Concurrent pretreatment serum and BALF galactomannan positivity as a prognostic indicator in non-neutropenic invasive pulmonary aspergillosis without malignancy or solid organ transplantation: a retrospective cohort study.

BACKGROUND

The prognostic evaluation of invasive pulmonary aspergillosis (IPA) in non-neutropenic patients remains clinically challenging. While galactomannan (GM) testing in serum and bronchoalveolar lavage fluid (BALF) aids in diagnosis, the prognostic significance of concurrent positivity in both compartments is not well-established. This study aimed to determine whether concurrent pretreatment GM positivity serves as an independent predictor of 30-day all-cause mortality in non-neutropenic IPA patients without underlying malignancy or solid organ transplantation.

METHODS

We conducted a single-center, retrospective cohort study including 162 patients with proven or probable IPA admitted between February 2018 and February 2025. Patients were stratified into two groups based on stringent, predefined criteria: the GM-positive group (concurrent pretreatment serum GM index ≥ 0.7 and BALF GM index ≥ 0.8, n = 81) and the GM-negative group (both indices below these diagnostic thresholds, n = 81). All patients received standardized first-line antifungal therapy (voriconazole). The primary outcome was 30-day all-cause mortality. Survival analysis was performed using Kaplan-Meier estimates and Cox proportional hazards models, with adjustment for relevant clinical confounders.

RESULTS

The overall 30-day mortality was 29.6% (48/162). Mortality was significantly higher in the GM-positive group compared to the GM-negative group (45.7% vs. 13.6%, P < 0.001). Multivariable Cox regression analysis confirmed that concurrent pretreatment GM positivity was independently associated with increased mortality (adjusted hazard ratio [HR] = 3.07; 95% confidence interval [CI], 1.5-6.29; P = 0.002), after adjusting for factors including APACHE II score and key laboratory parameters.

CONCLUSION

In non-neutropenic IPA patients without classic immunocompromising conditions (e.g., malignancy or solid organ transplantation), concurrent pretreatment positivity for both serum and BALF GM is an independent prognostic marker for increased 30-day all-cause mortality. This combined assessment may serve as a valuable tool for early risk stratification, potentially helping to identify a high-risk subgroup that could benefit from more vigilant monitoring and individualized management strategies.