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McTaggart LR, Varghese N, Sivaraman K, Patel SN, Kus JV. Genomic Epidemiology of Large Blastomycosis Outbreak, Ontario, Canada, 2021. Emerg Infect Dis 2024; 30:1487-1490. [PMID: 38916874 PMCID: PMC11210661 DOI: 10.3201/eid3007.231594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2024] Open
Abstract
Using phylogenomic analysis, we provide genomic epidemiology analysis of a large blastomycosis outbreak in Ontario, Canada, caused by Blastomyces gilchristii. The outbreak occurred in a locale where blastomycosis is rarely diagnosed, signaling a possible shift in geographically associated incidence patterns. Results elucidated fungal population genetic structure, enhancing understanding of the outbreak.
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Hillman E, Fu H, Obid R, Anele UA. Genitourinary Blastomycosis in a Young Male Patient: A Case Report and Review of Diagnostic Challenges. Case Rep Infect Dis 2023; 2023:4713948. [PMID: 38148871 PMCID: PMC10751171 DOI: 10.1155/2023/4713948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 11/27/2023] [Accepted: 12/08/2023] [Indexed: 12/28/2023] Open
Abstract
Disseminated blastomycosis is an endemic fungal infection that rarely manifests with genitourinary involvement. We present a unique case of a 28-year-old professional male gamer with a remote history of hemoptysis and cervical lymphadenopathy who presented with hematospermia, lower urinary tract symptoms (LUTS), and persistent groin abscesses after left orchiectomy at an outside hospital. He underwent drainage of groin abscess and prostate biopsy for an abnormal digital rectal exam which revealed disseminated blastomycosis requiring systemic, long-term antifungal treatment. We have also included a review of literature to note clinical patterns in presentations and highlight the diagnostic challenges that this infection presents.
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Affiliation(s)
- Emily Hillman
- Department of Urology, University of Louisville School of Medicine, Louisville, KY 40217, USA
| | - Hangcheng Fu
- Department of Urology, University of Louisville School of Medicine, Louisville, KY 40217, USA
| | - Randa Obid
- Department of Pathology, University of Louisville School of Medicine, Louisville, KY 40217, USA
| | - Uzoma A. Anele
- Department of Urology, University of Louisville School of Medicine, Louisville, KY 40217, USA
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Jenks JD, Prattes J, Wurster S, Sprute R, Seidel D, Oliverio M, Egger M, Del Rio C, Sati H, Cornely OA, Thompson GR, Kontoyiannis DP, Hoenigl M. Social determinants of health as drivers of fungal disease. EClinicalMedicine 2023; 66:102325. [PMID: 38053535 PMCID: PMC10694587 DOI: 10.1016/j.eclinm.2023.102325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 10/27/2023] [Accepted: 11/02/2023] [Indexed: 12/07/2023] Open
Abstract
Disparities in social determinants of health (SDOH) play a significant role in causing health inequities globally. The physical environment, including housing and workplace environment, can increase the prevalence and spread of fungal infections. A number of professions are associated with increased fungal infection risk and are associated with low pay, which may be linked to crowded and sub-optimal living conditions, exposure to fungal organisms, lack of access to quality health care, and risk for fungal infection. Those involved and displaced from areas of armed conflict have an increased risk of invasive fungal infections. Lastly, a number of fungal plant pathogens already threaten food security, which will become more problematic with global climate change. Taken together, disparities in SDOH are associated with increased risk for contracting fungal infections. More emphasis needs to be placed on systematic approaches to better understand the impact and reducing the health inequities associated with these disparities.
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Affiliation(s)
- Jeffrey D. Jenks
- Durham County Department of Public Health, Durham, NC, United States of America
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, NC, United States of America
| | - Juergen Prattes
- Division of Infectious Diseases, ECMM Excellence Center for Medical Mycology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- BioTechMed, Graz, Austria
| | - Sebastian Wurster
- Division of Internal Medicine, Department of Infectious Diseases, Infection Control and Employee Health, MD Anderson Cancer Center, University of Texas, Houston, TX, United States of America
| | - Rosanne Sprute
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Institute of Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging – Associated Diseases (CECAD), Cologne, Germany
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, University of Cologne, Center of Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center of Medical Mycology (ECMM), Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Danila Seidel
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Institute of Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging – Associated Diseases (CECAD), Cologne, Germany
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, University of Cologne, Center of Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center of Medical Mycology (ECMM), Cologne, Germany
| | - Matteo Oliverio
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Institute of Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging – Associated Diseases (CECAD), Cologne, Germany
- Department I of Internal Medicine, University of Cologne, Cologne, Germany
| | - Matthias Egger
- Division of Infectious Diseases, ECMM Excellence Center for Medical Mycology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- BioTechMed, Graz, Austria
| | - Carlos Del Rio
- Emory Center for AIDS Research, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Hatim Sati
- Department of Global Coordination and Partnership on Antimicrobial Resistance, World Health Organization, Geneva, Switzerland
| | - Oliver A. Cornely
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Institute of Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging – Associated Diseases (CECAD), Cologne, Germany
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, University of Cologne, Center of Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center of Medical Mycology (ECMM), Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
- Faculty of Medicine and University Hospital Cologne, Clinical Trials Centre Cologne (ZKS Koln), University of Cologne, Cologne, Germany
| | - George R. Thompson
- University of California Davis Center for Valley Fever, Sacramento, CA, United States of America
- Division of Infectious Diseases, Department of Internal Medicine, University of California Davis Medical Center, Sacramento, CA, United States of America
- Department of Medical Microbiology and Immunology, University of California Davis, Davis, CA, United States of America
| | - Dimitrios P. Kontoyiannis
- Division of Internal Medicine, Department of Infectious Diseases, Infection Control and Employee Health, MD Anderson Cancer Center, University of Texas, Houston, TX, United States of America
| | - Martin Hoenigl
- Division of Infectious Diseases, ECMM Excellence Center for Medical Mycology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- BioTechMed, Graz, Austria
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Blastomycosis: A Review of Mycological and Clinical Aspects. J Fungi (Basel) 2023; 9:jof9010117. [PMID: 36675937 PMCID: PMC9863754 DOI: 10.3390/jof9010117] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 01/11/2023] [Accepted: 01/12/2023] [Indexed: 01/18/2023] Open
Abstract
Blastomycosis is caused by a thermally dimorphic fungus that thrives in moist acidic soil. Blastomyces dermatitidis is the species responsible for most infections in North America and is especially common in areas around the Great Lakes, the St. Lawrence Seaway, and in several south-central and southeastern United States. Other Blastomyces species have more recently been discovered to cause disease in distinct geographic regions around the world. Infection almost always occurs following inhalation of conidia produced in the mold phase. Acute pulmonary infection ranges from asymptomatic to typical community-acquired pneumonia; more chronic forms of pulmonary infection can present as mass-like lesions or cavitary pneumonia. Infrequently, pulmonary infection can progress to acute respiratory distress syndrome that is associated with a high mortality rate. After initial pulmonary infection, hematogenous dissemination of the yeast form of Blastomyces is common. Most often this is manifested by cutaneous lesions, but osteoarticular, genitourinary, and central nervous system (CNS) involvement also occurs. The diagnosis of blastomycosis can be made by growth of the mold phase of Blastomyces spp. in culture or by histopathological identification of the distinctive features of the yeast form in tissues. Detection of cell wall antigens of Blastomyces in urine or serum provides a rapid method for a probable diagnosis of blastomycosis, but cross-reactivity with other endemic mycoses commonly occurs. Treatment of severe pulmonary or disseminated blastomycosis and CNS blastomycosis initially is with a lipid formulation of amphotericin B. After improvement, therapy can be changed to an oral azole, almost always itraconazole. With mild to moderate pulmonary or disseminated blastomycosis, oral itraconazole treatment is recommended.
