This was a retrospective study, conducted in Shanghai Public Health Clinical Center, a tertiary care hospital specializing in infectious diseases, especially hepatic diseases. Between November 2005 and February 2007, a total of 276 patients with hepatic failure were admitted. Medical and microbiological records as well as the chest radiographic imaging of all patients with hepatic failure and accompanying lung infection were reviewed. Patients' demography, duration of admission, predisposing factors, clinical features, investigations, treatment and outcome were noted.
Standardized criteria from European Organization for Research and Treatment of Cancer and the Mycosis Study Group of the National Institute of Allergy and Infectious Disease (EORTC/MSG) [7] were applied for the diagnosis of definite and probable IPA. Definite IPA was defined as the demonstration of filamentous fungi by microscopy from tissue samples with or without a positive culture for Aspergillus. Probable IPA was defined as the demonstration of filamentous fungi compatible with the morphology of Aspergillus and/or a positive culture for Aspergillus from bronchoalveolar lavage (BAL) specimen in patients in conjunction with 1 major (halo or "air crescent" on computed tomography (CT) scan) or at least two minor (signs of lower respiratory tract infection, pleural rub, and presence of any new infiltrate in a patient who did not fulfill the major criterion but for whom no alternative diagnosis was available) clinical findings. IPA developing after 48 hours of hospital admission and before the clinical diagnosis of fungal infection was considered nosocomial; otherwise, the fungal infection was regarded as community acquired.
Serological diagnosis, such as galactomannan or β-d-glucan, are not performed in Shanghai Public Health Clinical Center; thoracic CT imaging combined with the patient's condition despite antibiotic treatment was the main approach for preliminary diagnosis of IPA. In brief, appearance of pulmonary consolidation or infiltrate and rapid progression on thoracic CT scan with antibiotic resistant fever in the appropriate host setting was diagnosed as suspected IPA. Single-bed hospital room was provided for the patient with high index of suspicion of IPA. In patients with pulmonary infiltrates, especially those with diffuse pulmonary infiltrates, fiberoptic bronchoscopy with BAL and/or transbronchial lung biopsy (TBLB) was performed. In patients with focal pulmonary lesions, percutaneous puncture lung biopsy (PPLB) was considered the first-line diagnostic tool. BAL or lung biopsy was performed at the request of the treating physician with informed consent.
Thoracic CT scan was performed early in patients suspected of having IPA, and twice a week for early detection of IPA or preliminary evaluation of antifungal therapy. Results of chest X-ray and thoracic CT scan were described as normal, grand gross attenuation, non-specific infiltrates and consolidation, pleural fluid, nodular lesion(s), halo sign, air-crescent sign, and cavitation. The CT halo sign is described as a surrounding halo of ground glass attenuation surrounding a pulmonary nodule or mass and corresponds to a central fungal nodule surrounded by a rim of hemorrhage and coagulative necrosis. The air-crescent sign is described as a pulmonary cavitation [8].
All continuous data were expressed either as mean and standard deviation (SD), or median and range based on the distribution.
The study was approved by the Research Ethics Committee, Shanghai Public Health Clinical Center, Fudan University.