Diagnosis of Invasive Aspergillosis (IA) in HIV infected patients

Ref ID: 19484

Author:

B Denis1*, M Guiguet1, N de Castro2, M Revest3, F Mechaï4, A Mahamat5, G Melica-Gregoire2,
D Costagliola1, O Lortholary6,7, on behalf of the FHDH-ANRS CO4

Author address:

1UMR S 943, INSERM-UPMC Univ Paris 06, Paris, France
2Infectious Diseases, CHU Saint Louis, APHP, Université Paris Diderot, Paris, France
3Infectious Diseases, CHU Rennes, Rennes, France
4Infectious Diseases, CHU Avicenne, AP-HP, Bobigny, France

Full conference title:

6th Advances Against Aspergillosis 2014

Abstract:

Purpose:
A revised EORTC/MSG (EORTC) classification defining Invasive Aspergillosis (IA) has been
proposed in 2008 based on host factors, clinical and mycological criteria. Major host factors are
prolonged neutropenia, immunosuppressive treatments, allogeneic stem cell transplant patients,
inherited severe immunodeficiency, but HIV status is not considered as a host factor. A review has
reported that 8804;50% of IA cases in HIV infected patients occurred with a neutrophil count <500/mm3 (Khoo and Denning, CID 1994). In HIV infected patients, IA was previously described as a lifethreatening complication of advanced AIDS, with a median of survival of 2 months after diagnosis. As the EORTC classification was mainly developed for patients from hematology/oncology, we investigated its relevance in the context of HIV infection. Methods: Medical records of all HIV-infected patients followed up in the French Hospital Database on HIV (FHDH-ANRS CO4) cohort between 1992 and 2011 were screened for aspergillosis according to the ICD-10 codes (B440-B441-B442-B447-B448-B449) and reviewed by 2 experts. Each criterion for EORTC classification was checked. When another pathogen, such as M. tuberculosis and avium, S. pneumoniae, Histoplasma capsulatum, Pneumocystis jirovecii, that could be responsible for the clinical signs, was also identified with the Aspergillus specie, we excluded an IA diagnosis. We also excluded patients without clear radiologic involvement, incomplete charts, aspergillomas, allergic bronchopulmonary aspergillosis, Aspergillus colonization, or acute viral diseases. When validated cases of IA did not meet EORTC criteria, IA were defined as HIV-related IA based on previously published recommendations (Lortholary O and al, Am J Med 1993). Three periods were analyzed: before combined antiretroviral therapy (cART) (<1996), before voriconazole availability (1996-2001), and after 2001. Results: Diagnosis of IA was rejected for 102 of the 347 medical records which were reviewed. Out of 245 validated IA diagnosis, 72 (29%) cases occurred before 1996, 82 (34%) in 1996-2001 and 91(37%) in 2002-2011. IA diagnosis was assessed according to all EORTC criteria for 124 (51%) patients (7 possible, 65 probable and 52 proven) while HIV related IA were noted in 121 (49%) patients (83 probable and 38 possible). Over the three periods, the proportion of IA defined by EORTC criteria was unchanged with 50%, 48%, and 54%, respectively. Out of the 56 patients with hematologic diseases (23 Non Hodgkin Lymphomas, 8 Hodgkin diseases, 25 other (mainly myelodysplasia)), 8 (14%) did not fulfill EORTC criteria. Immunodepression was observed in the majority of patients with IA diagnosis. In the last period, 2002-2011, median CD4 at IA diagnosis were 37/mm3 (IQR: [9-300]) and 115/mm3 (IQR:[20-327]) for EORTC and HIV-related cases, respectively (p=0.11). Mortality at 3 months did not differ between EORTC and HIV-related cases (27% and 33%, p=0.5). Conclusion: EORTC criteria that have been proposed for patients from hematology/oncology applied to only half of IA diagnosed in HIV-infected patients. These criteria relied mainly on polynuclear cell count and could be misleading in HIV-infected patients. As IA remained an important threat with a 3-months mortality rate of 30% in the most recent period, we need to better identify specific HIV risk factors in order to improve diagnosis and early treatment. NOTE: THIS ABSTRACT HAS BEEN SELECTED FOR ORAL PRESENTATION.

Abstract Number: 12

Conference Year: 2014

Link to conference website: http://www.AAA2014.org

New link: NULL

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