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Jenks JD, Aneke CI, Al-Obaidi MM, Egger M, Garcia L, Gaines T, Hoenigl M, Thompson GR. Race and ethnicity: Risk factors for fungal infections? PLoS Pathog 2023; 19:e1011025. [PMID: 36602962 DOI: 10.1371/journal.ppat.1011025] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Racial and ethnic identities, largely understood as social rather than biologic constructs, may impact risk for acquiring infectious diseases, including fungal infections. Risk factors may include genetic and immunologic differences such as aberrations in host immune response, host polymorphisms, and epigenomic factors stemming from environmental exposures and underlying social determinants of health. In addition, certain racial and ethnic groups may be predisposed to diseases that increase risk for fungal infections, as well as disparities in healthcare access and health insurance. In this review, we analyzed racial and ethnic identities as risk factors for acquiring fungal infections, as well as race and ethnicity as they relate to risk for severe disease from fungal infections. Risk factors for invasive mold infections such as aspergillosis largely appear related to environmental differences and underlying social determinants of health, although immunologic aberrations and genetic polymorphisms may contribute in some circumstances. Although black and African American individuals appear to be at high risk for superficial and invasive Candida infections and cryptococcosis, the reasons for this are unclear and may be related to underling social determinants of health, disparities in access to healthcare, and other socioeconomic disparities. Risk factors for all the endemic fungi are likely largely related to underlying social determinants of health, socioeconomic, and health disparities, although immunologic mechanisms likely play a role as well, particularly in disseminated coccidioidomycosis.
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Affiliation(s)
- Jeffrey D Jenks
- Durham County Department of Public Health, Durham, North Carolina, United States of America
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, North Carolina, United States of America
| | - Chioma Inyang Aneke
- Department of Laboratory Medicine, National Institutes of Health, Bethesda, Maryland, United States of America
- Department of Veterinary Pathology and Microbiology, University of Nigeria, Nsukka, Nigeria
| | - Mohanad M Al-Obaidi
- Division of Infectious Diseases, Department of Medicine, University of Arizona, Tucson, Arizona, United States of America
| | - Matthias Egger
- Division of Infectious Diseases, Medical University of Graz, Graz, Austria
| | - Lorena Garcia
- Department of Public Health Sciences, UC Davis School of Medicine, Davis, California, United States of America
| | - Tommi Gaines
- Division of Infectious Diseases and Global Public Health, Department of Medicine, School of Medicine, University of California, San Diego, California, United States of America
| | - Martin Hoenigl
- Division of Infectious Diseases, Medical University of Graz, Graz, Austria
- Division of Infectious Diseases and Global Public Health, Department of Medicine, School of Medicine, University of California, San Diego, California, United States of America
| | - George R Thompson
- University of California Davis Center for Valley Fever, Sacramento, California, United States of America
- Department of Internal Medicine, Division of Infectious Diseases, University of California Davis Medical Center, Sacramento, California, United States of America
- Department of Medical Microbiology and Immunology, University of California Davis, Davis, California, United States of America
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Egger M, Hoenigl M, Thompson GR, Carvalho A, Jenks JD. Let's talk about Sex Characteristics - as a Risk Factor for Invasive Fungal Diseases. Mycoses 2022; 65:599-612. [PMID: 35484713 DOI: 10.1111/myc.13449] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 04/21/2022] [Accepted: 04/22/2022] [Indexed: 12/01/2022]
Abstract
Biological sex, which comprises differences in host sex hormone homeostasis and immune responses, can have a substantial impact on the epidemiology of infectious diseases. Comprehensive data on sex distributions in invasive fungal diseases (IFDs) is lacking. In this review we performed a literature search of in vitro/animal studies, clinical studies, systematic reviews, and meta-analyses of invasive fungal infections. Females represented 51.2% of invasive candidiasis cases, mostly matching the proportions of females among the general population in the United States and Europe (>51%). In contrast, other IFDs were overrepresented in males, including invasive aspergillosis (51% males), mucormycosis (60%), cryptococcosis (74%), coccidioidomycosis (70%), histoplasmosis (61%), and blastomycosis (66%). Behavioral variations, as well as differences related to biological sex, may only in part explain these findings. Further investigations concerning the association between biological sex/gender and the pathogenesis of IFDs is warranted.
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Affiliation(s)
- Matthias Egger
- Division of Infectious Diseases, Medical University of Graz, Austria
| | - Martin Hoenigl
- Division of Infectious Diseases, Medical University of Graz, Austria.,Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, CA, USA.,Clinical and Translational Fungal - Working Group, University of California San Diego, La Jolla, CA, USA
| | - George R Thompson
- University of California Davis Center for Valley Fever, California, USA.,Department of Internal Medicine, Division of Infectious Diseases, University of California Davis Medical Center, California, USA.,Department of Medical Microbiology and Immunology, University of California Davis, California, USA
| | - Agostinho Carvalho
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's -, PT Government Associate Laboratory, Braga/Guimarães, Portugal
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Kohn EM, Taira C, Dobson H, Dias LDS, Okaa U, Wiesner DL, Wüthrich M, Klein BS. Variation in Host Resistance to Blastomyces dermatitidis: Potential Use of Genetic Reference Panels and Advances in Immunophenotyping of Diverse Mouse Strains. mBio 2022; 13:e0340021. [PMID: 35089087 PMCID: PMC8725596 DOI: 10.1128/mbio.03400-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 11/22/2021] [Indexed: 11/20/2022] Open
Abstract
Host genetic determinants that underpin variation in susceptibility to systemic fungal infection are poorly understood. Genes responsible for complex traits can be identified by correlating variation in phenotype with allele in founder strains of wild mice with known genetic variation, assembled in genetic reference panels. In this work, we describe wide natural variation in both primary and acquired resistance to experimental pulmonary blastomycosis in eight founder strains, including 129, A/J, BL/6, CAST, NOD, NZO, PWK, and WSB of the Collaborative Cross collection, and the inbred DBA strain. These differences in susceptibility across strains were accompanied by sharp differences in the accumulation and function of immune cells in the lungs. Immune perturbations were mapped by identifying reagents that phenotypically mark immune cell populations in the distinct strains of mice. In particular, we uncovered marked differences between BL/6 and DBA/2 mouse strains in the development of acquired resistance. Our findings highlight the potential value in using genetic reference panels of mice, and particularly the BXD (recombinant inbred strains of mice from a cross of C57BL/6J and DBA/2J mice) collection harboring a cross between resistant BL/6 and susceptible DBA/2 mice, for unveiling genes linked with host resistance to fungal infection. IMPORTANCE Host genetic variation significantly impacts vulnerability to infectious diseases. While host variation in susceptibility to fungal infection with dimorphic fungi has long been recognized, genes that underpin this variation are poorly understood. We used a collection of seven mouse strains that represent nearly 90% of the genetic variation in mice to identify genetic variability among the strains in resistance to pulmonary infection with the dimorphic fungus Blastomyces dermatitidis. We analyzed differences between the strains in innate resistance by infecting naive mice and in acquired resistance by infecting vaccinated mice. We identified extreme variations in both innate and acquired resistance among the strains. In particular, we found sharp differences between C57BL/6 and DBA/2 strains in the ability to acquire vaccine-induced resistance. We also identified commercial reagents that allowed the phenotyping of immune cells from this strain collection of mice. Because there are additional mice harboring a genetic cross of the C57BL/6 and DBA/2 strains (BXD collection), such mice will permit future investigations to identify the genes that underlie differences in the ability to acquire resistance to infection.
