Coinfections of Viruses, Bacteria and Fungi Common and may be more deadly.
The Recent Emergence of Coronavirus Infections have killed thousands of people worldwide and has caused a great deal of fear. Many human viral, bacterial, and fungal infections occur simultaneously and the presence of more than one pathogen increases the morbidity and mortality of the infections.
For example, as reported earlier in this column, tuberculosis (TB) often coinfects with fungi in the same patient and such coinfections often have a higher mortality rate than either infection individually. A meta-analysis of 17 published studies involving 2,286 TB patients- including 352 with Aspergillus coinfection estimated the occurrence of Aspergillus/ TB coinfection of 15.4% (95% Confidence Interval 11.4-20.5%) (1). A 2020 French study found Aspergillus lung coinfection in 50 out of 140 patients, a 35.7% Coinfection rate (2). Aspergillus/ TB coinfections have increased mortality rates as compared to TB infections alone. A Japanese study of 329 TB patients reported that coinfection with Aspergillus (40 coinfections in all) were associated with a more than 4 fold higher mortality rate as compared to TB infections alone (HR 4.728, 95% CI of 2.033- 11.00, p<0.001) (3)
Coinfections of Coronavirus and Fungi fairly common.
Several reports have reported coninfection of coronavirus with common fungal infections . A report of 99 patients hospitalized with coronavirus in Wuhan, China reported that 5 had significantly coninfection with fungi, including 3 with Candida albicans, 1 with Candida glabrata, and 1 with Aspergillus flavus (4). A 2005 study of 20 patients who died of coronavirus related SARS infection reported that 2 (10%) had serious coninfection with Aspergillus (5). It is not known if such coinfections of coronavirus and fungi have higher mortality rates.
Coinfections of coronavirus with other viruses are also common and have been associated with worse outcome. A study of 236 hospitalized Brazilian children found that combined infections of coronaviruses and rhiboviruses (found in about 11% of the patients) was associated with a significantly increased risk of severe infections requiring PICU (pediatric intensive care unit) admissions (6).
Much more research is need to determine possible relationships of coinfection of coronavirus with other viruses, bacteria, and fungi.
Research and References:
1. Hosseini M, Shakerimoghaddam A, Ghazalibina M, Khaledi A. Aspergillus coinfection among patients with pulmonary tuberculosis in Asia and Africa countries; A systematic review and meta-analysis of cross-sectional studies. Microb Pathog. 2020:104018.
2. Delliere S, Angebault C, Fihman V, Foulet F, Lepeule R, Maitre B, et al. Concomitant Presence of Aspergillus Species and Mycobacterium Species in the Respiratory Tract of Patients: Underestimated Co-occurrence? Frontiers in microbiology. 2019;10:2980.
3. Furuuchi K, Ito A, Hashimoto T, Kumagai S, Ishida T. Clinical significance of Aspergillus species isolated from respiratory specimens in patients with Mycobacterium avium complex lung disease. European journal of clinical microbiology & infectious diseases : official publication of the European Society of Clinical Microbiology. 2018;37(1):91-8.
4. Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020;395(10223):507-13.
5. Hwang DM, Chamberlain DW, Poutanen SM, Low DE, Asa SL, Butany J. Pulmonary pathology of severe acute respiratory syndrome in Toronto. Modern pathology : an official journal of the United States and Canadian Academy of Pathology, Inc. 2005;18(1):1-10.
6. Matsuno AK, Gagliardi TB, Paula FE, Luna LKS, Jesus BLS, Stein RT, et al. Human coronavirus alone or in co-infection with rhinovirus C is a risk factor for severe respiratory disease and admission to the pediatric intensive care unit: A one-year study in Southeast Brazil. PLoS One. 2019;14(6):e0217744.