential cases of proven or probable aspergillosis documented in PLHA hospitalised in five medical centres between 2012 and 2020. RESULTS: We enrolled 25 patients ageing between 23 and 58 years (mean = 39) including 11 patients with invasive aspergillosis (IA) and 14 with chronic pulmonary aspergillosis (CPA). The prevalence rate of aspergillosis was 0.1% of 19.616 PLHA. Overall, 72.7% of patients with IA exhibited CD4 < 100 cells/mL and 42.8% of patients with CPA exhibited CD4 count >200 cells/mL. Most patients had a history of tuberculosis, especially those with CPA (85.7%). IA was documented after a mean of 16.5 days of hospitalisation, mainly in critically ill patients exposed to corticosteroids and broad-spectrum antibiotics. In the CPA group, a positive culture (71.4%) and radiological alterations were the most frequent findings supporting their diagnosis. Episodes of IA were mostly documented by tissue biopsies. Crude mortality rates were 72.7% and 42.8% in patients with IA and CPA, respectively. CONCLUSIONS: Despite being considered an unusual complication in PLHA (0.1%), IA should be considered in patients with profound immunosuppression and pneumonia refractory to conventional therapy. CPA should be investigated in PLHA with chronic deterioration of pulmonary function and previous diagnosis of tuberculosis.

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OBJECTIVES: Chronic pulmonary aspergillosis (CPA) is a research priority in fungal diseases with a need for new studies to reduce misdiagnosis with more common diseases, discuss improvement in diagnostic methods and better characterize gaps in antifungal and surgical treatments to improve clinical outcomes. METHODS: In this retrospective study, we reviewed medical records of patients diagnosed with CPA from January 2010 to June 2021 at University of São Paulo, São Paulo, Brazil. We evaluated clinical characteristics, radiological findings, serology, treatment, and outcomes. RESULTS: The study included 91 participants, with 43 (47.3%) patients who underwent surgery and 69 (75.8%) received antifungal therapy. We found a predominance of middle-aged adults (median 51 years), males (n = 58, 64%) with lower BMI (median 21.3 kg/m2). The most common underlying lung disease was pulmonary tuberculosis (n = 70, 76.9%). The commonest symptoms were cough (n = 67, 74%), haemoptysis, and dyspnea (n = 63, 70%). The most common chest computerized tomography abnormalities were cavity (n = 86, 94.5%), with a predominance of mycetomas (n = 78, 91%). The serology was positive in 81% (61/75). The one-year mortality was low (3.3%). Clinical improvement and stability occurred in 89% of participants for constitucional symptoms and 86% for pulmonary symptoms. While serological improvement and stability occurred in 71%. Radiological improvement and stability occurred in 75%. CONCLUSION: We observed a good outcome after 1-year follow-up, in which the majority had improvement or stability of pulmonary and constitutional symptoms, decrease in CIE titers and low mortality.

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Tecnologia: Detecção do antígeno galactomanana no soro. Contexto: A aspergilose pulmonar invasiva (API) é uma infecção fúngica oportunista de grande risco para pacientes imunocomprometidos. A detecção do antígeno galactomanana no soro por meio de um imunoensaio (ELISA) pode ser um teste não invasivo que auxilie no diagnóstico precoce da doença nestes pacientes. Objetivo: Avaliar a acurácia da detecção do antígeno galactomana no soro para o diagnóstico precoce de aspergilose pulmonar invasiva. Métodos: Revisão rápida sistematizada sobre acurácia de diagnóstico. As bases de dados utilizadas na pesquisa foram: PUBMED, EMBASE, SCOPUS, BVS e Cochrane Library. A avaliação da qualidade metodológica dos estudos incluídos foi realizada por meio da ferramenta AMSTAR-2. Resultados: Foram selecionadas três revisões sistemáticas que atendiam aos critérios de elegibilidade com as quais foi realizada uma análise descritiva dos dados encontrados. A avaliação da qualidade metodológica demonstrou que duas das revisões sistemáticas (RS) apresentaram qualidade criticamente baixa e uma das RS apresentou qualidade alta. Conclusão: A detecção da galactomanana sérica por ELISA pode ser um teste auxiliar no diagnóstico de API, entretanto, possui várias limitações e deve ser utilizado juntamente com outros critérios diagnósticos do consenso do EORTC/MSG. Novas pesquisas devem ser fomentadas para avaliar a utilização do teste no tempo do diagnóstico e no monitoramento da API