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Affiliation(s)
- Elaine M. Kohn
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, University of Wisconsin—Madison, Madison, Wisconsin, USA
| | - Cleison Taira
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, University of Wisconsin—Madison, Madison, Wisconsin, USA
| | - Hanah Dobson
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, University of Wisconsin—Madison, Madison, Wisconsin, USA
| | - Lucas Dos Santos Dias
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, University of Wisconsin—Madison, Madison, Wisconsin, USA
| | - Uju Okaa
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, University of Wisconsin—Madison, Madison, Wisconsin, USA
| | - Darin L. Wiesner
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, University of Wisconsin—Madison, Madison, Wisconsin, USA
| | - Marcel Wüthrich
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, University of Wisconsin—Madison, Madison, Wisconsin, USA
| | - Bruce S. Klein
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, University of Wisconsin—Madison, Madison, Wisconsin, USA
- Department of Internal Medicine, University of Wisconsin School of Medicine and Public Health, University of Wisconsin—Madison, Madison, Wisconsin, USA
- Department of Medical Microbiology and Immunology, University of Wisconsin School of Medicine and Public Health, University of Wisconsin—Madison, Madison, Wisconsin, USA
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Intensive Care Unit and Hospital Outcomes of Patients Admitted with Blastomycosis: A 14-Year Retrospective Study. Lung 2022; 200:129-135. [PMID: 34988618 DOI: 10.1007/s00408-021-00499-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 11/18/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Blastomycosis is an uncommon; potentially life-threatening granulomatous fungal infection. The aim of this study is to report hospital and intensive care unit (ICU) outcomes of patients admitted with blastomycosis. METHODS All patients admitted for treatment of blastomycosis at the Mayo Clinic-Rochester, Minnesota between 01/01/2006 and 09/30/2019 were included. Demographics, comorbidities, clinical presentation, ICU admission, and outcomes were reviewed. RESULTS A total of 84 Patients were identified with 90 unique hospitalizations primarily for blastomycosis. The median age at diagnosis was 49 (IQR 28.1-65, range: 6-85) years and 56 (66.7%) were male. The most frequent comorbidities included hypertension (n = 28, 33.3%); immunosuppressed state (n = 25, 29.8%), and diabetes mellitus (n = 21, 25%). The lungs were the only organ involved in 56 (66.7%) cases and the infection was disseminated in 19 (22.6%) cases. A total of 29 patients (34.5%) underwent ICU admission due to complications of blastomycosis. ICU related events included mechanical ventilation (n = 20, 23.8%), acute respiratory distress syndrome (ARDS) (n = 13, 15.5%), tracheostomy (n = 9, 10.7%), renal replacement therapy (n = 8, 9.5%), and extracorporeal membrane oxygenation (ECMO) (n = 4, 4.8%). A total of 12 patients (14.3%) died in the hospital; all of whom had undergone ICU admission. In-hospital mortality was associated with renal replacement therapy (RRT) (P = 0.0255). CONCLUSION Blastomycosis is a serious, potentially life-threatening infection that results in significant morbidity and mortality with a 34.5% ICU admission rate. RRT was associated with in-hospital mortality.
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Villacorta Cari E, Leedy N, Ribes JA, Soria J, Myint T. Risk factors of severe blastomycosis and comparison of diagnosis and outcomes between immunocompetent and immunocompromised patients. Mycoses 2021; 65:239-246. [PMID: 34874582 DOI: 10.1111/myc.13409] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 11/15/2021] [Accepted: 11/29/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Blastomycosis is an endemic fungal infection that causes pulmonary and systemic disease. It can occur irrespective of the patient's immune status. The risk factors associated with the severity of the disease are not well studied. METHODS This is a retrospective study of patients admitted with blastomycosis at the University of Kentucky Hospital from 2004 to 2019. Logistic regression was used to identify variables associated with severe blastomycosis. RESULTS A total of 76 patients were identified; 22 (28.9%) had at least one immunosuppressive condition. Pulmonary blastomycosis was reported in 49/76 (65%) of the patients and disseminated infection in 27/76 (35.5%). All diagnostic tests were not significantly different in diagnostic results in immunocompromised vs immunocompetent patients. Cultures and histopathology were positive in 56/61 (91.8%) and 54/63 (85.7%) respectively. Blastomyces or Histoplasma antigen test was positive in 13/17 (76.4%) in immunocompromised patients compared to 26/42 (61.9%) in immunocompetent patients. Immunocompromised patients were more likely to be admitted to the hospital and ICU compared to immunocompetent patients. In the multivariate analysis, pulmonary multilobar disease (RR 5.68; 95% CI 2.13-15.15), obesity (RR 2.39; 95% CI 1.26-4.51), diabetes mellitus (RR 3.50; 95% CI 1.38-8.90) and immunosuppression (RR 2.28; 95% CI 1.14-4.56) were significant independent risk factors for severe blastomycosis. Inpatient mortality proportion was higher in immunocompromised patients but not statistically significant. CONCLUSION Pulmonary multilobar disease, obesity, diabetes mellitus and immunosuppression were risk factors associated with severe blastomycosis. Immunocompromised patients required more frequent hospitalisations compared to immunocompetent patients.
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Affiliation(s)
- Evelyn Villacorta Cari
- Division of Infectious Diseases, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Nicole Leedy
- Division of Infectious Diseases, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Julie A Ribes
- Department of Pathology and Laboratory Medicine, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Jaime Soria
- Division of Infectious Diseases, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Thein Myint
- Division of Infectious Diseases, University of Kentucky College of Medicine, Lexington, Kentucky, USA
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O’Dowd TR, Mc Hugh JW, Theel ES, Wengenack NL, O’Horo JC, Enzler MJ, Vergidis P. Diagnostic Methods and Risk Factors for Severe Disease and Mortality in Blastomycosis: A Retrospective Cohort Study. J Fungi (Basel) 2021; 7:jof7110888. [PMID: 34829177 PMCID: PMC8619313 DOI: 10.3390/jof7110888] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/11/2021] [Accepted: 10/12/2021] [Indexed: 12/18/2022] Open
Abstract
Background: Blastomycosis can cause severe disease with progressive respiratory failure and dissemination even in immunocompetent individuals. We sought to evaluate risk factors for severe disease and mortality using clinical and laboratory data within a large health system in an endemic area. Methods: We performed a retrospective cohort study of patients diagnosed with blastomycosis at all Mayo Clinic sites from 1 January 2004 through 31 March 2020. Diagnosis was established by culture, histopathology/cytopathology, serology, antigen testing, or PCR. Disease was categorized as mild for patients treated in the outpatient setting, moderate for hospitalized patients who did not require intensive care, and severe for patients admitted to the intensive care unit. Logistic regression was used to evaluate risk factors for severe disease. A Cox proportional hazards model was constructed to evaluate mortality. Findings: We identified 210 patients diagnosed with blastomycosis. Mean age was 51 years (range, 6–84). Most subjects were male (71.0%). Extrapulmonary disease was confirmed in 24.8%. In this cohort, 40.5% of patients had mild disease, 37.6% had moderate disease, and 21.9% had severe disease. Independent risk factors for severe disease were neutrophilia (odds ratio (OR) 3.35 (95% CI 1.53–7.35), p = 0.002) and lymphopenia (OR 3.34 (95% CI 1.59–7.03), p = 0.001). Mortality at 90 days was 11.9%. Median time from diagnosis to death was 23 days (interquartile range 8–31 days). Independent risk factors for mortality were age (OR 1.04 (95% CI 1.01–1.08), p = 0.009), neutrophilia (OR 2.84 (95% CI 1.04–7.76), p = 0.041), and lymphopenia (OR 4.50 (95% CI 1.67–12.11), p = 0.003). Blastomyces immunodiffusion had an overall sensitivity of 39.6% (95% CI 30.1–49.8). Sensitivity was higher among those who were tested 4 weeks or longer after the onset of symptoms. Urine Blastomyces antigen had a significantly higher sensitivity of 80.8% (95% CI 68.1–89.2) compared to serology. There was a trend towards higher antigen concentration in patients with severe disease. The sensitivity of PCR from respiratory specimens was 67.6% (95% CI 50.1–85.5). Conclusion: In this cohort, we did not find an association between pharmacologic immunosuppression and disease severity. Lymphopenia at diagnosis was an independent risk factor for mortality. This simple marker may aid clinicians in determining disease prognosis.
