In the initial bronchoalveolar lavage of both patients only COVID-19 was found (PCR negative for influenza virus and respiratory syncytial virus); a follow-up bronchoalveolar lavage because of ongoing fever a few days later (days 5 and 6 after ICU admission) showed elevated galactomannan and growth of Aspergillus fumigatus in standard culture, suggesting IPA (Table 1 ). All patients received a chest computed tomography scan before ICU admittance with typical signs for COVID-19 pneumonia but no specific signs for IPA. Follow-up computed tomography scans were not performed for safety reasons.
Table 1 Results of galactomannan (bronchoalveolar lavage and serum) and standard culture
Patient 1(80 years, male, suspected pulmonary fibrosis) Patient 2(70 years, male, no risk factors)
Galactomannan from BAL (ODI; normal range <1.0) 6.3 6.1
Galactomannan from serum (ODI; normal range <0.5) 1.5 <0.5
Standard culture Aspergillus fumigatus Aspergillus fumigatus
SARS-CoV-2 (at follow up) positive positive
Laboratory parameters, mean at IPA diagnosis
 CRP (mg/dL) 26 5.1
 IL-6 (pg/mL) 460 82
 PCT (ng/mL) 3.7 0.4
 D-Dimer (μg/L) 4820 14 151
 LDH (U/L) 481 530
 Leucocyte count (G/L) 10.38 14.55
 Lymphocytes (%) 15 7
Renal failure Yes Yes
Classical risk factors for invasive pulmonary aspergillosis No No
Abbreviations: BAL, bronchoalveolar lavage; CRP, C-reactive protein; IL-6, interleukin 6; IPA, invasive pulmonary aspergillosis; LDH, lactate dehydrogenase; ODI, optical density index; PCT, procalcitonin.