# Features of Invasive Aspergillosis Caused by Aspergillus flavus, France, 2012–2018

Lise Bertin-Biasutto, Olivier Paccoud, Dea Garcia-Hermoso, Blandine Denis, Karine Boukris-Sitbon, Olivier Lortholary, Stéphane Bretagne, Maud Gits-Muselli, Raoul Herbrecht, Valérie Letscher-Bru, et al.

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Lise Bertin-Biasutto, Olivier Paccoud, Dea Garcia-Hermoso, Blandine Denis, Karine Boukris-Sitbon, et al.. Features of Invasive Aspergillosis Caused by Aspergillus flavus, France, 2012–2018. Emerging Infectious Diseases, 2025, 31 (5), pp.896-905. 10.3201/eid3105.241392. hal-05169425

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# Features of Invasive Aspergillosis Caused by Aspergillus flavus, France, 2012–2018

Lise Bertin-Biasutto, Olivier Paccoud, Dea Garcia-Hermoso, Blandine Denis, Karine Boukris-Sitbon, Olivier Lortholary, Stéphane Bretagne, Maud Gits-Muselli, Raoul Herbrecht, Valérie Letscher-Bru, François Danion, Sophie Cassaing, Florent Morio, Céline Nourrisson, Marc Pihet, Milène Sasso, Guillaume Desoubeaux, Marie-Fleur Durieux, Julie Bonhomme, Elisabeth Chachaty, Taieb Chouaki, Nicole Desbois-Nogard, Alexandre Alanio,¹ Jean-Pierre Gangneux,¹ Fanny Lanternier

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## Authors

Lise Bertin-Biasutto, MD; Olivier Paccoud, MD; Dea Garcia-Hermoso, PhD; Blandine Denis, MD, PhD; Karine Boukris-Sitbon, MD; Olivier Lortholary, MD, PhD; Stéphane Bretagne, MD, PhD; Maud Gits-Muselli, MD, PhD; Raoul Herbrecht, MD, PhD; Valérie Letscher-Bru, PharmD, PhD; François Danion, MD, PhD; Sophie Cassaing, MD, PhD; Florent Morio, PharmD, PhD; Céline Nourrisson, MD; Marc Pihet, MD; Milène Sasso, MD; Guillaume Desoubeaux, MD, PhD; Marie-Fleur Durieux, MD; Julie Bonhomme, MD; Elisabeth Chachaty, PharmD, PhD; Taieb Chouaki, PharmD; Nicole Desbois-Nogard, MD, PhD; Alexandre Alanio, MD, PhD; Jean-Pierre Gangneux, MD, PhD; Fanny Lanternier, MD, PhD.
Invasive aspergillosis (IA) caused by *Aspergillus flavus* remains poorly described. We retrospectively analyzed 54 cases of IA caused by *A. flavus* reported in France during 2012–2018. Among cases, underlying IA risk factors were malignancy, solid organ transplantation, and diabetes. Most (87%, 47/54) infections were localized, of which 33 were pleuropulmonary and 13 were ear-nose-throat (ENT) infection sites. Malignancy (70% [23/33]) and solid organ transplantation (21% [7/33]) were the main risk factors in localized pulmonary infections, and diabetes mellitus was associated with localized ENT involvement (61.5%, [8/13]). Fungal co-infections were frequent in pulmonary (36%, 12/33) but not ENT IA (0 cases). Antifungal monotherapy was prescribed in 45/50 (90%) cases, mainly voriconazole (67%, 30/45). All-cause 30-day case-fatality rates were 39.2% and 90-day rates were 47.1%, and rates varied according to risk factor, IA site, and fungal co-infections. Clinicians should remain vigilant for *A. flavus* and consider it in the differential diagnosis for IA.

After invasive candidiasis and pneumocystosis, invasive aspergillosis (IA) is the third most frequent invasive fungal infection in Europe. IA occurs primarily in immunocompromised patients, including those with a hematologic malignancy (HM) and those who receive solid organ transplants or immunosuppressive treatments (1). After *A. fumigatus*, *A. flavus* is the second most frequently reported *Aspergillus* species isolated from clinical specimens in invasive and noninvasive aspergillosis, but *A. flavus* IA has marked differences in infection sites and geographic locations. Indeed, *A. flavus* is reported as the main etiologic agent of sinusitis, keratitis, and invasive aspergillosis in the Middle East, northern Africa, and South Asia (2–4). In stark contrast, *A. flavus* accounts for <10% of IA cases reported in Europe and North America (5,6). For instance, according to data from the Fungal Infection Surveillance Network (RESSIF; RESeau de Surveillance des Infections Fongiques)

in France, *A. flavus* represented 8.7% (74/845) of all IA during 2012–2018, second only to the 86% of IA caused by *A. fumigatus*.

Data regarding the epidemiology, risk factors, clinical manifestations, and management of IA caused by *A. flavus* remain scarce, particularly in Europe. We sought to describe patient characteristics, underlying conditions, clinical presentations, and outcomes of IA cases caused by *A. flavus* reported in France.

## Material and Methods

### Database Management and Case Definition

The RESSIF (1,7), based at the French National Reference Center for Invasive Mycoses and Antifungals (NRCMA), Institut Pasteur, Paris, is a nationwide surveillance network for cases of invasive mycoses in France. RESSIF relies on the active participation of 21 collaborative centers in 15 of the 18 regions of France, including overseas territories. Case details are sent to the NRCMA by referent medical mycologists in collaboration with clinicians.

We included all patients registered in RESSIF during 2012–2018 with proven or probable IA caused by *A. flavus*, according to the 2020 European Organization for Research and Treatment of Cancer/Mycoses Study Group Education and Research Consortium criteria (8), which include diabetes mellitus and severe burns as additional risk factors for probable IA. We excluded cases for which data were unavailable and cases of noninvasive aspergillosis (e.g., aspergiloma). We considered the date of IA diagnosis to be the date of the first microbiological criteria leading to diagnosis.