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Affiliation(s)
- Timothy R. O’Dowd
- Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (T.R.O.); (J.W.M.H.)
| | - Jack W. Mc Hugh
- Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (T.R.O.); (J.W.M.H.)
| | - Elitza S. Theel
- Department of Laboratory Medicine and Pathology, Division of Clinical Microbiology, Mayo Clinic, Rochester, MN 55905, USA; (E.S.T.); (N.L.W.)
| | - Nancy L. Wengenack
- Department of Laboratory Medicine and Pathology, Division of Clinical Microbiology, Mayo Clinic, Rochester, MN 55905, USA; (E.S.T.); (N.L.W.)
| | - John C. O’Horo
- Department of Medicine, Division of Infectious Diseases, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA; (J.C.O.); (M.J.E.)
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Mark J. Enzler
- Department of Medicine, Division of Infectious Diseases, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA; (J.C.O.); (M.J.E.)
| | - Paschalis Vergidis
- Department of Medicine, Division of Infectious Diseases, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA; (J.C.O.); (M.J.E.)
- Correspondence:
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11
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Hernandez L, Jha P, Sohnle P. An Unusual Case of Blastomycosis and Severe Lung Necrosis in a Hmong Woman With Preexisting Liver Cirrhosis. Cureus 2021; 13:e17406. [PMID: 34589317 PMCID: PMC8459804 DOI: 10.7759/cureus.17406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2021] [Indexed: 11/23/2022] Open
Abstract
Predisposing factors that lead to blastomycosis remain unknown, although like other fungal infections, blastomycosis is an opportunistic infection. Here, we report on an unusual presentation in a Hmong woman with preexisting liver disease. This case highlights genetic and medical factors that may increase susceptibility to blastomycosis.
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Affiliation(s)
| | - Pinky Jha
- Internal Medicine, Medical College of Wisconsin, Wauwatosa, USA
| | - Peter Sohnle
- Division of Infectious Diseases, Department of Medicine, Medical College of Wisconsin, Wauwatosa, USA
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Hall JM, Havens PL, Mitchell EA, De Vela GN, Titus LL, Dasgupta M, Simpson PM, Kehl SC, Willoughby RE, Henrickson KJ, Mitchell ML, Huppler AR, Chusid MJ. Blastomycosis in 64 Wisconsin Children: Unanticipated Infection Risk and Severity in Urban Residents. Pediatr Infect Dis J 2021; 40:802-807. [PMID: 33990518 DOI: 10.1097/inf.0000000000003178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Blastomycosis, an endemic mycosis of immunocompetent individuals, is typically seen after exposure to waterways within rural wooded regions. It is not considered a disease of urban environments. Infection can be solely pneumonic or disseminate to skin, bone or central nervous system. Unknown factors influence disease acquisition and severity in children. METHODS We analyzed acquisition risks and disease characteristics of blastomycosis in children seen at a tertiary care center from 1998 to 2018 to identify potential exposure sources, measure disease severity and assess the effect of race upon disease severity. RESULTS Of 64 infected children, mean age was 12.9 years, with median time to diagnosis 38.5 days. About 72% were male, 38% resided in urban counties and 50% had typical environmental exposure. Isolated pulmonary infection occurred in 33 (52%). The remainder had evidence of dissemination to skin (N = 13), bone (N = 16; 7 clinically silent) and cranium (N = 7; 3 clinically silent). Infection was moderate/severe in 19 (30%). Two children (3%) died. About 79% of children with moderate/severe disease (P = 0.008) and 71% of urban children (P = 0.007) lacked typical environmental exposure. Comparing children from urban counties to other residences, 63% versus 5% were black (P < 0.001) and 71% versus 35% developed extrapulmonary dissemination (P = 0.006). Moderate/severe disease was seen in 7/17 (42%) black children but only 12/47 (26%) children of other races (P = 0.23). CONCLUSIONS Blastomycosis, can be endemic in urban children in the absence of typical exposure history, have frequent, sometimes clinically silent, extrapulmonary dissemination and possibly produces more severe disease in black children.
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Affiliation(s)
- Jaimee M Hall
- From the Department of Pediatrics, Medical College of Wisconsin, Wauwatosa, Wisconsin
- Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri
| | - Peter L Havens
- From the Department of Pediatrics, Medical College of Wisconsin, Wauwatosa, Wisconsin
| | - Errin A Mitchell
- From the Department of Pediatrics, Medical College of Wisconsin, Wauwatosa, Wisconsin
| | - Gabriel N De Vela
- From the Department of Pediatrics, Medical College of Wisconsin, Wauwatosa, Wisconsin
| | - Lauren L Titus
- From the Department of Pediatrics, Medical College of Wisconsin, Wauwatosa, Wisconsin
| | - Mahua Dasgupta
- Department of Pediatrics, Quantitative Health Sciences, Medical College of Wisconsin, Wauwatosa, Wisconsin
| | - Pippa M Simpson
- Department of Pediatrics, Quantitative Health Sciences, Medical College of Wisconsin, Wauwatosa, Wisconsin
| | - Sue C Kehl
- Department of Pathology, Medical College of Wisconsin, Wauwatosa, Wisconsin
| | - Rodney E Willoughby
- From the Department of Pediatrics, Medical College of Wisconsin, Wauwatosa, Wisconsin
| | - Kelly J Henrickson
- From the Department of Pediatrics, Medical College of Wisconsin, Wauwatosa, Wisconsin
| | - Michelle L Mitchell
- From the Department of Pediatrics, Medical College of Wisconsin, Wauwatosa, Wisconsin
| | - Anna R Huppler
- From the Department of Pediatrics, Medical College of Wisconsin, Wauwatosa, Wisconsin
| | - Michael J Chusid
- From the Department of Pediatrics, Medical College of Wisconsin, Wauwatosa, Wisconsin
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Benedict K, Gibbons-Burgener S, Kocharian A, Ireland M, Rothfeldt L, Christophe N, Signs K, Jackson BR. Blastomycosis Surveillance in 5 States, United States, 1987-2018. Emerg Infect Dis 2021; 27. [PMID: 33757624 PMCID: PMC8007286 DOI: 10.3201/eid2704.204078] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The median time from symptom onset to diagnosis and the severity of illness suggest that surveillance underestimates the true number of cases. Blastomycosis is caused by inhalation of Blastomyces spp. fungi. Limited data are available on the incidence and geographic range of blastomycosis in the United States. To better characterize its epidemiologic features, we analyzed combined surveillance data from the 5 states in which blastomycosis is reportable: Arkansas, Louisiana, Michigan, Minnesota, and Wisconsin. Surveillance identified 4,441 cases during 1987–2018, a mean of 192 cases per year. The mean annual incidence was <1 case/100,000 population in most areas but >20 cases/100,000 population in some northern counties of Wisconsin. Median patient age was 46 years, 2,892 (65%) patients were male, 1,662 (57%) were hospitalized, and 278 (8%) died. The median time from symptom onset to diagnosis was 33 days. The severity of illness and diagnostic delays suggest that surveillance underestimates the true number of cases. More in-depth surveillance in additional states could elucidate blastomycosis incidence and inform efforts to increase awareness.
