Pulmonary fungal infections in immunocompromised patients: incidence and risk factors

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Abstract
In a prospective study, 178 patients with fever > 38.4 °C and newly diagnosed pulmonary infiltrates underwent bronchoscopy with bronchoalveolar lavage (BAL), aspiration of bronchial secretions (BS) and, in 71 cases, protected specimen brushing (PSB). In 42/143 immunocom-promised patients (haematological malignancies, n= 92; AIDS, n = 22; immunosuppressant therapy, n = 29) and in 4/35 patients with no defined underlying disease fungal pneumonia was present (candidosis, n= 35; aspergillosis, n = 8 mixed fungal infection, n = 3). Candidosis was combined, in 17 cases, with Aspergillus (n=3), bacterial (n= 15) or cytomegalovirus (n=2) infection. Aspergillosis was combined in eight cases with infection with Candida (n = 3), Pneumocystis carinii (n=1) or bacteria (n = 5). The sensitivity of BAL and PSB in Candida pneumonia was 48% and 50%, respectively; specificity was 75% and 74% respectively. Bronchial secretions were more sensitive in detecting Candida pneumonia, but specificity was only 55%. In aspergillosis, the specificity of BAL, BS and PSB in each case was 100%; the sensitivity of BAL, BS and PSB was 38%, 64% and 100%. Twenty-four fungal infections were fatal. Unfavourable prognostic factors were respiratory failure needing mechanical ventilation, diffuse bilateral pulmonary infiltrates, mixed fungal infections and start of i.v. antifungal treatment > 14 days after fever onset, which were associated with a mortality rate of 74%, 67%, 67% and 63% respectively.

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