### Data Collection and Classification

Data were collected by using a standardized case report form that included patient demographic characteristics, clinical and radiologic manifestations, time

Author affiliations: Hopital Necker-Enfants Malades, Paris, France (L. Bertin-Biasutto, O. Paccoud, O. Lortholary, F. Lanternier); Université de Paris, Paris (L. Bertin-Biasutto, O. Lortholary, F. Lanternier); Institut Pasteur, Paris (D. Garcia-Hermoso, K. Boukris-Sitbon, O. Lortholary, S. Bretagne, A. Alanio, F. Lanternier); Hôpital Saint Louis, Paris (B. Denis, S. Bretagne, M. Gits-Muselli, A. Aliano); Institut de Cancérologie de Strasbourg, Strasbourg, France (R. Herbrecht); Hôpitaux Universitaires de Strasbourg, Strasbourg (V. Letscher-Bru, F. Danion); Toulouse University Hospital, Toulouse, France (S. Cassaing); Nantes University Hospital, Nantes, France (F. Morio); CHU Clermont-Ferrand, Clermont-Ferrand, France (C. Nourrisson); CHU d'Angers, Angers, France (M. Pihet); CHU Nîmes and Université

de Montpellier, Nîmes, France (M. Sasso); Hôpital Bretonneau, Tours, France (G. Desoubeaux); Limoges University, Limoges, France (M.-F. Durieux); Unicaen Université Normandie, Caen, France (J. Bonhomme); Gustave Roussy, Villejuif, France (E. Chachaty); CHU Amiens-Picardie, Amiens, France (T. Chouaki); Inserm U1285, University of Lille, Lille, France (T. Chouaki); Centre Hospitalier Universitaire de Martinique, Fort-de-France, France (N. Desbois-Nogard); Université de Rennes, CHU Rennes, Rennes, France (J.-P. Gangneux); Rennes Teaching Hospital, Rennes (J.-P. Gangneux)

DOI: https://doi.org/10.3201/eid3105.241392

<footnote n="1">¹These authors contributed equally to this article.</footnote>
from symptom onset to diagnosis, diagnostic methods, treatment regimen, and 30- and 90-day case-failure rates (CFRs). We assigned each patient to 1 of 6 main underlying condition categories: HM, including acute leukemia (myeloid or lymphoid) and other lymphoid malignancies; solid organ tumors; solid organ transplant; diabetes mellitus; severe burns; other risk factors, such as HIV and iatrogenic agranulocytosis; or no risk factors, in the absence of all other conditions. For patients with multiple potential risk factors, we prioritized HM and solid organ transplantation. We considered patients with HM, solid organ tumors under chemotherapy treatment, solid organ transplants, and other risk factors to be severely immunocompromised and grouped them for statistical comparisons; we did not include patients with severe burns in that group because, although immunocompromised, those case-patients have specific features. We considered patients with diabetes moderately immunocompromised and considered patients without risk factors to be immunocompetent.

We defined dissemination as infection in ≥2 non-contiguous sites. We separated localized IA into pleuropulmonary, ear-nose-throat (ENT), central nervous system (CNS), and skin disease. We considered cases with ENT and skull base infection sites as localized ENT infections with contiguous skull base extension. We considered cases with pleuropulmonary and ENT sites of infection as localized pulmonary infections with a contiguous sinus localization. We defined neutropenia as a neutrophil polymorphonuclear cell count of <0.5 × 10⁶ cells/mL. We considered positive galactomannan (GM) antigen in blood samples only, with a positivity threshold of ≥0.5 optical density. We defined bacterial, viral, or fungal co-infections as microbial pathogens found in the same microbiological samples as *A. flavus* at time of diagnosis and compatible with the patient's clinical manifestations.

Because *A. flavus* has higher prevalence in dry and warm regions (2-4), we evaluated seasonality of infections in France. We chose April 1-October 31 as the warmest months of the year in France, with average temperatures of ≥14°C, compared with November 1-March 31, during which average temperatures were <10°C, according to the 2018 report from the national meteorological organization in France (9).

## Species Identification and Antifungal Susceptibility Testing

NRCMA centralized all isolates for identification confirmation. NMRCA identified *A. flavus* by morphology and partial DNA sequence analysis of the calmodulin gene. We only retained *A. flavus* var. *flavus*.

We performed in vitro susceptibility testing according to the European Committee on Antimicrobial Susceptibility Testing (EUCAST) broth microdilution method (https://www.eucast.org/fileadmin/src/media/PDFs/EUCAST_files/AFST/Files/EUCAST EDef_9.4_method_for_susceptibility_testing_of_moulds.pdf) with some modifications. NRCMA determined MICs for 7 antifungal agents, including liposomal amphotericin B (L-AmB), isavuconazole, voriconazole, posaconazole, itraconazole, caspofungin, and micafungin.

## Statistical Analyses

We calculated continuous variables by using Mann-Whitney nonparametric test and expressed results as medians and interquartile range (IQRs). We used Fisher exact test for categorical variables and expressed results as frequencies and percentages. We performed all analyses in Stata 17 (StataCorp LLC, https://www.stata.com) and considered p<0.05 to be statistically significant.

## Ethics

This research was performed in compliance with French law and the Declaration of Helsinki as adopted in 2000. NRCMA monitoring was approved by the Institute Pasteur institutional review board 1 (approval no. 2009-34 IRB) and the Commission Nationale de l'Informatique et des Libertés (National Commission for Information Technology and Civil Liberties) according to regulations in France.