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Abstract
Blastomycosis is a systemic disease caused by Blastomyces spp. fungi. To determine its epidemiology in blastomycosis-endemic Minnesota, USA, we evaluated all cases reported to public health officials during 1999-2018. We focused on time to diagnosis, exposure activities, and exposure location. A total of 671 cases and a median of 34 cases/year were reported. Median time to diagnosis was 31 days; 61% of patients were not tested for blastomycosis until they were hospitalized. The case-fatality rate was 10%, and patients who died were 5.3 times more likely to have a concurrent medical condition. Outdoor activities and soil exposure were reported by many patients, but no specific activity or exposure was common to most. Almost one third of patients were probably exposed in geographic areas other than their home county. Providers should consider alternative etiologies for patients with pneumonia not responding to antibacterial treatment, and public health officials should increase awareness in blastomycosis-endemic areas.
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15
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Rush B, Lother S, Paunovic B, Mooney O, Kumar A. Outcomes With Severe Blastomycosis and Respiratory Failure in the United States. Clin Infect Dis 2021; 72:1603-1607. [PMID: 32227089 DOI: 10.1093/cid/ciaa294] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 03/18/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Outcomes of patients with severe pulmonary blastomycosis requiring mechanical ventilation (MV) are not well understood in the modern era. Limited historical case series reported 50-90% mortality in patients with acute respiratory distress syndrome caused by blastomycosis. The objective of this large retrospective cohort study was to describe the risk factors and outcomes of patients with severe pulmonary blastomycosis. METHODS We performed a retrospective cohort analysis utilizing the Nationwide Inpatient Sample from 2006-2014. Patients aged >18 years with a diagnosis of blastomycosis who received MV were included. RESULTS There were 1848 patients with a diagnosis of blastomycosis included in the study. Of these, 219 (11.9%) underwent MV with a mortality rate of 39.7% compared with 2.5% in patients not requiring ventilatory support (P < .01). The median (IQR) time to death for patients requiring MV was 12 (8-16) days. The median length of hospital stay for survivors of MV was 22 (14-37) days. The rate of MV was higher for patients treated in teaching hospitals (63.4% vs 57.2%, P = .05) and lower for those receiving care at a rural hospital (12.3% vs 17.2%, P = .04). In a multivariate model, female gender was associated with increased risk of mortality (OR, 1.84; 95% CI, 1.06-3.20; P = .03) as was increasing patient age (10-year age increase OR, 1.64; 95% CI, 1.33-2.02; P < .01). CONCLUSIONS In the largest published cohort of patients with blastomycosis, mortality for patients on MV is high at ~40%, 16-fold higher than those without MV.
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Affiliation(s)
- Barret Rush
- Division of Critical Care Medicine, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sylvain Lother
- Division of Critical Care Medicine, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Bojan Paunovic
- Division of Critical Care Medicine, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Owen Mooney
- Division of Critical Care Medicine, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Anand Kumar
- Division of Critical Care Medicine, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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16
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McBride JA, Sterkel AK, Matkovic E, Broman AT, Gibbons-Burgener SN, Gauthier GM. Clinical Manifestations and Outcomes in Immunocompetent and Immunocompromised Patients With Blastomycosis. Clin Infect Dis 2021; 72:1594-1602. [PMID: 32179889 DOI: 10.1093/cid/ciaa276] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 03/14/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Blastomyces is a dimorphic fungus that infects persons with or without underlying immunocompromise. To date, no study has compared the clinical features and outcomes of blastomycosis between immunocompromised and immunocompetent persons. METHODS A retrospective study of adult patients with proven blastomycosis from 2004-2016 was conducted at the University of Wisconsin. Epidemiology, clinical features, and outcomes were analyzed among solid-organ transplantation (SOT) recipients, persons with non-SOT immunocompromise (non-SOT IC), and persons with no immunocompromise (NIC). RESULTS A total of 106 cases met the inclusion criteria including 74 NIC, 19 SOT, and 13 non-SOT IC (malignancy, HIV/AIDS, idiopathic CD4+ lymphopenia). The majority of patients (61.3%) had at least 1 epidemiologic risk factor for acquisition of Blastomyces. Pneumonia was the most common manifestation in all groups; however, immunocompromised patients had higher rates of acute pulmonary disease (P = .03), more severe infection (P = .007), respiratory failure (P = .010), and increased mortality (P = .02). Receipt of SOT primarily accounted for increased severity, respiratory failure, and mortality in immunosuppressed patients. SOT recipients had an 18-fold higher annual incidence of blastomycosis than the general population. The rate of disseminated blastomycosis was similar among NIC, SOT, and non-SOT IC. Relapse rates were low (5.3-7.7%). CONCLUSIONS Immunosuppression had implications regarding the acuity, severity, and respiratory failure. The rate of dissemination was similar across the immunologic spectrum, which is in sharp contrast to other endemic fungi. This suggests that pathogen-related factors have a greater influence on dissemination for blastomycosis than immune defense.
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Affiliation(s)
- Joseph A McBride
- Department of Medicine, University of Wisconsin, Madison, Wisconsin, USA.,Department of Pediatrics, University of Wisconsin, Madison, Wisconsin, USA
| | - Alana K Sterkel
- Department of Pathology and Laboratory Medicine, University of Wisconsin, Madison, Wisconsin, USA.,Wisconsin State Laboratory of Hygiene, Madison, Wisconsin, USA
| | - Eduard Matkovic
- Department of Pathology and Laboratory Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | - Aimee T Broman
- Department of Biostatistics and Medical Informatics, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | | | - Gregory M Gauthier
- Department of Medicine, University of Wisconsin, Madison, Wisconsin, USA
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Endemic and Other Dimorphic Mycoses in The Americas. J Fungi (Basel) 2021; 7:jof7020151. [PMID: 33672469 PMCID: PMC7923431 DOI: 10.3390/jof7020151] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/17/2021] [Accepted: 02/17/2021] [Indexed: 12/14/2022] Open
Abstract
Endemic fungi are thermally dimorphic fungi that have a limited geographic range and can cause both primary disease and opportunistic infections. The Americas are home to more genera of endemic fungi than anywhere else on earth. These include Coccidioides, Histoplasma, Blastomyces, Paracoccidioides, and Sporothrix. Endemic fungi are found across the Americas and the Caribbean, from Blastomyces gilchristi, which extends into the northeast corners of North America, to Histoplasma capsulatum, which occurs all the way down in the southern regions of South America and into the Caribbean Islands. Symptoms of endemic fungal infection, when present, mimic those of many other diseases and are often diagnosed only after initial treatment for a bacterial or viral disease has failed. Endemic fungi place a significant medical burden on the populations they affect, especially in immunocompromised individuals and in resource-limited settings. This review summarizes the ecology, geographical range, epidemiology, and disease forms of the endemic fungi found in the Americas. An emphasis is placed on new and proposed taxonomic changes, including the assignment of new species names in Histoplasma, Blastomyces, and Paracoccidioides.