Technology: Detection of galactomannan antigen in serum. Background: Invasive pulmonary aspergillosis (IPA) is an opportunistic fungal infection of serious risk for immunocompromised patients. Detection of galactomannan antigen in serum by immunoassay (ELISA) could be a noninvasive test that contributes to the early diagnosis of the disease in this group of patients. Objective: To evaluate the accuracy of serum galactomannan antigen detection for the early diagnosis of invasive pulmonary aspergillosis. Methods: Rapid review of diagnostic accuracy. Databases used in the search were: PUBMED, EMBASE, SCOPUS, BVS, and Cochrane Library. The methodological quality of the included studies was assessed using the AMSTAR-2 tool. Results: Three systematic reviews that satisfied the eligibility criteria were selected, and a descriptive analysis of the data found was performed. The methodological quality assessment showed that two of the systematic reviews (SR) presented critically low quality, and one of the SR presented high quality. Conclusion: Detection of serum galactomannan by ELISA may be a valuable test for diagnosing IPA; however, it has a series of limitations and should be used in conjunction with other diagnostic criteria of the EORTC/MSG consensus. Further research should be encouraged to evaluate the use of this assay, considering the time to diagnosis and IPA monitoring

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Bacterial coinfections, which increase the severity of respiratory viral infections, are frequent causes of mortality in influenza pandemics but have not been well characterized in patients with Coronavirus disease 2019 (COVID-19). Moreover, the association of COVID-19 infection with pulmonary Mycobacterium tuberculosis disease (TB) and concurrent pulmonary fungal infection is not well known. The classification of patients with COVID-19-associated pulmonary aspergillosis (CAPA) using the current definitions for invasive fungal diseases has proven difficult. In this study, we aimed to provide information about three patients with underlying diseases ongoing with COVID-19 and co-infection with pulmonary TB, and with COVID-19-associated pulmonary aspergillosis (CAPA). At the time of hospital admission, each patient presented complications such as decompensated T2DM with diabetic ketoacidosis and/or hypertension. Findings of chest computed tomography and serum galactomannan by radioimmunoassay were useful for classifying them as possible CAPA. One of the three possible CAPA cases was fatal. These three cases are rare and are the first of their kind reported worldwide. The generation of reliable algorithms, early diagnosis, standardization of classification criteria, and the selection of specific and personalized treatments for COVID-19-associated opportunistic infections, including CAPA, are necessary to improve outcomes in these kinds of patients.

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BACKGROUND: Data on the prevalence of chronic pulmonary aspergillosis (CPA) in patients with active or cured tuberculosis (TB) are scarce, mainly due to diagnostic difficulties. The diagnosis of CPA is based on pulmonary symptoms and chest computed tomography (CT) scans and is considered confirmed when there is microbiological or serological evidence of Aspergillus spp. OBJECTIVES: To estimate the prevalence of CPA in patients treated or undergoing treatment for PTB, seen in two referral hospitals in Mato Grosso do Sul, Brazil. PATIENTS AND METHODS: A total of 193 consecutive patients who were treated or previously treated for pulmonary tuberculosis underwent prospective evaluation: (a) clinical evaluation; (b) chest CT scan; (c) sputum examination-culture for fungi and smears for direct mycology; (d) detection of anti-Aspergillus fumigatus antibodies using an enzyme-linked immunosorbent assay Platelia® test; and (e) anti-Aspergillus spp. antibodies were assessed via a DID test. RESULTS: The global prevalence of CPA was 10.9% (95% confidence interval, 7.2%-16.1%), but it increased with the time of TB diagnosis. The variables independently associated with CPA were previous pulmonary tuberculosis over 4 years ago and haemoptysis. Cavities, pleural thickening and the presence of a fungal ball were the most frequent tomographic findings in patients with CPA. CONCLUSIONS: The high prevalence observed and its increase over time suggest the need for continuous surveillance of CPA in patients with active or previous pulmonary tuberculosis and throughout life, with clinical, tomographic and serological evaluations (ELISA) for a timely diagnosis and a better prognosis.