## Results

### Patient Characteristics and Underlying Conditions

During January 2012-December 2018, a total of 54 patients with proven (44.4%) or probable (55.6%) IA caused by *A. flavus* were reported to RESSIF. Median patient age was 58 (IQR 48-70) years; 48.1% were male and 51.8% were female (Table 1). The main underlying condition was HM (53.7%, 29/54), most frequently acute leukemia (20/54, including 10 with acute myeloid leukemia and 10 with acute lymphoid leukemia) (Table 1). Almost all (90%, 26/29) HM patients had neutropenia at diagnosis. The second most frequent underlying condition was solid organ transplant (16.7%, 9/54), including kidney (n = 3), heart (n = 3), lung (n = 2), and liver (n = 1) transplantation. Median time between transplantation and IA was 5 months, with differences according to the type of organ transplant, from 1 month for heart transplant recipients to 36 months for kidney transplant recipients. Eight (14.8%) patients had diabetes mellitus as
<table><caption>**Table 1.** Characteristics of 54 patients with probable or proven invasive aspergillosis caused by *Aspergillus flavus*, France, 2012–2018*</caption><thead><tr><th>Characteristics</th><th>Value</th></tr></thead><tbody><tr><td>Median age, y (IQR)</td><td>58 (48–70)</td></tr><tr><td>Originating from Africa, n = 50</td><td>14 (28)</td></tr><tr><td>Diagnosis during April 1–Oct 31</td><td>32 (59.2)</td></tr><tr><td>Sex</td><td></td></tr><tr><td>M</td><td>26 (48.1)</td></tr><tr><td>F</td><td>28 (51.8)</td></tr><tr><td>Primary underlying risk factor</td><td></td></tr><tr><td>Malignancy</td><td>31 (57.4)</td></tr><tr><td>Solid organ cancer</td><td>2 (3.7)</td></tr><tr><td>Hematologic malignancy, n = 29</td><td>29 (54)</td></tr><tr><td>Acute myeloid leukemia</td><td>10 (34.5)</td></tr><tr><td>Acute lymphoid leukemia</td><td>10 (34.5)</td></tr><tr><td>Lymphoma</td><td>2 (6.9)</td></tr><tr><td>Chronic lymphoid leukemia</td><td>2 (6.9)</td></tr><tr><td>Other hematologic malignancy</td><td>5 (17.2)</td></tr><tr><td>Solid organ transplant, n = 9</td><td>9 (16.7)</td></tr><tr><td>Kidney</td><td>3 (33.3)</td></tr><tr><td>Heart</td><td>3 (33.3)</td></tr><tr><td>Lung</td><td>2 (22.2)</td></tr><tr><td>Liver</td><td>1 (11.1)</td></tr><tr><td>Diabetes mellitus</td><td>8 (14.8)</td></tr><tr><td>Severe burns</td><td>2 (3.7)</td></tr><tr><td>Other immunodeficiency, n = 2</td><td>2 (3.7)</td></tr><tr><td>HIV</td><td>1 (50)</td></tr><tr><td>Iatrogenic agranulocytosis</td><td>1 (50)</td></tr><tr><td>No risk factor</td><td>2 (3.7)</td></tr><tr><td>Median time between onset of symptoms and diagnosis, d (IQR)</td><td>20 (10–50)</td></tr><tr><td>Site of infection</td><td></td></tr><tr><td>Localized infections, n = 47</td><td>47 (87)</td></tr><tr><td>Pulmonary†</td><td>33 (70.2)</td></tr><tr><td>Ear-nose-throat†</td><td>13 (27.7)</td></tr><tr><td>Cerebral contiguous extension‡</td><td>10 (21.3)</td></tr><tr><td>Skin and soft tissue</td><td>1 (2.1)</td></tr><tr><td>Disseminated infections, n = 7</td><td>7 (13)</td></tr><tr><td>Pulmonary</td><td>6 (85.7)</td></tr><tr><td>Ear-nose-throat</td><td>2 (28.8)</td></tr><tr><td>Cerebral</td><td>2 (28.8)</td></tr><tr><td>Skin and soft tissue</td><td>5 (71.4)</td></tr><tr><td>Fungemia</td><td>2 (28.6)</td></tr><tr><td>Positive serum galactomannan antigen, n = 38</td><td>23 (60.5)</td></tr><tr><td>Proven infection</td><td>24 (44.4)</td></tr><tr><td>Fungal coinfection at same site as A. flavus, n = 16§</td><td>16 (29.7)</td></tr><tr><td>A. fumigatus</td><td>6 (37.5)</td></tr><tr><td>A. niger</td><td>3 (18.8)</td></tr><tr><td>Mucorales</td><td>5 (31.2)</td></tr><tr><td>Pneumocystis jirovecii</td><td>3 (18.8)</td></tr><tr><td>Candidemia</td><td>1 (6.2)</td></tr><tr><td>Influenza coinfection</td><td>2 (3.7)</td></tr><tr><td>First-line antifungal therapy, including combinations, n = 50</td><td></td></tr><tr><td>Voriconazole</td><td>32 (64)</td></tr><tr><td>Posaconazole</td><td>3 (6)</td></tr><tr><td>Itraconazole</td><td>2 (4)</td></tr><tr><td>Isavuconazole</td><td>2 (4)</td></tr><tr><td>Liposomal amphotericin B</td><td>9 (18)</td></tr><tr><td>Echinocandin</td><td>7 (14)</td></tr><tr><td>Antifungal combination</td><td>5 (10)</td></tr><tr><td>Death, n = 51 patients with outcome data</td><td></td></tr><tr><td>30-day case-fatality, all causes</td><td>20 (39.2)</td></tr><tr><td>90-day case-fatality, all causes</td><td>24 (47.1)</td></tr></tbody></table>

<footnote>*Values are no. (%) patients except as indicated.</footnote>

<footnote>†Four patients had lung and ear-nose-throat infections.</footnote>

<footnote>‡All were sinus infections with contiguous cerebral lesions.</footnote>