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18
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Canfield GS, Bock A, Mann S, Zimmer S, Somerset H, Franco-Paredes C, Wilson CC, Metter RB. A 31-year-old Micronesian Man With Shoulder Fungating Mass. Clin Infect Dis 2021; 70:973-975. [PMID: 32055859 DOI: 10.1093/cid/ciz591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Gregory S Canfield
- Division of Infectious Diseases, University of Colorado School of Medicine, Denver
| | - Allison Bock
- Division of Internal Medicine, University of Colorado School of Medicine, Denver
| | - Sarah Mann
- Division of Infectious Diseases, University of Colorado School of Medicine, Denver
| | - Shanta Zimmer
- Division of Infectious Diseases, University of Colorado School of Medicine, Denver
| | - Hilary Somerset
- Division of Pathology, University of Colorado School of Medicine, Denver
| | | | - Cara C Wilson
- Division of Infectious Diseases, University of Colorado School of Medicine, Denver
| | - Robert B Metter
- Division of Hospital Medicine, University of Colorado School of Medicine, Denver
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19
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Human Fungal Pathogens: Diversity, Genomics, and Preventions. Fungal Biol 2021. [DOI: 10.1007/978-3-030-60659-6_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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20
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Carignan A, Denis M, Abou Chakra CN. Mortality associated with Blastomyces dermatitidis infection: A systematic review of the literature and meta-analysis. Med Mycol 2020; 58:1-10. [PMID: 31111911 DOI: 10.1093/mmy/myz048] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 02/27/2019] [Accepted: 04/18/2019] [Indexed: 11/13/2022] Open
Abstract
Published case fatality in blastomycosis patients ranges between 4% and 78%. This study aimed to assess mortality associated with blastomycosis and identify its associated risk factors. We conducted a systematic review of publications related to Blastomyces dermatitidis available in PubMed and Scopus databases. Studies that reported data on blastomycosis mortality and that were published from inception through February 2018 were assessed and included in the analysis. Using the R meta package, a random-effect model meta-analysis was used to calculate pooled and stratified estimates of case-fatality proportions and risk ratios. Of 1553 publications, we included 20 studies reporting on a total of 2820 cases of blastomycosis between 1970 and 2014 and three case series reports with 10, 21, and 36 patients. The mean or median ages ranged from 28 to 59 years. Mortality was defined as attributable mortality caused by blastomycosis in 13 studies. Among 14 studies with a standard error ≤0.05, the overall pooled mortality was 6.6% (95% confidence interval [CI], 4.9-8.2) with 57% heterogeneity. The mortality rate was 37% (95% CI, 23-51) in immunocompromised patients and 75% (95% CI, 53-96) in patients who developed an acute respiratory distress syndrome (ARDS) (n = 3 studies each). ARDS was the only identified risk factor in general patients (risk ratio = 10.2). The overall mortality was significantly higher in studies involving immunocompromised patients and ARDS patients. Our analysis showed considerable heterogeneity among studies. Inconsistent mortality definitions may have contributed to the observed heterogeneity. Further research is needed to assess potential risk factors for mortality.
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Affiliation(s)
- Alex Carignan
- Department of Microbiology and Infectious Diseases, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Mélina Denis
- Department of Microbiology and Infectious Diseases, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Claire Nour Abou Chakra
- Department of Microbiology and Infectious Diseases, Université de Sherbrooke, Sherbrooke, Quebec, Canada
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21
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Kirkland TN, Fierer J. Innate Immune Receptors and Defense Against Primary Pathogenic Fungi. Vaccines (Basel) 2020; 8:E303. [PMID: 32545735 PMCID: PMC7350247 DOI: 10.3390/vaccines8020303] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 06/10/2020] [Accepted: 06/11/2020] [Indexed: 02/07/2023] Open
Abstract
The innate immune system is critical for natural resistance to all pathogenic microorganisms, including fungi. The innate response plays a vital role in resistance to infections before the antigen-specific immune response and also influences antigen-specific adaptive immunity. There are many different receptors for the innate immune response to fungi, and some receptors have been found to play a significant role in the response to human infections with opportunistic fungi. Most human infections are caused by opportunistic fungi, but a small number of organisms are capable of causing infections in normal hosts. The primary pathogenic fungi that cause invasive infections include Blastomyces spp., Cryptococcus gattii, Coccidioides spp., Histoplasma spp., and Paracoccidioides spp. In this review of innate immune receptors that play a role in infections caused by these organisms, we find that innate immunity differs between organisms.
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Affiliation(s)
- Theo N. Kirkland
- Division of Infectious Diseases, Departments of Pathology and Medicine, School of Medicine, University of California San Diego, San Diego, CA 92037, USA;
| | - Joshua Fierer
- Division of Infectious Diseases, Departments of Pathology and Medicine, School of Medicine, University of California San Diego, San Diego, CA 92037, USA;
- VA HealthCare San Diego, San Diego, CA 92161, USA
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22
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Samrah S, Aleshawi A, Khassawneh B, Lahren K. Bronchoscopy in the diagnosis of pulmonary blastomycosis. Int J Infect Dis 2020; 96:187-191. [PMID: 32371194 DOI: 10.1016/j.ijid.2020.04.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/26/2020] [Accepted: 04/28/2020] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Diagnosing pulmonary blastomycosis (PB) requires the detection of Blastomyces dermatitidis in pulmonary secretions or tissue, which can be achieved via bronchoscopic procedures like bronchoalveolar lavage (BAL) or brush and transbronchial biopsy (TBBx). This descriptive study retrieved the data of PB that was diagnosed by bronchoscopy to define which bronchoscopic procedure produced the highest yield. METHODS Retrospectively, all patients diagnosed with PB via bronchoscopic approach were identified. Non-invasive BAL was referred to when performed first in the order of bronchoscopic procedures, and invasive BAL was used when it was performed after other bronchoscopic procedures. RESULTS A total of 111 patients were included in the study. BAL produced the highest yield of all bronchoscopic procedures (>87%), regardless if it was performed first in order (non-invasive, 87.3%) or not (invasive BAL, 89.6%) (p = 0.43). Performing bronchoscopy and BAL earlier in the course of the disease resulted in a significantly better diagnostic yield. CONCLUSIONS BAL is probably enough to diagnose PB. Also, it had the best yield when performed earlier, regardless of whether it was performed first in order or not. BAL culture had a better yield in detecting Blastomyces dermatitidis over fungal stain and cytology.
