Blastomycosis in a South Indian patient after visiting an endemic area in USA

Re-drawing the Maps for Endemic Mycoses

Endemic mycoses such as histoplasmosis, coccidioidomycosis, blastomycosis, paracoccidioidomycosis, and talaromycosis are well-known causes of focal and systemic disease within specific geographic areas of known endemicity. However, over the past few decades, there have been increasingly frequent reports of infections due to endemic fungi in areas previously thought to be “non-endemic.” There are numerous potential reasons for this shift such as increased use of immune suppressive medications, improved diagnostic tests, increased disease recognition, and global factors such as migration, increased travel, and climate change. Regardless of the causes, it has become evident that our previous understanding of endemic regions for these fungal diseases needs to evolve. The epidemiology of the newly described Emergomyces is incomplete; our understanding of it continues to evolve. This review will focus on the evidence underlying the established areas of endemicity for these mycoses as well as new data and reports from medical literature that support the re-thinking these geographic boundaries. Updating the endemic fungi maps would inform clinical practice and global surveillance of these diseases.

Blastomycosis Misdiagnosed as Tuberculosis, India

Chronic pulmonary blastomycosis is often misdiagnosed and treated as tuberculosis in disease-endemic and non–disease-endemic areas. We report the case of a 32-year-old man who after visiting Chicago, Illinois, USA, returned to India and received treatment for tuberculosis for 12 months before receiving the correct diagnosis of blastomycosis.

The Changing Epidemiology of Invasive Fungal Infections

Invasive fungal infections (IFI) are an emerging problem worldwide with invasive candidiasis and candidemia responsible for the majority of cases. This is predominantly driven by the widespread adoption of aggressive immunosuppressive therapy among certain patient populations (e.g., chemotherapy, transplants) and the increasing use of invasive devices such as central venous catheters (CVCs). The use of new immune modifying drugs has also opened up an entirely new spectrum of patients at risk of IFIs. While the epidemiology of candida infections has changed in the last decade, with a gradual shift from C. albicans to non-albicans candida (NAC) strains which may be less susceptible to azoles, these changes vary between hospitals and regions depending on the type of population risk factors and antifungal use. In certain parts of the world, the incidence of IFI is strongly linked to the prevalence of other disease conditions and the ecological niche for the organism; for instance cryptococcal and pneumocystis infections are particularly common in areas with a high prevalence of HIV disease. Poorly controlled diabetes is a major risk factor for invasive mould infections. Environmental factors and trauma also play a unique role in the epidemiology of mould infections, with well-described hospital outbreaks linked to the use of contaminated instruments and devices. Blastomycosis is associated with occupational exposure (e.g., forest rangers) and recreational activities (e.g., camping and fishing).The true burden of IFI is probably an underestimate because of the absence of reliable diagnostics and lack of universal application. For example, the sensitivity of most blood culture systems for detecting candida is typically 50 %. The advent of new technology including molecular techniques such as 18S ribosomal RNA PCR and genome sequencing is leading to an improved understanding of the epidemiology of the less common mould and dimorphic fungal infections. Molecular techniques are also providing a platform for improved diagnosis and management of IFI.Many factors affect mortality in IFI, not least the underlying medical condition, choice of therapy, and the ability to achieve early source control. For instance, mortality due to pneumocystis pneumonia in HIV-seronegative individuals is now higher than in seropositive patients. Of significant concern is the progressive increase in resistance to azoles and echinocandins among candida isolates, which appears to worsen the already significant mortality associated with invasive candidiasis. Mortality with mould infections approaches 50 % in most studies and varies depending on the site, underlying disease and the use of antifungal agents such as echinocandins and voriconazole. Nevertheless, mortality for most IFIs has generally fallen with advances in medical technology, improved care of CVCs, improved diagnostics, and more effective preemptive therapy and prophylaxis.