<footnote>§Including 1 case with 3 fungal co-infections.</footnote>
<table><caption>**Table 2.** Main underlying risk factors for 54 patients with probable or proven invasive aspergillosis caused by *Aspergillus flavus*, France, 2012–2018*</caption><thead><tr><th>Characteristics</th><th>HM, n = 29</th><th>SOC, n = 2</th><th>SOT, n = 9</th><th>DM, n = 8</th><th>Other, n = 2</th><th>Severe burns, n = 2</th><th>No risk factors, n = 2</th><th>p value†</th></tr></thead><tbody><tr><td>Median age, y (IQR)</td><td>53 (28–66)</td><td>73 (66–80)</td><td>60 (57–70)</td><td>72.5 (70–74)</td><td>49 (48–50)</td><td>60 (50–69)</td><td>21 (16–25)</td><td><strong>&lt;0.001</strong></td></tr><tr><td>Originating from Africa, n = 26</td><td>5/26 (19.2)</td><td>0</td><td>2/8 (25)</td><td>5 (62.5)</td><td>0</td><td>0</td><td>2 (100)</td><td><strong>0.02</strong></td></tr><tr><td>Sex</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>M</td><td>12 (41.4)</td><td>1 (50)</td><td>5 (55.6)</td><td>5 (62.5)</td><td>1 (50)</td><td>0</td><td>1 (50)</td><td>0.46</td></tr><tr><td>F</td><td>17 (58.6)</td><td>1 (50)</td><td>4 (44.4)</td><td>3 (37.5)</td><td>1 (50)</td><td>2 (100)</td><td>1 (50)</td><td>0.46</td></tr><tr><td>Median delay to diagnosis, d (IQR)</td><td>17 (5–30)</td><td>5 (2–7)</td><td>20 (13.5–54)</td><td>105 (68–163)</td><td>32 (20–43)</td><td>7 (5–9)</td><td>NA</td><td><strong>&lt;0.001</strong></td></tr><tr><td>Neutropenia‡§</td><td>26 (89.6)</td><td>0</td><td>1/8 (12)</td><td>0</td><td>1 (50)</td><td>0</td><td>0</td><td><strong>&lt;0.001</strong></td></tr><tr><td>Positive serum galactomannan antigen§</td><td>15/22 (68.1)</td><td>1/1 (100)</td><td>3/7 (43)</td><td>2/4 (50)</td><td>1 (50)</td><td>1 (50)</td><td>0</td><td>0.63</td></tr><tr><td>Infection site</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Disseminated infection</td><td>4 (13.7)</td><td>1 (50)</td><td>1 (11.1)</td><td>0</td><td>0</td><td>1 (50)</td><td>0</td><td>0.57</td></tr><tr><td>Localized infection</td><td>25 (86.2)</td><td>1 (50)</td><td>8 (88.9)</td><td>8 (100)</td><td>2 (100)</td><td>1 (50)</td><td>2 (100)</td><td>0.57</td></tr><tr><td>Pleuropulmonary</td><td>23/25 (92)</td><td>0</td><td>7/8 (87.5)</td><td>0</td><td>2 (100)</td><td>0</td><td>1 (50)</td><td><strong>&lt;0.001</strong></td></tr><tr><td>ENT</td><td>2/25 (8)</td><td>1/1 (100)</td><td>1/8 (12.5)</td><td>8/8 (100)</td><td>0</td><td>0</td><td>1 (50)</td><td><strong>&lt;0.001</strong></td></tr><tr><td>CNS</td><td>0</td><td>1/1 (100)</td><td>1/8 (12.5)</td><td>7/8 (87.5)</td><td>0</td><td>0</td><td>1 (50)</td><td><strong>&lt;0.001</strong></td></tr><tr><td>Skin and soft tissue</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>1 (100)</td><td>0</td><td>&gt;0.999</td></tr><tr><td>First-line antifungal therapy¶</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Voriconazole</td><td>18 (66.7)</td><td>2 (100)</td><td>3 (4.8)</td><td>6/8 (75)</td><td>1 (50)</td><td>1 (50)</td><td>1 (50)</td><td>0.69</td></tr><tr><td>L-AmB</td><td>5 (18.5)</td><td>0</td><td>2 (28.6)</td><td>0/8 (0)</td><td>1 (50)</td><td>1 (50)</td><td>0</td><td>0.32</td></tr><tr><td>Other agent</td><td>6 (22.2)</td><td>0</td><td>2 (28.6)</td><td>3/8 (37.5)</td><td>1 (50)</td><td>0</td><td>1 (50)</td><td>0.41</td></tr><tr><td>Death</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>30-d CFR</td><td>13 (46.4)</td><td>0</td><td>4 (44.4)</td><td>0</td><td>1 (50)</td><td>2 (100)</td><td>0</td><td><strong>0.017</strong></td></tr><tr><td>90-d CFR</td><td>15 (53.6)</td><td>0</td><td>5 (55.6)</td><td>1 (12.5)</td><td>1 (50)</td><td>2 (100)</td><td>0</td><td>0.052</td></tr></tbody></table>

the sole risk factor. The other patients had solid organ tumors under chemotherapy (n = 2), severe burns (n = 2), HIV infection (n = 1), or carbimazole-induced agranulocytosis (n = 1); 2 patients had no identified risk factors.

Patients with diabetes were significantly older (median age 72.5 [IQR 70–74] years) than patients with malignancy, either HM or solid organ cancer (median age 54 [IQR 32–66] years), or solid organ transplantation (median age 60 [IQR 53.5–70.5] years) (p<0.001) (Table 2). Patients with diabetes also had longer time between symptom onset and diagnosis (median 105 [IQR 68–163] days) than HM patients (median 16 [IQR 5–30] days) or patients with solid organ transplant (median 20 [IQR 13.5–54] days). Pleuropulmonary involvement was more frequent in patients with HM, solid organ tumors, or solid organ transplant (88%, 30/34) than those with diabetes (0/8) (p<0.001). In contrast, all 8 patients with diabetes mellitus had ENT infections, and most (88%, 7/8) had extension to the skull bases, but ENT infections were much less frequent (12%, 4/34) among HM,

solid organ tumor, and solid organ transplant patients (p<0.001). We noted no cases of disseminated IA in patients with diabetes, compared with 5 cases (16%, 5/31) in HM patients and 1 (11%, 1/16) case in a solid organ transplant patient (p = 0.57).

## Infection Sites and Clinical Manifestations

Of the 54 cases, 47 (87%) were localized (Table 3) and 7 (12.3%) disseminated (Table 4). Among the 47 localized infections, 33 were (70.2%) pleuropulmonary infections and 13 (27.6%) were ENT infections; 10 (77%) of the ENT infections had extension to the skull bases. No isolated CNS infections and only 1 case of localized skin and soft tissue infection were reported.

Compared with patients with pleuropulmonary IA, those with ENT infections were significantly older (median age 72 [IQR 61–74] years vs. 57 [IQR 48–67] years; p = 0.03) and had a longer duration of symptoms before diagnosis (median 90 [IQR 42–163] days vs. 19 [IQR 12–30] days; p = 0.0005). Patients with pleuropulmonary IA had higher rates of HM and solid organ transplantation than patients with

<footnote>*Values are no. (%) except as indicated. Bold font indicates statistical significance. CFR, case-fatality rate; CNS, central nervous system; DM, diabetes mellitus; ENT, ear-nose-throat; HM, hemolytic malignancy; IQR, interquartile range; L-AmB, liposomal amphotericin B; NA, not applicable; SOC, solid organ cancer; SOT, solid organ transplant.</footnote>

<footnote>†For solid organ transplant, solid organ cancer, hemolytic malignancy, and other versus diabetes mellitus.</footnote>

