4  DISCUSSION
Patients with ARDS triggered by viral infection, in particular influenza, are prone to invasive aspergillosis even in absence of prior immunodeficiency. 2 ,  3  We report putative IPA in five of 19 COVID‐19 patients with moderate to severe ARDS without underlying immunocompromising disease on two separate ICUs.
Spontaneous intrapulmonary bleeding and haemoptysis are typical complications of IPA. Ground‐glass opacities characterise COVID‐19 as well as IPA, thus comprehensive microbiological evaluation can prevent missing IPA.
By applying strict interpretation of the host and risk factors for invasive aspergillosis according to the European Organization for Research and Treatment of Cancer/Mycoses Study Group definitions the risk of missed diagnosis increases in the COVID‐19 population. 8  However, a most complicated issue in ARDS patients is to differentiate Aspergillus colonisation from invasive disease—especially as radiological imaging is non‐specific. To address this issue, a consensus project will seek to provide standard definitions for invasive fungal disease in critically ill adult patients. 10
Our observations suggest increased risk for critically ill COVID‐19 patients to develop co‐infection with Aspergillus, which is likely to increase mortality rates further. Therefore, testing for the presence of Aspergillus in lower respiratory secretions and galactomannan in consecutive serum samples in COVID‐19 ICU patients should be considered. 11
Our findings need to be confirmed in clinical trials to elucidate the role of potential IPA after COVID‐19. With this report, we aim to call attention to the critical phenomenon of COVID‐19 associated IA in ARDS patients.