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BACKGROUND: Several studies to evaluate the accuracy of galactomannan (GM) in bronchoalveolar lavage fluid (BALF) as a diagnostic tool have been carried out; however, there are still controversies about the optimal cut-off point of BALF GM. AIMS: The objective of this study was to determine the diagnostic accuracy and the optimal cut-off point on BALF GM from patients with suspected invasive pulmonary aspergillosis (IPA) in a tertiary care hospital. METHODS: A cross-sectional study with 188 patients (≥18 years) that had undergone a bronchoscopy with BAL due to suspected IPA was carried out. IPA was diagnosed according to the EORTC/MSG guidelines. RESULTS: The optimal optical density cut-off point for BALF GM was 0.67, with sensitivity, specificity, positive predictive value, and negative predictive value of 100%, 70%, 32.3%, and 100%, respectively. CONCLUSIONS: BALF GM detection proved to be a useful supplementary technique in the early diagnosis of IPA in both neutropenic and non-neutropenic patients.

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In 2019, severe acute respiratory syndrome caused by CoV-2 virus became a pandemic worldwide, being the fast spread of the disease due to the movement of infected people from one country to another, from one continent to another, or within the same country. Associated comorbidities are important factors that predispose to any fungal coinfections. Because of the importance of fungal infections in COVID-19 patients, the aim of this work was to collect data of the more encountered mycoses related to patients undergoing this disease. Aspergillosis was the first COVID-19-related fungal infection reported, being A. fumigatus the most frequent species for CAPA. Other fungal infections related include mainly candidiasis and mucormycosis, being Rhizopus spp. the more prevalent species found. Influenza-associated pulmonary aspergillosis is well documented; thus, similar complications are expected in severe forms of COVID-19 pneumonia. Therefore, in patients with COVID-19, it is important to take special attention to the surveillance and suspicion of fungal coinfections that might worsen the patient's prognosis.

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ResumenIntroducción: Es una de las infecciones oportunistas de mayor impacto en el paciente con patologías hematooncológicas, su detección precoz y tratamiento oportuno impide su diseminación. Objetivo: Determinar factores de riesgo de mortalidad en pacientes hematológicos con aspergilosis pulmonar de pacientes internados en clínica médica en el Instituto de Previsión Social del Hospital Central durante 2016 a 2018. Metodología: Estudio observacional, descriptivo, transversal, se incluyó a pacientes con patologías hematooncológicas e infección por aspergillus internados por un periodo de tres años. Resultados: Se incluyó a 55 pacientes, con edad promedio de 57,2±19,5 años. El 36,3% con edades comprendidas entre 40 a 59 años. 52,8% fue sexo femenino. 56,3% presentó hipertensión arterial. 27,2% linfoma no Hodking. 34,5% se encontraba en fase de mantenimiento al momento del diagnóstico de aspergilosis pulmonar. Respecto al grado de neutropenia el 34,7% presentó neutropenia severa. El 83,6% fue diagnosticado a traves de TACAR y galactomanano. El tiempo de inicio de síntomas hasta el momento del diagnóstico en promedio de días fue de 12,4±4,7 días. 38,1% presentó esputo con aislamiento positivo. Del tratamiento antifúngicos el 78,2% recibió anfotericina B y 21,8% Voriconazol. En relación a la evolución clínica 50,9% fueron alta, el 25,45% requirieron de Unidad de cuidados intensivos, 23,6%obitaron. Conclusión: Las aspergilosis pulmonar se presentó con predominio femenino, la mayoría se encontraba con neutropenia severa en fase de mantenimiento quimioterápico, dos tercios fue tratado con anfotericina B y la mitad fue dado de alta médica.

