Invasive aspergillosis (IA) is a dangerous consequence that is difficult to identify in immunocompromised and critically sick individuals. For a study, researchers sought to determine how many instances go misdiagnosed and what clinical and radiologic characteristics are related to fatal IA. 

They examined 67 instances of fatal IA confirmed at autopsy at a tertiary academic institution between 1999 and 2019. At autopsy, pulmonary involvement was found in 97% of patients, with 46% restricted to the lungs and 51% having simultaneous extrapulmonary involvement. In 85% of cases, immunosuppression with glucocorticoids and/or other immunosuppressive medications was present. 

Chronic lung illness was observed in 70% of those who were not immunocompromised (15%), and a respiratory coinfection was found in 50%. Consolidation, ground-glass opacities, halo sign, cavitation, and air crescent sign were found in 49%, 49%, 37%, 22%, and 7% of instances, respectively. In 61% of instances, diagnostic bronchoscopy was done, and aspergillus was identified in 63% of those cases using bronchoalveolar lavage (galactomannan and/or culture), bronchial washings, or transbronchial biopsy cultures. In 64% of cases, a respiratory or other systemic coinfection was detected. The accuracy of pre-mortem diagnosis of IA was linked with diagnostic bronchoscopy performance (P=0.001). Only 27% of fatal IA cases detected at autopsy were accurately diagnosed by clinicians as the cause of death. 

Complex presenting characteristics, a high proportion of co-infections, and a low rate of invasive diagnostic tests may have resulted in missed IA diagnosis.