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Affiliation(s)
- Shaher Samrah
- Department of Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan.
| | | | - Basheer Khassawneh
- Department of Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
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23
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Bennie Ho K, Ng M, Tallon K. A case of disseminated blastomycosis with pulmonary, genitourinary, and osteoarticular involvement in southern Saskatchewan. JOURNAL OF THE ASSOCIATION OF MEDICAL MICROBIOLOGY AND INFECTIOUS DISEASE CANADA = JOURNAL OFFICIEL DE L'ASSOCIATION POUR LA MICROBIOLOGIE MEDICALE ET L'INFECTIOLOGIE CANADA 2020; 5:39-43. [PMID: 36339010 PMCID: PMC9603311 DOI: 10.3138/jammi.2019-0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 09/27/2019] [Indexed: 06/16/2023]
Abstract
Although southern Saskatchewan is not known to be a region endemic to blastomycosis, we present a case of disseminated blastomycosis in a 39-year-old man with pulmonary, genitourinary, and osteoarticular involvement. The patient presented with persistent fevers despite recent antibiotic therapy, arthritis in his left foot, and urinary obstruction. A computed tomography (CT) scan of the chest revealed a diffuse miliary pattern. A transbronchial biopsy only showed granulomatous changes, and washings were negative for fungal culture. Magnetic resonance imaging (MRI) of the left foot revealed signs of septic arthritis. Pathology from the joint aspiration and debridement revealed budding yeast in keeping with blastomycosis. Urine culture also grew blastomycosis, confirming urinary involvement. He was initiated on itraconazole, with complete resolution of his symptoms within 2 weeks. This case illustrates the challenges in diagnosing disseminated blastomycosis, and further establishes the endemicity of blastomycosis in southern Saskatchewan.
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Affiliation(s)
- Karen Bennie Ho
- Department of Internal Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Maxwell Ng
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Kelsey Tallon
- Department of Internal Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
- Department of Respirology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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24
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Merkhofer RM, Klein BS. Advances in Understanding Human Genetic Variations That Influence Innate Immunity to Fungi. Front Cell Infect Microbiol 2020; 10:69. [PMID: 32185141 PMCID: PMC7058545 DOI: 10.3389/fcimb.2020.00069] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 02/12/2020] [Indexed: 12/30/2022] Open
Abstract
Fungi are ubiquitous. Yet, despite our frequent exposure to commensal fungi of the normal mammalian microbiota and environmental fungi, serious, systemic fungal infections are rare in the general population. Few, if any, fungi are obligate pathogens that rely on infection of mammalian hosts to complete their lifecycle; however, many fungal species are able to cause disease under select conditions. The distinction between fungal saprophyte, commensal, and pathogen is artificial and heavily determined by the ability of an individual host's immune system to limit infection. Dramatic examples of commensal fungi acting as opportunistic pathogens are seen in hosts that are immune compromised due to congenital or acquired immune deficiency. Genetic variants that lead to immunological susceptibility to fungi have long been sought and recognized. Decreased myeloperoxidase activity in neutrophils was first reported as a mechanism for susceptibility to Candida infection in 1969. The ability to detect genetic variants and mutations that lead to rare or subtle susceptibilities has improved with techniques such as single nucleotide polymorphism (SNP) microarrays, whole exome sequencing (WES), and whole genome sequencing (WGS). Still, these approaches have been limited by logistical considerations and cost, and they have been applied primarily to Mendelian impairments in anti-fungal responses. For example, loss-of-function mutations in CARD9 were discovered by studying an extended family with a history of fungal infection. While discovery of such mutations furthers the understanding of human antifungal immunity, major Mendelian susceptibility loci are unlikely to explain genetic disparities in the rate or severity of fungal infection on the population level. Recent work using unbiased techniques has revealed, for example, polygenic mechanisms contributing to candidiasis. Understanding the genetic underpinnings of susceptibility to fungal infections will be a powerful tool in the age of personalized medicine. Future application of this knowledge may enable targeted health interventions for susceptible individuals, and guide clinical decision making based on a patient's individual susceptibility profile.
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Affiliation(s)
- Richard M Merkhofer
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
| | - Bruce S Klein
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States.,Department of Pediatrics, University of Wisconsin-Madison, Madison, WI, United States.,Department of Medicine, University of Wisconsin-Madison, Madison, WI, United States.,Department of Microbiology and Immunology, University of Wisconsin-Madison, Madison, WI, United States
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25
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Anderson JL, Frost HM, King JP, Meece JK. Racial Differences in Clinical Phenotype and Hospitalization of Blastomycosis Patients. Open Forum Infect Dis 2019; 6:ofz438. [PMID: 31696142 PMCID: PMC6824527 DOI: 10.1093/ofid/ofz438] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 10/01/2019] [Indexed: 01/09/2023] Open
Abstract
Background Dimorphic fungal infections, such as blastomycosis, cause significant morbidity and mortality. Historically, blastomycosis studies have focused on non-Hispanic whites, which limits our understanding of the clinical presentation and outcomes for patients of other races and ethnicities. We evaluated whether clinical presentation and disease severity varied across racial and ethnic groups. Methods Blastomycosis patients were identified from Marshfield Clinic Health System and data were abstracted from electronic medical records. Blastomyces genotyping was performed for cases with available isolates. Bivariate analyses (χ 2 tests/analysis of variance) assessed associations of race and/or ethnicity, Blastomyces spp, and hospitalization status with demographics and clinical presentation. Multivariable logistic regression was used to evaluate the association of race and/or ethnicity and hospitalization. Results In total, 477 patients were included. Age differences were observed across race and ethnicity categories (P < .0001). Non-Hispanic whites were oldest (median, 48 years; interquartile range [IQR], 31–62) and Asians were youngest (26 years; IQR, 19–41). Non-Hispanic whites (55%) and African Americans (52%) had underlying medical conditions more frequently than Hispanic whites (27%) and Asians (29%). Odds of hospitalization were 2 to 3 times higher for Hispanic whites (adjusted odds ratio [aOR], 2.9; 95% confidence interval [CI], 1.2–1.7), American Indian or Alaska Native (AIAN) (aOR, 2.4; 95% CI, 1.0–5.5), and Asian (aOR, 1.9; 95% CI, 1.0–3.6) patients compared with non-Hispanic white patients. Ninety percent of Blastomyces dermatitidis infections occurred in non-Hispanic whites, whereas blastomycosis in Hispanic whites, AIAN, and Asian patients was frequently caused by Blastomyces gilchristii (P < .0001). Conclusions Hispanic whites, AIAN, and Asian blastomycosis patients were younger and healthier but more frequently hospitalized. Patients in these racial and ethnic groups may need more aggressive treatment and closer therapeutic monitoring.