<footnote>‡<0.5 × 10³ cells/mL.</footnote>

<footnote>§No. positive/no. tested (%).</footnote>

<footnote>¶Including combination therapy. Other first-line agents included posaconazole, itraconazole, isavuconazole, and echinocandin.</footnote>
<table><caption>**Table 3.** Characteristics of localized invasive aspergillosis cases caused by *Aspergillus flavus*, France, 2012–2018*</caption><thead><tr><th>Characteristics</th><th>Localized pleuropulmonary<br>infection, n = 33</th><th>Localized ENT infection, n = 13</th><th>p value</th></tr></thead><tbody><tr><td>Median age, y (IQR)</td><td>57 (48–67)</td><td>72 (61–74)</td><td><strong>0.03</strong></td></tr><tr><td>Originating from Africa</td><td>6/29 (21)</td><td>7/13 (54)</td><td>0.068</td></tr><tr><td>Sex</td><td></td><td></td><td></td></tr><tr><td>M</td><td>16 (48.5)</td><td>7 (53.8)</td><td>&gt;0.999</td></tr><tr><td>F</td><td>17 (51.5)</td><td>6 (46.2)</td><td>&gt;0.999</td></tr><tr><td>Primary risk factors</td><td></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>Hemolytic malignancy</td><td>23 (69.7)</td><td>2 (15.4)</td><td><strong>0.001</strong></td></tr><tr><td>Solid organ cancer</td><td>0</td><td>1 (7.7)</td><td>0.28</td></tr><tr><td>Solid organ transplant</td><td>7 (21.2)</td><td>1 (7.7)</td><td>0.41</td></tr><tr><td>Diabetes mellitus</td><td>0</td><td>8 (61.5)</td><td><strong>&lt;0.001</strong></td></tr><tr><td>Other</td><td>2 (6.1)</td><td>0</td><td>&gt;0.999</td></tr><tr><td>No risk factors</td><td>1 (3)</td><td>1 (7.7)</td><td>0.49</td></tr><tr><td>Clinical signs and symptoms</td><td></td><td></td><td></td></tr><tr><td>Fever</td><td>22 (66.7)</td><td>5 (38.5)</td><td>0.1</td></tr><tr><td>Dyspnea</td><td>18 (54.5)</td><td>0</td><td><strong>&lt;0.001</strong></td></tr><tr><td>Cough</td><td>11 (33.3)</td><td>0</td><td><strong>0.02</strong></td></tr><tr><td>Hemoptysis</td><td>4 (12.1)</td><td>0</td><td>0.09</td></tr><tr><td>Otalgia, otorrhea</td><td>0</td><td>8 (61.5)</td><td><strong>&lt;0.001</strong></td></tr><tr><td>Chemosis, exophthalmia</td><td>2 (6.1)</td><td>2 (15.4)</td><td>0.56</td></tr><tr><td>Facial nerve palsy, headache</td><td>2 (6.1)</td><td>3 (23.1)</td><td>0.13</td></tr><tr><td>No symptoms</td><td>1 (3)</td><td>0</td><td>&gt;0.999</td></tr><tr><td>Imaging features</td><td></td><td></td><td></td></tr><tr><td>Nodules, mass lesion</td><td>17 (51.5)</td><td>0</td><td>0.11</td></tr><tr><td>Alveolar consolidation, ground-glass opacities</td><td>32 (96.9)</td><td>0</td><td><strong>&lt;0.001</strong></td></tr><tr><td>Pleural effusion</td><td>18 (54.5)</td><td>0</td><td>0.11</td></tr><tr><td>Sinus opacification</td><td>4 (12.1)</td><td>12 (92.3)</td><td><strong>&lt;0.001</strong></td></tr><tr><td>Sinus or mastoids lytic lesions</td><td>2 (6.1)</td><td>9 (69.2)</td><td><strong>&lt;0.001</strong></td></tr><tr><td>Median time to diagnosis, d (IQR)</td><td>19 (12–30)</td><td>90 (42–163)</td><td><strong>&lt;0.001</strong></td></tr><tr><td>Positive serum galactomannan antigen†</td><td>14/26 (53.8)</td><td>4/7 (57.1)</td><td>1</td></tr><tr><td>Diagnostic method‡</td><td></td><td></td><td>&gt;0.999</td></tr><tr><td>Smear sputum</td><td>9/10 (90)</td><td>0</td><td><strong>&lt;0.001</strong></td></tr><tr><td>BAL direct examination</td><td>15/25 (60)</td><td>NA</td><td>NA</td></tr><tr><td>BAL culture</td><td>24/25 (96)</td><td>NA</td><td>NA</td></tr><tr><td>Biopsy direct examination</td><td>5/7 (71)</td><td>10 (76.9)</td><td>&gt;0.999</td></tr><tr><td>Biopsy culture</td><td>6/7 (86)</td><td>13 (100)</td><td>0.35</td></tr><tr><td>Proven cases</td><td>6 (18)</td><td>13 (100)</td><td><strong>&lt;0.001</strong></td></tr><tr><td>Associated localizations</td><td></td><td></td><td></td></tr><tr><td>Pulmonary</td><td>NA</td><td>0</td><td>NA</td></tr><tr><td>Ear, nose, throat</td><td>4 (12.1)</td><td>NA</td><td>NA</td></tr><tr><td>Central nervous system</td><td>0</td><td>10 (76.9)</td><td><strong>&lt;0.001</strong></td></tr><tr><td>Mediastinal</td><td>1 (3)</td><td>0</td><td><strong>&lt;0.001</strong></td></tr><tr><td>Fungal coinfection at same site§</td><td>12 (36.3)</td><td>0</td><td><strong>0.01</strong></td></tr><tr><td>Aspergillus fumigatus</td><td>5(15.1)</td><td>0</td><td>0.31</td></tr><tr><td>A. niger</td><td>3 (9.1)</td><td>0</td><td>0.55</td></tr><tr><td>Mucorales</td><td>4 (12.1)</td><td>0</td><td>0.31</td></tr><tr><td>Pneumocystis jirovecii</td><td>2 (6.1)</td><td>0</td><td>&gt;0.999</td></tr><tr><td>Influenza co-infection</td><td>2 (6.1)</td><td>0</td><td>&gt;0.999</td></tr><tr><td>First-line antifungal monotherapy¶</td><td>26/30 (86.7)</td><td>11/12 (91.7)</td><td>&gt;0.999</td></tr><tr><td>Voriconazole</td><td>16/26 (61.5)</td><td>8/11 (72.7)</td><td>0.71</td></tr><tr><td>Other triazole</td><td>4/26 (15.3)</td><td>3/11 (27.3)</td><td>0.40</td></tr><tr><td>Echinocandin</td><td>2/26 (7.7)</td><td>0/11</td><td>&gt;0.999</td></tr><tr><td>Liposomal amphotericin B</td><td>4/26 (15.4)</td><td>0/11</td><td>0.30</td></tr><tr><td>Antifungal combination therapy¶</td><td>4/30 (13.3)</td><td>1/12 (8.3)</td><td>&gt;0.999</td></tr><tr><td>Curative surgery</td><td>3 (9.1)</td><td>6 (46.1)</td><td><strong>0.01</strong></td></tr><tr><td>Death</td><td>N = 31</td><td>N = 12</td><td></td></tr><tr><td>30-day case-fatality</td><td>14 (45.2)</td><td>1 (8.3)</td><td><strong>0.03</strong></td></tr><tr><td>3-month case-fatality</td><td>17 (54.8)</td><td>2 (16.7)</td><td><strong>0.04</strong></td></tr></tbody></table>

