The criteria for proven disease include a patient fulfilling the entry criterion plus histological evidence of invasive fungal elements and mycological evidence for the presence of Aspergillus (obtained by Aspergillus PCR or culture from tissue). Tracheobronchitis (tracheal and/or bronchial ulcerations or nodules, pseudomembranes or plaques visualized at bronchoscopy), as also described in the EORTC/MSGERC definitions [10], is a separate entity. Although a tissue biopsy would normally be required to prove a case of IAPA, in tracheobronchitis cases hyphal elements suggestive of Aspergillus seen on sloughed-off pseudomembrane, and Aspergillus identified on culture or PCR, can also be considered proven disease (Table 1).
Table 1 Proposed case definition for IAPA in ICU patients
Entry criteria: influenza-like illness + positive influenza PCR or antigen + temporally relationship
Aspergillus tracheobronchitis IAPA in patients without documented Aspergillus tracheobronchitis
Proven Biopsy or brush specimen of airway plaque, pseudomembrane or ulcer showing hyphal elements and Aspergillus growth on culture or positive Aspergillus PCR in tissue Lung biopsy showing invasive fungal elements and Aspergillus growth on culture or positive Aspergillus PCR in tissue
Probable Airway plaque, pseudomembrane or ulcer
and at least one of the following:
Serum GM index > 0.5
or
BAL GM index ≥ 1.0
or
Positive BAL culture
or
Positive tracheal aspirate culture
or
Positive sputum culture
or
Hyphae consistent with Aspergillus A: Pulmonary infiltrate
and at least one of the following:
Serum GM index > 0.5
or
BAL GM index ≥ 1.0
or
Positive BAL culture
OR
B: Cavitating infiltrate (not attributed to another cause)
and at least one of the following:
Positive sputum culture
or
Positive tracheal aspirate culture