Critically ill patients with COVID-19 who are not recovering as expected should be screened for pulmonary aspergillosis, UK experts advise.

A group of infectious disease specialists, haematologists and respiratory specialists from institutions across London have said fungal disease consistent with invasive aspergillosis (IA) had been observed with other severe coronaviruses and its risk was likely underappreciated in patients with COVID-19.

“Importantly, the recent finding by the UK RECOVERY trial of a one- third mortality reduction conferred by dexamethasone in ventilated patients with COVID-19, while leading to a crucial new therapeutic avenue, may increase the risk of patients acquiring CAPA and emphasises the need for enhanced fungal surveillance,” they wrote in an early view published in the European Respiratory Journal. 

The researchers acknowledged that screening patients for CAPA was challenging given the Hazard Group 3 rating of the SARS-CoV-2 virus, alongside an overburdened critical care service.

“Ideally, screening for CAPA entails using a combination of CT chest imaging and Aspergillus antigen tests on BAL and serum including galactomannan (GM) ELISA or lateral-flow tests, or Aspergillus PCR,” they wrote.

They noted that in CAPA cases reported to date, BAL culture and GM had a sensitivity of 72.7% and 66.7% respectively, but serum GM was positive in only 6/28 (21.4%).

“Therefore, bronchoscopy, including tracheobronchial inspection and BAL sampling for culture and GM should be the diagnostic gold standards whenever CAPA is suspected, providing this is compatible with local infection prevention and control guidance for aerosol-generating procedures,” they advised.

A positive BAL GM (index >1.0) would be indicative of CAPA and a positive serum GM result (≥ 0.5) would be highly suspicious for CAPA although  a negative result should not be used to exclude the diagnosis, they added.