AbstractIntroduction: It is one of the opportunistic infections with the greatest impact on the patient with hemato-oncological pathologies, its early detection and timely treatment prevents its spread. Objective: To determine risk factors for mortality in hematological patients with pulmonary aspergillosis of patients hospitalized in a medical clinic at the Social Security Institute of the Central Hospital during 2016 to 2018. Methodology: Observational, descriptive, cross-sectional study included patients with hemato-oncological pathologies and infection by aspergillus hospitalized for a period of three years. Results: 55 patients were included, with an average age of 57.2 ± 19.5 years. 36.3% with ages between 40 to 59 years. 52.8% were female. 56.3% presented hypertension. 27.2% non-Hodking lymphoma. 34.5% were in the maintenance phase at the time of pulmonary aspergillosis diagnosis. Regarding the degree of neutropenia, 34.7% presented severe neutropenia. 83.6% were diagnosed through TACAR and galactomannan. Symptom onset time until diagnosis on average days was 12.4 ± 4.7 days. 38.1% presented sputum with positive isolation. Of the antifungal treatment, 78.2% received amphotericin B and 21.8% Voriconazole. In relation to the clinical evolution, 50.9% were high, 25.45% required an intensive care unit, 23.6% obliged. Conclusion: Pulmonary aspergillosis presented with a female predominance, the majority were with severe neutropenia in the phase of chemotherapy maintenance, two thirds were treated with amphotericin B and half were discharged medically.

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RESUMEN La aspergilosis pulmonar invasiva es una enfermedad presente principalmente en pacientes inmunocomprometidos con alta carga de mortalidad. La neumonía por Pneumocystis jirovecii es una infección oportunista potencialmente mortal que afecta a pacientes inmunocomprometidos por diversas etiologías. La coinfección por estos patógenos en pacientes inmunocompetentes es inusual. Reportamos un caso de un paciente sin las causas tradicionales de inmunocompromiso en el desarrollo de una neumonía en coinfección por Aspergillus fumigatus y Pneumocystis jirovecii.

ABSTRACT Invasive pulmonary aspergillosis is a condition that mainly occurs in immunosuppressed patients, and it has a high mortality rate. Pneumonia caused by Pneumocystis jirovecii is a potentially lethal opportunistic infection affecting immunosuppressed patients with different etiology. Coinfection by Aspergillus and P. jirovecii in immunocompetent patients is unusual. We report a case of a patient with no common causes of immunosuppression who developed pneumonia coinfection caused by Aspergillus fumigatus and Pneumocystis jirovecii.

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Viral or bacterial co-infections with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been reported in the literature. However, the knowledge on Aspergillus co-infection among patients with coronavirus disease 2019 (COVID-19) is limited. COVID-19-associated pulmonary aspergillosis (CAPA) has been seen in critically ill COVID-19 patients with acute respiratory distress syndrome (ARDS), which has raised concerns about the worsening disease course of COVID-19 and increasing mortality. We describe a clinical case of CAPA infection and acute respiratory distress syndrome (ARDS) with a deathly outcome in a previously well, non-immunocompromised pregnant woman with intrauterine death of the fetus. Hence, we suggest that clinicians and pathologists keep alerting the possible occurrence of pulmonary aspergillosis in severe/critical COVID-19 patients, and aggressive investigations should be done to rule out the possibility of CAPA so that early treatment can be administrated.

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Invasive aspergillosis is an uncommon infection, which is mainly seen among immunocompromised patients. In recent years, cases of aspergillosis involving immunocompetent hosts are increasingly being reported. Herein, we report the case of a 27-year-old man with fever, productive cough, shortness of breath, and left hemiparesis. He had suffered trauma to his head 25 days prior. Imaging of the chest showed bilateral cavitary lesions in the lungs, and neuroimaging revealed a space-occupying lesion in the right frontoparietal cerebrum. He was suspected of having an abscess or metastasis. He died on day 3 of hospitalization, and an autopsy was performed. The autopsy revealed the cause of death to be invasive pulmonary aspergillosis, with brain dissemination. Invasive aspergillosis is uncommon in apparently immunocompetent individuals, and we discuss the autopsy findings in detail.

