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Objective: We investigated the performance of enzyme linked immunospot (ELISpot) assay for the diagnosis of invasive aspergillosis (IA) in high-risk patients with hematologic malignancies., Methods: We prospectively enrolled two cohorts of patients undergoing intensive myelosuppressive or immunosuppressive treatments at high risk for IA. ELISpot was performed to detect Aspergillus-specific T cells producing Interleukin-10., Results: In the discovery cohort, a derived cut-off of 40 spot forming cells (SFCs)/106 PBMCs has shown to correctly classify IA cases with a sensitivity and specificity of 89.5% and 88.6%, respectively. This cut-off is lowered to 25 SFC when considering the subset of possible IA patients, with sensitivity and specificity of 76% and 93%, respectively. The application of the 40 SFCs cut-off to the validation cohort resulted in a positivity rate of 83.3% in proven/probable cases and a negativity rate of 92.5% in possible/non-IA cases. Adopting the 25 SCFs cut-off, the assay resulted positive in 83.3% of proven/probable cases while it resulted negative in 66.7% of possible/non-IA cases., Conclusions: ELISpot shows promises in the diagnosis of IA and the possibility to use two distinct cut-offs with similar diagnostic performances according to patients' different pre-test probability of infection can widen its use in patients at risk., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: M. Luppi, L. Potenza and P. Barozzi have applied for an Italian patent regarding clinical applications of the ELISpot assay for the diagnosis of Aspergillus infection [PCT: WO2008/075395A3, IT2007/000867]. M. Luppi, L. Potenza, D. Vallerini, P. Barozzi and F. Forghieri have applied for an Italian and US patent regarding clinical applications of the ELISpot assay for the diagnosis of Mucorales infection [PCT: WO2012073160 A1, IT MI20102224, US 2013/0260395]. This does not alter the authors’ adherence to all Journal policies. This does not alter our adherence to PLOS ONE policies on sharing data and materials. Other authors of this manuscript have no conflicts of interest related to the study to disclose., (Copyright: © 2024 Bettelli et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)