Response to “Missed diagnosis and misdiagnosis of infectious diseases in hematopoietic cell transplant recipients: an autopsy study”

TO THE EDITOR:

Multani et al recently described the results of an autopsy study, showing that 35 of 185 (18.9%) hematopoietic cell transplant (HCT) recipients (83% of which received an allogeneic HCT) had 41 missed infectious diseases premortem.¹  Among those, there were 4 cases of Candida, and 2 were cases of Enterococcus pneumonia. Although 3 of 4 Candida pneumonia cases appeared to be in the context of disseminated Candida infection, there was 1 single case of Candida pneumonia without any evidence of hematogenous spread. For the 2 cases of Enterococcus pneumonia, no additional information was provided. The authors suggest that a “positive culture for Enterococcus should not be disregarded in an HCT recipient whose respiratory status is declining while on antimicrobial therapy lacking antienterococcal activity.” Although these findings are intriguing, we question whether they suffice to warrant such a strong statement. First, it is not entirely clear whether there was microbiologic confirmation for both organisms on tissue level by culture, polymerase chain reaction, or other methods. Second, the existing body of evidence referenced in the original publication is not conclusive as to the mere existence of clinical entities as such. It is well known that disseminated candidiasis can lead to hematogenous seeding of the lungs, occasionally appearing with a miliary pattern on chest computed tomography.^2-4  However, data on primary Candida and, even less on Enterococcus pneumonia, remain sparse and lack definitive documentation.^3-5  This study could provide important information for our better understanding of these clinical entities and challenge the Infectious Disease status quo. To that scope, additional detailed information, particularly on those cases of nonhematogenous Candida and Enterococcus pneumonias, should be presented. Clinical, microbiologic, imaging, and pathologic data would be of great interest to clinicians caring for such patients and allow the Infectious Disease community to assess these cases in depth. Furthermore, a detailed description of the 3 cases of disseminated candidiasis with lower respiratory tract seeding would be additional useful information and a reference tool for this rare clinical entity. Last, it would be interesting to see if there were any cases with a premortem infectious disease diagnosis, in which an infection was not documented on autopsy. In conclusion, the question of whether the presence of Candida or Enterococcus in the respiratory secretions of allogeneic HCT recipients and other immunocompromised hosts should be treated or not remain unanswered. More data are required before we should even start posing this question. Until then, clinicians should remain cautious before making any changes in their clinical practices and approaches.

Send data sharing requests via e‐mail to the corresponding author, Dionysios Neofytos (dionysios.neofytos@hcuge.ch).

Contribution: D.N. and G.P. participated in the writing of the manuscript.

Conflict-of-interest disclosure: The authors declare no competing financial interests.

Correspondence: Dionysios Neofytos, University Hospital of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva, Switzerland; e-mail: dionysios.neofytos@hcuge.ch