Table 1.

Current Limitations Associated With Invasive Fungal Disease in the Coronavirus Disease 2019 Patient

Invasive Fungal Disease	Limitation and Gaps in Knowledge
Aspergillosis	Varied incidence of disease: dependent on diagnostic strategy and disease classification
	Varied confidence in classification of disease: disease classified using varying mycological, potentially associated with colonization, with prognosis not necessarily associated with or lack of antifungal treatment
	The impact of underlying disease and risk factors for disease, including immunosuppressive COVID-19 treatments: evidence can be conflicting, generally anecdotal or limited to single-center studies
	Limited proven disease: rates of autopsy-confirmed diagnosis are generally low, but variable—does this reflect overclassification of disease or disease pathogenesis?
	Limited understanding of disease pathogenesis: disease progression in the patient will affect optimal diagnostic test selection and clinical presentation and possibly prognosis
	Limited understanding of diagnostic test performance: when tests are used to define disease, it is not possible to define accurate performance and determine an optimal test or combination of tests. Even for tests previously established in ICU patients (eg, GM-EIA on BAL fluid), performance has generally been derived from the non–COVID-19 cohort
	Management of disease is based on existing knowledge among non–COVID-19 patients
Candidiasis	The impact of underlying disease and risk factors for disease, including immunosuppressive COVID-19 treatments, remains unclear
	Limited understanding of disease pathogenesis and relation to candidemia
	Management of disease is based on existing knowledge among non–COVID-19 patients
Mucormycosis	Varied incidence of disease: dependent on diagnostic strategy and risk factors/populations
	The true impact of underlying diseases (diabetes, etc) and risk factors for disease, including immunosuppressive COVID-19 treatments
	Management of disease is based on existing knowledge among non–COVID-19 patients
Pneumocystosis	Varied incidence of disease: dependent on diagnostic strategy and limitation of testing (ie, colonization vs infection)
	The impact of underlying disease (HIV, transplant) and risk factors for disease, including immunosuppressive COVID-19 treatments, are unclear
	Management of disease is based on existing knowledge among non–COVID-19 patients
Endemic mycoses	Varied incidence of disease, with few cases reported to date
	The impact of underlying disease (HIV, transplant) and risk factors for disease, including immunosuppressive COVID-19 treatments, are unclear
	Management of disease is based on existing knowledge among non–COVID-19 patients
Cryptococcosis	Few cases reported to date

Abbreviations: BAL, bronchoalveolar lavage; COVID-19, coronavirus disease 2019; GM-EIA, galactomannan enzyme immunoassay; HIV, human immunodeficiency virus; ICU, intensive care unit.