Invasive pulmonary aspergillosis in patients with influenza infection: report of two cases and systematic review of the literature

Abstract

Superinfection or coinfections are major causes of morbidity and mortality in patients with influenza. There are limited data on invasive pulmonary aspergillosis (IPA) in this setting. We conducted a systematic review of the literature for patients with IPA following influenza infection. A total of 68 patients (two reported from our institution and 66 identified by literature review) were analyzed. The majority of patients had underlying comorbid illnesses. Overall, the mortality rate in this cohort was 47%. On multivariate analysis, H1N1 infection was associated with better outcome (odds ratio [OR]: 0.19; 95% CI: 0.05–0.67; p = 0.010), whereas corticosteroid therapy during hospitalization was associated with worse outcome (OR: 13.5; 95% CI: 3.65–49.67; p < 0.0001). In conclusion, IPA is an emerging serious infection in patients with influenza. A high index of suspicion is necessary for the timely identification and treatment of these patients.

Keywords:

• aspergillosis
• H1N1 influenza
• infections
• influenza
• outcome

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Invasive pulmonary aspergillosis (IPA) is a potential infection in patients with severe influenza.

• Majority of patients with IPA in this review had co-morbid illnesses.

• IPA was reported in immunocompromised patients as well as those with no significant immunosuppression.

• The clinical and radiological features of IPA in the setting of influenza infection were nonspecific. High index of suspicion is necessary for timely identification and treatment of IPA in this patient population.

• The mortality associated with IPA following influenza infection was significant (47%); however, relatively lower than that reported in other critically ill patients with IPA.

• On multivariate analysis, H1N1 infection was associated with better outcome, whereas corticosteroid therapy during hospitalization was associated with worse outcome.

• Multicenter studies are needed to confirm that patients with influenza infection are at increased risk for IPA and to identify the risk factors for developing this serious infection.