Better analysis and reporting needed

Blastomycosis, coccidioidomycosis (Valley fever), and histoplasmosis are the most common endemic fungal diseases (mycoses) in North America. Authors of opinion articles in Annals of Internal Medicine argue that we need to improve diagnosis and reporting of these infections to better serve patients and understand the extent of the problem.

Traditionally, these infections have known areas of endemicity, allowing for targeted education of physicians and the community. Unfortunately, the boundaries of these areas seem to be shifting due to climate change.

Lead author George R. Thompson III, MD, professor of medicine at the University of California, Davis, said Medscape Medical News in an email, “These fungi are increasingly being recognized outside of their traditional endemic areas. The areas where they occur are expanding.”

Underreported and underreported

Because these environmentally acquired fungi present as community-acquired pneumonia (CAP) or with other nonspecific symptoms such as night sweats, fever, chills, cough, or fatigue, providers often mistakenly treat patients for bacterial or viral disease, without suspecting a fungal infection. . Overlooking antifungals leads to treatment delays, multiple unnecessary and potentially harmful antibiotic prescriptions, not to mention excess healthcare costs and healthcare utilization.

Even in areas where fungal diseases are known to be endemic, fungal diseases can often be overlooked, says Fariba Donovan, MD, PhD, assistant professor of medicine at the University of Arizona Valley Fever Center for Excellence (VFCE), in Tucson. (Donovan was not involved Annals article.) Tucson is in an area considered hyperemic due to valley fever. In hypoglycemic areas of Arizona and California, valley fever is thought to be the causative agent of approximately 20% of CAP cases.

Even with this increased regional awareness, Donovan’s research showed that 43% of valley fever patients at Banner University Medical Center in Tucson had a delay in diagnosis of more than 1 month, with a median delay of 23 days. “The most important factor in early detection of Valley Fever is awareness in the medical community,” she said Medscape Medical News. VFCE regularly provides education about Valley fever to healthcare professionals and community members.

In addition to the general lack of awareness, the Annals The authors point out that endemic fungi are not included in common diagnostic charts used for pneumonia patients. Serum antibody and urine antibody tests for endemic fungal infection are usually only available from certain laboratories, so providers need to be trained to order them.

Endemic fungi are also not specifically addressed in the professional guidelines that clinicians should follow regarding CAP. For example, the 2019 joint guidelines for community-acquired pneumonia from the American Thoracic Society and the Infectious Diseases Society of America do not directly address when endemic mycoplasma is suspected.

Epidemiology of endemic fungi

A region’s temperature and precipitation patterns are important to fungal ecology, so climate change can lead to geographic shifts in endemicity. Forest fires can also play a role in the spread of some of these organisms. For the benefit of human and other patients, the authors argue that the current map must be redrawn.

In recent years, researchers have discovered valley fever among tourists in Nebraska, much further east than the historical hotspots of Arizona and California. Similarly, scientists and doctors are finding histoplasmosis and Blastomyces infections in areas far outside what was previously thought to be their endemic areas.

If state, federal, and state public health authorities do not specifically mandate that a particular pathogen be reported to them, epidemiologic data will not be consistently collected from providers and laboratories. A lack of data means a lack of awareness among providers who may not consider fungal infections in the differential diagnosis.

These endemic fungi often infect non-human animals, so the authors recommend increased surveillance and reporting of veterinary infections, arguing that this could help determine current borders for endemicity. “The much larger number of animals and their greater environmental exposure puts them at greater risk of contracting these infections,” Thompson explained.

Five suggestions to help improve analysis and reporting

The authors have five recommendations to improve the rate of diagnosis and reporting of endemic fungal infections:

1. National surveillance and disease notification of endemic fungal infection in humans and veterinarians

2. Education directed at providers and patients

3. Listing of endemic fungal infections in future CAP guidelines

4. Development of point-of-care diagnostics to shorten the time from patient presentation to diagnosis and receipt of effective treatment

5. Survey of endemic mycoses vaccine to prevent infection

Thompson recommends, “In areas where these fungal diseases flourish, clinicians need to consider diagnosis and testing for fungal infections in all patients with suggestive illness.”

Ann Intern Med. Published online 22 November 2022. Abstract. doi:10.7326/M22-2371.

This study received financial support from the National Institutes of Health (5U19AI166798-02) and the UC-Davis Burden Family Gift Fund for Coccidiosis Research. Thompson and Donovan report no relevant financial relationships.

Erin Archer, RN, BSN, CIC is a registered nurse, freelance writer and infection control practitioner in Tucson, Arizona.

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