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Invasive pulmonary aspergillosis (IPA) is a severe infection caused by aspergillus sp. that usually develops in patients with severe immunosuppression. IPA has been recently described in critically ill COVID-19 patients (termed as COVID-associated pulmonary aspergillosis, or CAPA) that are otherwise immunocompetent. In order to describe the characteristics of patients with CAPA, we conducted a retrospective cohort study in a tertiary care center in Mexico City. We included all patients with confirmed COVID-19 admitted to the intensive care unit that had serum or bronchoalveolar lavage galactomannan measurements. We used the criteria proposed by Koehler et al. to establish the diagnosis of CAPA. Main outcomes were the need for invasive mechanical ventilation (IMV) and in-hospital mortality. Out of a total of 83 hospitalized patients with COVID-19 in the ICU, 16 (19.3%) met the criteria for CAPA. All patients diagnosed with CAPA required IMV whereas only 84% of the patients in the non-IPA group needed this intervention (P = 0.09). In the IPA group, 31% (n = 5) of the patients died, compared to 13% (n = 9) in the non-CAPA group (P = 0.08). We conclude that CAPA is a frequent co-infection in critically ill COVID-19 patients and is associated with a high mortality rate. The timely diagnosis and treatment of IPA in these patients is likely to improve their outcome. LAY SUMMARY: We studied the characteristics of patients with COVID-19-associated invasive pulmonary aspergillosis (CAPA). Patients with CAPA tended to need invasive mechanical ventilation more frequently and to have a higher mortality rate. Adequate resources for its management can improve their outcome.

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Invasive pulmonary aspergillosis is a complication in critically ill patients with acute respiratory distress syndrome, especially those with severe coronavirus disease-associated pneumonia. In this study, five cases of presumed invasive pulmonary aspergillosis in one immunocompromised and four immunocompetent patients with COVID-19 in Buenos Aires are described. In all cases, the underlying conditions, clinical presentation, fungal diagnostic tests used and their results, features of the chest scan images, antifungals used and clinical outcomes are detailed.

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Invasive aspergillosis is an uncommon infection, which is mainly seen among immunocompromised patients. In recent years, cases of aspergillosis involving immunocompetent hosts are increasingly being reported. Herein, we report the case of a 27-year-old man with fever, productive cough, shortness of breath, and left hemiparesis. He had suffered trauma to his head 25 days prior. Imaging of the chest showed bilateral cavitary lesions in the lungs, and neuroimaging revealed a space-occupying lesion in the right frontoparietal cerebrum. He was suspected of having an abscess or metastasis. He died on day 3 of hospitalization, and an autopsy was performed. The autopsy revealed the cause of death to be invasive pulmonary aspergillosis, with brain dissemination. Invasive aspergillosis is uncommon in apparently immunocompetent individuals, and we discuss the autopsy findings in detail.

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Viral or bacterial co-infections with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been reported in the literature. However, the knowledge on Aspergillus co-infection among patients with coronavirus disease 2019 (COVID-19) is limited. COVID‐19‐associated pulmonary aspergillosis (CAPA) has been seen in critically ill COVID-19 patients with acute respiratory distress syndrome (ARDS), which has raised concerns about the worsening disease course of COVID-19 and increasing mortality. We describe a clinical case of CAPA infection and acute respiratory distress syndrome (ARDS) with a deathly outcome in a previously well, non-immunocompromised pregnant woman with intrauterine death of the fetus. Hence, we suggest that clinicians and pathologists keep alerting the possible occurrence of pulmonary aspergillosis in severe/critical COVID-19 patients, and aggressive investigations should be done to rule out the possibility of CAPA so that early treatment can be administrated.

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