Autochthonous blastomycosis of the adrenal: first case report from Asia

Systemic endemic mycoses, such as blastomycosis, are rare in Asia and have been reported as health risks among travelers who visit or reside in an endemic area. Adrenal involvement is rarely seen in blastomycosis and has never been reported from Asia. We report the first case of blastomycosis with bilateral involvement of the adrenals in a diabetic patient residing in the state of Arunachal Pradesh, India.

Cutaneous Blastomycosis – a case report

We present a 46-year-old non-atopic HIV-negative woman from Doboj, Republic of Srpska, Bosnia and Herzegovina, who was referred to the Department of Dermatovenereology, Clinical Center Banja Luka, Republic of Srpska, Bosnia and Herzegovina, with a 3-month long history of an erythematous, large indurated infl amed area on the upper arm. The condition was asymptomatic, immediately following surgical excision of a small tumor. After exlusion of pulmonary blastomycosis and other organ involvement, the diagnosis of primary inoculation cutaneous blastomycosis was made based on clinical presentation and histopathological fi ndings. Histopathology revealed thick-walled, rounded, budding yeasts with broad-based buds that stained pink with periodic acid-schiff (PAS) staining. Itraconazole therapy was initiated at a dose of 2x100 mg/day. After three months of therapy, the dose of itraconazole was increased to 2x200 mg/day during the next three months, and then the dose was reduced to 2x100 mg. Blastomycosis is an uncommon, chronic granulomatous and suppurative mycosis caused by Blastomyces dermatitidis, which belongs to the group of main endemic systemic mycoses and in the great majority of cases represents a primary pulmonary disease. Few sporadic cases have been reported in Europe. There are three forms of blastomycosis: primary cutaneous, pulmonary and disseminated. B. dermatitidis has rarely been isolated from the environment. Wood debris or land close to rivers or subject to fl ooding are considered to be the natural substrate. The fungus can grow in sterile soil in the laboratory, and it is believed that humans get infected by inhaling spores from a saprophytic source. Primary cutaneous blastomycosis is very rare and it is found in farmers and laboratory workers. Human to human transmission does not normally occur. The diagnosis of the skin lesions is made by direct microscopy of skin samples (e.g., pus, scrapings) with 10% potassium hydroxide mount and confi rmed by culture or biopsy. Histopathological analysis provides identifi cation of all the dimorphic fungi. However, this can be complicated by the fact that in some cases they can be morphologically atypical or sterile. In the tissues, B. dermatitidis produces characteristic thick-walled, rounded, refractile, and spherical budding yeasts with broad-based buds. Of the available antimycotic drugs, itraconazole 200 mg/day is probably the most effective, but at least 400 mg/day is redommended initially.

Endemic fungal infections in the Asia-Pacific region

Endemic mycoses are important fungal infections in their respective habitats. In the Asia-Pacific region, an accurate epidemiological picture of endemic mycoses is elusive; few epidemiological surveys have been performed, and limited laboratory facilities and experience with fungal infections have further hampered recognition of infection. However, pockets of endemicity do indeed exist, and endemic fungal infections can have a significant impact on public health. This article reviews the most common endemic mycoses in the Asia-Pacific region: histoplasmosis, penicilliosis, and sporotrichosis. Blastomycosis, which has been infrequently reported within the region, is also briefly discussed. Certain areas of the Asia-Pacific region are endemic for histoplasmosis; however, the ecologic niche for this infection remains unclear. Penicilliosis is restricted to Southeast and Eastern Asia, whereas sporotrichosis is encountered in tropical areas of the Asia-Pacific region linked to environmental reservoirs distinct from those seen in the Western world. Before the advent of acquired immune deficiency syndrome (AIDS), histoplasmosis and penicilliosis were only occasionally reported; however, the incidence of both mycoses has increased with the rise in the incidence of AIDS. Comprehensive studies are needed to fully assess the areas of endemicity and the impact of endemic mycoses in the Asia-Pacific region.