Abstract

We read with interest the case report by Garcia and colleagues regarding an apparently immunocompetent individual.¹ As the authors state, invasive aspergillosis is mainly encountered in patients suffering from severe immunodeficiency, such as hematologic malignancy, or in patients receiving chemotherapy or immunosuppressive therapy following solid organ transplantation. However, we disagree with the authors' statement that invasive aspergillosis occurs almost exclusively in patients with severely impaired immune function. Evidence that invasive aspergillosis is an emerging opportunistic infection in nonimmunocompromised patients is accumulating.²Especially in critically ill patients, it appears that invasive aspergillosis might be an underestimated problem, but yet, with a very high associated and attributable mortality rate.³ In a series of 38 intensive care unit (ICU) patients with invasive aspergillosis, we found that only 17 had specific risk factors for the development of the disease.⁴ In a larger series of 127 medical ICU patients, Meersseman et al found 70% of patients to have no malignancy.⁵ Because the definitions of probable aspergillosis include an immunocompromised state, this diagnosis may be easily missed or delayed in patients with a nonspecific risk profile, resulting in higher fatality rates.^4,6Furthermore, diagnostic examination by tissue biopsy in ICU patients is often impossible due to coagulation disorders, and medical imaging of the lungs is frequently nonspecific due to mechanical ventilation. To overcome these problems, Vandewoude et al proposed a diagnostic algorithm, partially derived from the European Organisation for the Research and Treatment of Cancer (EORTC) criteria, but designed to deal with the specific conditions of ICU patients.⁷ Although this algorithm can be a guideline toward a more timely diagnosis of invasive aspergillosis, further validation is necessary.