COVID-19–Associated Pulmonary Aspergillosis, March–August 2020

Jon Salmanton-García; Rosanne Sprute; Jannik Stemler; Michele Bartoletti; Damien Dupont; Maricela Valerio; Carolina Garcia-Vidal; Iker Falces-Romero; Marina Machado; Sofía de la Villa; Maria Schroeder; Irma Hoyo; Frank Hanses; Kennio Ferreira-Paim; Daniele Roberto Giacobbe; Jacques F. Meis; Jean-Pierre Gangneux; Azucena Rodríguez-Guardado; Spinello Antinori; Ertan Sal; Xhorxha Malaj; Danila Seidel; Oliver A. Cornely; Philipp Koehler


Emerging Infectious Diseases. 2021;27(4):1077-1086. 

In This Article

Abstract and Introduction


Pneumonia caused by severe acute respiratory syndrome coronavirus 2 emerged in China at the end of 2019. Because of the severe immunomodulation and lymphocyte depletion caused by this virus and the subsequent administration of drugs directed at the immune system, we anticipated that patients might experience fungal superinfection. We collected data from 186 patients who had coronavirus disease–associated pulmonary aspergillosis (CAPA) worldwide during March–August 2020. Overall, 182 patients were admitted to the intensive care unit (ICU), including 180 with acute respiratory distress syndrome and 175 who received mechanical ventilation. CAPA was diagnosed a median of 10 days after coronavirus disease diagnosis. Aspergillus fumigatus was identified in 80.3% of patient cultures, 4 of which were azole-resistant. Most (52.7%) patients received voriconazole. In total, 52.2% of patients died; of the deaths, 33.0% were attributed to CAPA. We found that the cumulative incidence of CAPA in the ICU ranged from 1.0% to 39.1%.


Cases of pneumonia caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) were first described in Wuhan, China, at the end of December 2019.[1] The infection rapidly spread, causing the coronavirus disease (COVID-19) pandemic.[2]

Because SARS-CoV-2 and treatments such as dexamethasone or tocilizumab can impair the immune system, some researchers anticipated the possibility of fungal superinfection among COVID-19 patients.[3–6] As of August 2020, researchers have documented COVID-19–associated pulmonary aspergillosis (CAPA),[7–9] invasive candidiasis,[10] coccidioidomycosis,[11] fusariosis,[12] histoplasmosis,[13] mucormycosis,[14] pneumocystosis,[15] and saccharomycosis.[16] Varying cumulative rates of CAPA have been described, including rates of 0.7%–7.7% among COVID-19 patients,[17,18] 2.5%–39.1% among ICU patients with COVID-19,[19,20] and 3.2%–29.6% among COVID-19 patients on mechanical ventilation.[7,17] Many of these patients lack the concurrent conditions usually associated with invasive pulmonary aspergillosis (IPA) such as malignancies, neutropenia, or history of allogeneic stem cell or solid organ transplantation.[21] Admission to the ICU or severe influenza are also risk factors for IPA in nonneutropenic patients.[22–25] Reports of CAPA have been mostly limited to a few single-center studies; therefore, a comprehensive analysis of international distribution currently is lacking.[4]

We analyzed reports in the literature (;[26–50] references 51–54 in Appendix and the FungiScope registry (reference 55 in Appendix) to describe baseline conditions, clinical management, and associated deaths in CAPA patients. This analysis also contextualizes the available cumulative incidences.