Invasieve aspergillose op de intensive care: Een lastige en vaak te laat gestelde diagnose

Although it is widely recognized that critically ill patients in the ICU are at high risk for nosocomial infections, it is not generally appreciated that such patients may also be at risk for opportunistic infections usually seen only in immuno-compromised patients. The reason for this is that the immune response in patients with sepsis and multiple organ failure may be biphasic: an initial phase characterized by a massive inflammatory, response and cytokine release, followed by a dwindling immune response and monocyte deactivation. This phenomenon has been named compensatory anti-inflammatory response syndrome (CARS), or immunoparalysis. We describe three patients admitted to our ICU for various reasons, without a history of abnormal immune function prior to ICU admission, who developed invasive pulmonary aspergillosis in the course of their ICU stay. Despite significant co-morbidity, the infective aspergillosis seems a plausible multifactorial aspect in the etiology of each of the patient's fatal events. The diagnosis was difficult to establish in part because aspergillosis was considered highly unlikely in these patients, who where thought to have normal immune function. Physicians treating patients with multiple organ dysfunction (MODS) in the ICU should be aware that rare opportunistic injections such as invasive aspergillosis may occur in these patients due to the CARS-syndrome. Critically ill patients with MODS should be viewed as at least partially immuno-compromised.