<footnote>*Values are no. (%) except as indicated. BAL, bronchoalveolar lavage; IQR, interquartile range.</footnote>

<footnote>†Positive galactomannan antigen in blood with an optical density index cutoff value of ≥0.5.</footnote>

<footnote>‡Values are no. positive/no. tested (%).</footnote>

<footnote>§13 cases with pulmonary fungal coinfections, including one with more than 1 coinfection.</footnote>

<footnote>¶Values are no. positive/no. treated (%).</footnote>
<table><caption>**Table 4.** Main characteristics of patients with disseminated infections in a study of features of invasive aspergillosis caused by *Aspergillus flavus*, France, 2012–2018*</caption><thead><tr><th>Characteristics</th><th>Value</th></tr></thead><tbody><tr><td>Median age, y (IQR)</td><td>36 (14.5–58)</td></tr><tr><td>Sex</td><td></td></tr><tr><td>M</td><td>3 (42.8)</td></tr><tr><td>F</td><td>4 (57.1)</td></tr><tr><td>Main risk factor</td><td></td></tr><tr><td>Hematologic malignancy</td><td>4 (57.1)</td></tr><tr><td>Solid organ cancer</td><td>1 (14.3)</td></tr><tr><td>Solid organ transplant</td><td>1 (14.3)</td></tr><tr><td>Others, severe burns</td><td>1 (14.3)</td></tr><tr><td>Fever as primary clinical sign</td><td>5 (71.4)</td></tr><tr><td>Site of infection</td><td></td></tr><tr><td>Pulmonary</td><td>6 (85.7)</td></tr><tr><td>Ear, nose, throat</td><td>2 (28.6)</td></tr><tr><td>Central nervous system</td><td>2 (28.6)</td></tr><tr><td>Skin and soft tissues</td><td>3 (42.8)</td></tr><tr><td>Fungemia</td><td>2 (28.6)</td></tr><tr><td>Median time to diagnosis, d (IQR)</td><td>5 (4.5–28)</td></tr><tr><td>Positive serum galactomannan antigen, n = 5</td><td>5 (100)</td></tr><tr><td>Proven cases</td><td>5 (71.4)</td></tr><tr><td>Fungal co-infection</td><td>3 (42.8)</td></tr><tr><td>Voriconazole first-line antifungal therapy</td><td>6 (85.7)</td></tr><tr><td>3-month case-fatality</td><td>4 (57.1)</td></tr><tr><td>*IQR, interquartile range.</td><td></td></tr></tbody></table>

ENT IA (69.7% [23/33]) vs. 15.4% [2/13] for HM, and 21.2% [7/33] vs. 15.4% [1/13] for solid organ transplantation; p<0.001). In contrast, diabetes mellitus was the most common underlying condition in patients with ENT IA (61.5% [8/13]), compared with no diabetes mellitus in patients with pleuropulmonary IA (p<0.001).

We also assessed available imaging results for the 54 included IA cases. All 33 patients with pleuropulmonary IA had chest computed tomography scans, 17 (51.5%) of whom had nodules, 32 (96.6%) had alveolar consolidations or ground-glass opacities, and 18 (54.5%) had pleural effusion. All 13 ENT IA patients had computed tomography scans of the sinuses, ear, or brain, showing sinus opacification in 12 (92.3%) and lytic lesions of sinus, mastoid, or skull base walls in 9 (69.2%) cases. When performed, serum GM testing was positive in 53.8% (14/26) of cases of pleuropulmonary IA and in 57.1% (4/7) of ENT IA cases.

Among pulmonary IA cases, 36.4% (12/33) of patients had ≥1 fungal co-infection at the same site; 11 had 1 co-infection and 1 had 3 fungal co-infections. Co-infections included 5 *A. fumigatus*, 3 *A. niger*, 4 Mucorales, and 2 *Pneumocystis jirovecii*. Patients with ENT IA did not exhibit relevant fungal co-infections. Of note, influenza co-infection was reported in 6.1% (2/33) of pulmonary IA. In those cases, influenza was diagnosed before IA, and the diagnosis was considered influenza-associated pulmonary aspergillosis.

Among the 7 disseminated IA cases, the most frequent underlying condition was HM in 4 (57%) cases,

followed by 1 (14.3%) case each of solid-organ tumor under chemotherapy, solid organ transplant, and severe burns. Patients with disseminated IA infections were younger (median age 36 [IQR 14–66] years) than patients with localized IA (median age 60 [IQR 50–70] years; p = 0.04). The most frequent sites involved in disseminated IA were pulmonary (85.7%), skin and soft tissues (42.8%), ENT (28.6%), and CNS (28.6%). Serum galactomannan was positive in all disseminated cases. Two patients had *A. flavus* fungemia (1 patient had metastatic cholangiocarcinoma and 1 had severe burns). Fungal co-infections were found in 43% (3/7) of cases, including various pathogens identified in different sites: 1 *P. jirovecii* in a bronchoalveolar lavage sample associated with *A. flavus* cutaneous infection, and 1 candidemia and 1 sinusal mucormycosis associated with *A. flavus* found in a puncture of a frontonasal subcutaneaus collection. Finally, disseminated IA with pulmonary involvement (6/7) accounted for 15.4% (6/39) of all cases of pulmonary IA, and disseminated IA with ENT involvement (2/7) accounted for 13.3% (2/15) of all ENT IA.

