Prevalence and clinical implications of Aspergillus infection among tuberculosis patients in Peru

Objectives Aspergillosis is a fungal infection known to contribute to post-tuberculosis lung disease, but its prevalence and impact during tuberculosis (TB) treatment are not well understood. We aimed to estimate the prevalence of Aspergillus infection among newly diagnosed TB patients and its association with treatment response and outcomes. Methods We conducted a prospective cohort study of pulmonary TB patients in Lima, Peru. We screened for Aspergillus infection by measuring anti-Aspergillus antibodies in serum at TB treatment initiation and after two months of treatment. We assessed patient disease status at baseline and two months with chest x-ray, the St. George's Respiratory Questionnaire (SGRQ) and 6-minute walking test. We used modified Poisson regression to identify risk factors for baseline Aspergillus seropositivity and study the association of Aspergillus seropositivity with clinical non-improvement at 2 months and with final treatment outcomes. Results At baseline, 5.4% of 1,998 participants were seropositive for anti-Aspergillus antibodies. Older age and a history of prior TB were associated with baseline Aspergillus seropositivity. Cavitary lesions were not a significant risk factor for the presence of Aspergillus antibodies. The presence of baseline Aspergillus antibodies was found to be independently associated with non-improvement on chest-xray (adjusted RR= 1.76, 95% CI: 1.07, 2.89) and non-improvement in SGRQ score (adjusted RR= 1.44, 95% CI: 1.02, 2.03) after 2 months. Conclusions Aspergillus seropositivity was associated with poorer clinical response during TB treatment, including among patients with no prior history of TB. These findings raise the possibility that aspergillosis may emerge during TB treatment itself and underscore the importance of careful end-of-treatment and post-treatment monitoring to improve longer-term outcomes.