## Treatment and Outcomes

Before invasive *A. flavus* infection, only 3 patients, all of whom had HM, had been receiving antifungal prophylaxis (1 fluconazole and 2 L-AmB). An antifungal treatment was recorded in 50 (92.6%) of 54 cases. The other 4 (7.4%) patients did not receive antifungal therapy: 3 patients had localized pleuropulmonary IA cases diagnosed postmortem, and the fourth patient had a complete curative surgical treatment for ENT IA. Antifungal monotherapy was prescribed as the first-line treatment for 45 (90%) of the 50 patients who received antifungal treatment, most (66.7%, 30) of whom received voriconazole, but other azoles (posaconazole in 7%, itraconazole in 4%, and isavuconazole in 4%) were also administered, as were L-AmB in 13% (n = 6) and an echinocandin in 4% (n = 2). Five (10%) patients received combined antifungal therapy, including L-AmB and an echinocandin in 3 cases and voriconazole and an echinocandin in 2 cases. Of the 54 ctotal cases, curative surgery was performed in 9 (16.6%), more frequently in ENT IA (46.1%, 6/13) cases than in pleuropulmonary IA (3%, 1/33) cases (p = 0.01).

We determined EUCAST MICs for itraconazole, posaconazole, voriconazole, isavuconazole, L-AmB, caspofungin, and micafungin on 46 isolates (Table 5). The MICs for amphotericin B ranged from 0.5 to >4 mg/L, and the MICs for voriconazole ranged from 0.125 to 1 mg/L. *A. flavus* showed lower susceptibility to amphotericin B (MIC<sub>50</sub> of 2 mg/L and MIC<sub>90</sub> of
4 mg/L) than to voriconazole (MIC<sub>50</sub> of 0.5 mg/L and MIC<sub>90</sub> of 1 mg/L).

Among 51 patients with available outcome data, 20 patients died, yielding a 30-day CFR of 39.2% (95% CI 25.8%-53.9%) (Table 1). The CFR was higher (46%) for patients with malignancy or solid organ transplant than for patients with diabetes mellitus (n = 0) (p = 0.013) (Table 2). Although not statistically significant, CFR was higher for disseminated (57%) than localized (36%) infections (p = 0.4). Among the different localized IA, pleuropulmonary IA had a higher CFR than did ENT IA (45% vs. 8%; p = 0.03) (Table 3). IA associated with fungal co-infections tended to have a higher 30-day CFR than those without fungal coinfections (44% [7/16] vs. 37% [13/35]; p = 0.8).

## Discussion

Herein, we describe 54 cases of invasive aspergillosis caused by *A. flavus* reported in France during 2012–2018. Few data on *A. flavus* IA in the Northern Hemisphere are available, probably because *A. flavus* is scarce in high-income countries, cases are underdiagnosed because of nonspecific clinical manifestations and absence of diagnostic confirmation in mildly immunocompromised patients, and most countries do not have specific fungal surveillance programs. Thus, we sought to identify risk factors specific to *A. flavus* and the association of risk factors with clinical manifestations and outcomes.

Although some characteristics of our patients, such as median age (58 years) and CFR (42%), were similar to cases of IA (all species combined) reported in France during 2005–2007 (7) and 2012–2018 (1), we found a relatively lower percentage (55%) of patients with HM and a higher percentage (14.8%) with diabetes among the underlying factors, compared with 71% for patients with HM and <10% for those with diabetes mellitus from in an earlier study (1). Because *A. flavus* has a higher prevalence in dry and warm regions (2–4), we also investigated the possibility of *A. flavus* acquisition in tropical or subtropical countries such as northern or southern Africa and East Asia, where patients might have lived. Of note, although recent travel history was not recorded for all patients in our study, 28% of patients originated from Africa, suggesting acquisition of *A. flavus* in the Southern Hemisphere.

We also assessed seasonality of infections in France. We found a higher rate (59.2%) of diagnoses of IA caused by *A. flavus* in the hottest months (Table 1), highlighting the probable influence of hot temperatures on *A. flavus* development, as previously reported (10).

We identified 2 distinct patterns of disease: pulmonary IA in highly immunocompromised patients, and ENT IA primarily occurring in patients with diabetes mellitus. Most (87%) cases of IA in our study were localized pleuropulmonary infections. Characteristics of infection were similar in terms of underlying condition, clinical manifestations, and prognosis to previously reported IA cases caused by *A. fumigatus* (11). HM and solid organ transplantation accounted for 91% of underlying risk factors in IA cases, consistent with the >85% reported on pulmonary IA from all species combined in a previous study (11). Clinical manifestations of *A. flavus* pulmonary IA among our patient cohort were similar to those for pulmonary IA caused by *A. fumigatus*, including acute symptom onset and a short diagnostic delay. ENT IA was the second main site of infection in our study, which is consistent with prior data reporting *A. flavus* as the main causative species in ENT IA in tropical and subtropical countries (2–4). ENT infection might be related to the larger size of *A. flavus* conidia compared with that of *A. fumigatus* (12,13), making progression through the lower airways difficult.

The main underlying condition among our cohort was uncontrolled diabetes mellitus, which we noted in 61.5% of cases. The association between diabetes mellitus and IA was previously observed in aspergillosis otitis in a study where all 12 patients had diabetes mellitus (14) and another in which where 46.2% of patients were diabetic (15). The association between diabetes mellitus and IA has been assumed to be the result of susceptibility to functional impairment of innate immunity because of alteration of phagocytosis and efficiency of neutrophil polymorphonuclear cells that are known to play a pivotal role in antifungal immunity (16). We noted a higher (54%) percentage of patients originating from North Africa, where environmental prevalence of *A. flavus* is high, among cases of ENT IA compared with 21% among patients with pulmonary

<table><caption>**Table 5.** MICs of first-line antifungal drugs used for 46 cases of invasive aspergillosis caused by *Aspergillus flavus*, France, 2012–2018*</caption><thead><tr><th>Antifungal drug</th><th>Range, mg/L</th><th>MIC<sub>50</sub></th><th>MIC<sub>90</sub></th></tr></thead><tbody><tr><td>Voriconazole</td><td>0.125–1</td><td>0.5</td><td>1</td></tr><tr><td>Isavuconazole</td><td>0.25–2</td><td>0.5</td><td>1</td></tr><tr><td>Itraconazole</td><td>0.06–0.5</td><td>0.125</td><td>0.25</td></tr><tr><td>Posaconazole</td><td>&lt;0.015–0.25</td><td>0.125</td><td>0.25</td></tr><tr><td>Liposomal amphotericin B</td><td>0.5 to &gt;4</td><td>1</td><td>4</td></tr><tr><td>Caspofungin</td><td>0.125–0.5</td><td>0.25</td><td>0.5</td></tr><tr><td>Micafungin</td><td>0.007–0.03</td><td>0.007</td><td>0.015</td></tr></tbody></table>

<footnote>*Values according to European Committee on Antimicrobial Susceptibility Testing broth microdilution method (https://www.eucast.org/fileadmin/src/media/PDFs/EUCAST_files/AFST/Files/EUCAST_EDef_9.4_method_for_susceptibility_testing_of_moulds.pdf). MIC<sub>50</sub>, MIC that inhibited 50% of tested microorganisms; MIC<sub>90</sub>, that inhibited 90% of tested microorganisms.</footnote>
IA (p = 0.068). Despite less acute progression of in-ection in those forms, ENT IA cannot be considered
benign, considering the frequent (77%) extension to
the skull base reported in our study. That finding is
similar to 2 meta-analyses of osteoarticular aspergil-
losis reported during 1936–2013 (17,18), wherein skull
base osteomyelitis accounted for 18% of cases, 68% of
which were related to a contiguous ENT injury.

Concerning antifungal drug therapy, voricon-
azole, the first-line recommended treatment in current
guidelines (19), was only used in 64% of cases in this
study, similar to data reported in previous epidemio-
logic studies (7). The use of other first-line antifungal
drugs, mainly in L-AmB (23%) and echinocandins
(20%) in pulmonary IA, could be explained by initial
disease severity and diagnostic uncertainty in severe-
ly immunocompromised patients with frequent fun-
gal co-infections. Consistent with prior studies (20),
we found that MICs for L-AmB were high. However,
because of the retrospective design of the study, we
could not evaluate whether the use of L-AmB as ini-
tial therapy was associated with increased mortality
rates. Curative surgical management was also preva-
lent (46%) for ENT IA in our study, consistent with
a previous case series of ENT aspergillosis (15). Re-
search on surgical therapy, which has been shown to
influence illness and death, deserves to be better codi-
fied (21). Despite rapid initiation of treatment, over-
all mortality rates remained high (47% at 3 months),
with notable variability according to underlying risk
factors and IA localizations (17% in ENT vs. 55% in
pulmonary infections).

One of the main limitations of our study remains
the low number of cases reported, which limits the
statistical power of comparisons between groups,
needing further collaborative studies among coun-
tries in Europe or more broadly to increase the num-
ber of cases assessed. Another limitation is a lack of
comparison between groups. We compared general
characteristics of *A. flavus* IA patients, including sex
ratio, age, underlying conditions at diagnosis, and
mortality rates, to all cases of IA reported from RES-
SIF for all *Aspergillus* species, >86% of which were *A.
fumigatus*, for the same period (2012–2018) (1). How-
ever, we could not compare specific subgroups, such
as those with localized infections, because of the ab-
sence of individual patient data. International studies
would also increase the number of cases studied and
enable comparisons with infections caused by other
non-*A. fumigatus* species.

A. flavus IA could represent an increasing issue
in the Northern Hemisphere, and further studies
are needed to clarify its prevalence and risk factors.

Indeed, during 2005-2007 in France, 3% of reported IA cases were caused by *A. flavus* (7), which increased to 8.7% during 2012-2018 (1). That increase is probably to the result of multiple reasons, including climate, migration, and rates of immunodeficiency. First, global warming could create a more favorable ecosystem for *A. flavus*, as observed in the seasonal pattern in North America, which has seen increased cases in summer months (10). Second, migrating populations could be at risk for IA after long-term carriage of *A. flavus* previously acquired in more southern countries, as noted by the high percentage of patients originating from North Africa among our *A. flavus* IA cohort. Finally, increases in the population of patients with acquired immunodeficiency, such as organ recipients (22), could mean that more patients are susceptible to present *A. flavus* infection and have more severe outcomes.

In conclusion, we found that IA caused by *A. fla-
vus* shared many similarities with IA caused by *A.
fumigatus*. Clinical manifestations mainly showed 2
distinct patterns: aggressive pleuropulmonary or dis-
seminated infection in highly immunocompromised
patients, with a high rate of co-infection and a high
mortality rate despite antifungal treatment; and ENT
infections, usually occurring in patients with uncon-
trolled diabetes mellitus, frequently among persons
originating from countries in North Africa, and show-
ing low mortality rates after curative surgery and an-
tifungal treatment. Surveillance studies such as ours
can raise awareness of non-*A. fumigatus* IA, includ-
ing in Western countries, where their incidence may
increase in the future because of climate change. Cli-
nicians should remain vigilant for *A. flavus* and con-
sider it during differential diagnosis for IA.

Acknowledgments

We thank Françoise Dromer for her tremendous input in
the conceptualization of this study, particularly for the
expansion of the RESSIF surveillance network and her
continuous investment in its management.

This work was supported by recurrent financial support
from Santé Publique France and Institut Pasteur.

Author contributions: L.B. and F.L. conceptualized the
study; L.B., O.P., and F.L. developed study methodology;
J.P.G, K.B.S., D.G.H, O.L., S.B., A.A., R.H., F.D., G.D., S.C.,
F.M., S.D., C.N., J.B., M.P., E.C, T.C., M.S., N.D.B., and F.L.
curated study data; L.B. and O.P. wrote the original draft;
J.P.G, K.B.S., D.G.H, O.L., S.B., A.A., R.H., F.D., G.D., S.C.,
F.M., S.D., C.N., J.B., M.P., E.C, T.C., M.S., N.D.B., and F.L.
reviewed and edited the draft article. Methods and results
were reported according to STROBE guidelines.
## About the Author

Dr. Bertin is an internal medicine physician currently pursuing a PhD at the University of Paris-Cité, France. Her primary research interests include infectious diseases and immunology, notably mucosal-associated invariant T cells.

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Address for correspondence: Fanny Lanternier, Department of Infectious Diseases and Tropical Medicine, Necker-Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), IHU Imagine, Paris 75014, France; email: fanny.lanternier@aphp.fr