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Affiliation(s)
- Jennifer L Anderson
- Integrated Research and Development Laboratory, Marshfield Clinic Research Institute, Marshfield Clinic Health System, Marshfield, Wisconsin
| | - Holly M Frost
- Department of Pediatrics, Denver Health Medical Center, University of Colorado School of Medicine, Denver, Colorado
| | - Jennifer P King
- Center for Clinical Epidemiology and Population Health, Marshfield Clinic Research Institute, Marshfield Clinic Health System, Marshfield, Wisconsin
| | - Jennifer K Meece
- Integrated Research and Development Laboratory, Marshfield Clinic Research Institute, Marshfield Clinic Health System, Marshfield, Wisconsin
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26
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Anderson JL, Meece JK. Molecular detection of Blastomyces in an air sample from an outbreak associated residence. Med Mycol 2019; 57:897-899. [PMID: 30508124 DOI: 10.1093/mmy/myy085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 11/22/2018] [Indexed: 11/13/2022] Open
Abstract
Based on epidemiologic data during a blastomycosis outbreak, exposure within the home was suspected for two case patients that resided together. Soil and air samples were collected from the basement of their residence. Samples were tested for Blastomyces by culture and polymerase chain reaction (PCR) to compare with an available clinical isolate. An air sample from the basement of the residence was PCR positive for Blastomyces. Sequence data from the air sample and the outbreak clinical isolate were identified as different Blastomyces spp. Despite this, our findings suggest that the basement was suitable for the growth of Blastomyces and airborne organism was circulating.
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Affiliation(s)
- Jennifer L Anderson
- Integrated Research and Development Laboratory, Marshfield Clinic Research Institute, Marshfield Clinic Health System, Marshfield, Wisconsin, USA
| | - Jennifer K Meece
- Integrated Research and Development Laboratory, Marshfield Clinic Research Institute, Marshfield Clinic Health System, Marshfield, Wisconsin, USA
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Jorgenson MR, Cardinale B, Descourouez JL, Yang DY, Leverson GE, Parajuli S, Smith JA, Redfield RR. Evaluation of infectious risk and outcomes in the hmong renal transplant population. Transpl Infect Dis 2019; 21:e13142. [PMID: 31283867 DOI: 10.1111/tid.13142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 06/10/2019] [Accepted: 06/30/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND Hmong ethnicity has been associated with infection, particularly fungal. The risk of infection after transplant in the Hmong population is unknown. METHODS Observational study of adult renal transplant (RTX) recipients between 1/1/1994 and 12/31/2015. Primary objective was to identify infectious risk in the Hmong RTX population as compared to non-Hispanic whites (NHW). Secondary objective was to evaluate transplant outcomes. RESULTS There was a total of 2599 patients in the study window; 95 Hmong, 2504 NHW. The Hmong population had significantly fewer bacterial and fungal infections at 1 and 3 years (Bacterial: Hmong 21.7%, 32.4% vs NHW 36.9%, 46.7%, P = .004; Fungal: Hmong 3.3%, 5.7% vs NHW 12.7%, 16.6%, P = .0005) and improved graft and patient survival at 1, 5, and 10 years (Graft: Hmong 92.6%, 78.4%, 61.9% vs NHW 90.7%, 72.2%, 48.5%, P = .006; Patient: Hmong 97.8%, 94.5%, 83.3% vs NHW 95.3%, 82.1%, 62.1% P < .001). Spectrum of bacterial infection was similar, but with significantly more Staphylococcal infection in the NHW population. Blastomycoses were the major fungal pathogen in Hmong (2/3, 67%) vs Candida in NWH (77%). When minimally adjusted for PRA and age, rates of bacterial infection (HR 0.69, 95% CI 0.48-0.99, P = .047), fungal infection (HR 0.39, 95% CI 0.17-0.87, P = .02), and mortality (HR 0.5, 95% CI 0.28-0.88, P = .02) were more favorable in the Hmong population. When analyzed in a stepwise Cox proportional hazards model; Hmong ethnicity was not a significant risk factor for graft failure, rejection, CMV, BK, or fungal infection after RTX and was associated with reduced risk of bacterial infection (HR 0.61, 95% CI 0.4-0.9, P = .02) and mortality (HR 0.51, 95% CI 0.27-0.96, P = .04). CONCLUSIONS Despite concern regarding infective risk in the Hmong population, infection after RTX is no higher than NHW comparator. In all analyses, the Hmong population has equal or better outcomes. It does not appear variance in standard infection prophylaxis is necessary for the Hmong population after RTX.
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Affiliation(s)
- Margaret R Jorgenson
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | | | - Jillian L Descourouez
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Dou-Yan Yang
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Glen E Leverson
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Sandesh Parajuli
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Jeannina A Smith
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Robert R Redfield
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI, USA
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Merkhofer RM, O'Neill MB, Xiong D, Hernandez-Santos N, Dobson H, Fites JS, Shockey AC, Wuethrich M, Pepperell CS, Klein BS. Investigation of Genetic Susceptibility to Blastomycosis Reveals Interleukin-6 as a Potential Susceptibility Locus. mBio 2019; 10:e01224-19. [PMID: 31213563 PMCID: PMC6581865 DOI: 10.1128/mbio.01224-19] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 05/16/2019] [Indexed: 12/12/2022] Open
Abstract
Genetic differences are hypothesized to underlie ethnic disparities in incidence rates of the endemic systemic mycoses, including blastomycosis. Individuals of Hmong ancestry display elevated risk for this serious fungal infection. Here, we interrogated the genomes of Wisconsin (WI) Hmong blastomycosis patients using homozygosity mapping to uncover regions of the genome that are likely shared among the greater Hmong population and filtered for variants with high potential to affect disease susceptibility. This approach uncovered 113 candidate susceptibility variants, and among the most promising are those in genes involved in the interleukin-17 (IL-17) response. In particular, we identified 25 linked variants near the gene encoding IL-6 (IL6). We validated differences in cytokine production between Hmong and European volunteers and formally demonstrated a critical role for IL-6 in the development of adaptive immunity to Blastomyces dermatitidis Our findings suggest that the dysregulation of IL-17 responses underlies a recently reported and poorly understood ethnic health disparity.IMPORTANCE Blastomycosis is a potentially life-threatening infection caused by the fungus Blastomyces dermatitidis As with related fungal diseases, blastomycosis is noted to affect some populations more than others. These patterns of illness are often not related to predisposing conditions or exposure risks; thus, genetic differences are thought to underlie these health disparities. People of Hmong ancestry in Wisconsin are at elevated risk of blastomycosis compared to the general population. We studied the genetic codes of Hmong blastomycosis patients and identified candidate sites in their genomes that may explain their susceptibility to this infection. We further studied one particular region of the genome that is involved with the immune processes that fight B. dermatitidis Our work revealed population differences in the response to fungi. A better understanding of the genetic underpinnings of susceptibility to infectious diseases has broader implications for community health, especially in the paradigm of personalized medicine.
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Affiliation(s)
- Richard M Merkhofer
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Mary B O'Neill
- Laboratory of Genetics, University of Wisconsin-Madison, Madison, Wisconsin, USA
- Department of Medical Microbiology and Immunology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Donny Xiong
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Nydiaris Hernandez-Santos
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Hannah Dobson
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - J Scott Fites
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Abigail C Shockey
- Department of Medical Microbiology and Immunology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Marcel Wuethrich
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Caitlin S Pepperell
- Department of Medical Microbiology and Immunology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Bruce S Klein
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
- Department of Medical Microbiology and Immunology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
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Brown EM, McTaggart LR, Dunn D, Pszczolko E, Tsui KG, Morris SK, Stephens D, Kus JV, Richardson SE. Epidemiology and Geographic Distribution of Blastomycosis, Histoplasmosis, and Coccidioidomycosis, Ontario, Canada, 1990-2015. Emerg Infect Dis 2019; 24:1257-1266. [PMID: 29912691 PMCID: PMC6038754 DOI: 10.3201/eid2407.172063] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Elevated incidence of blastomycosis in Ontario calls for diagnostic vigilance. Endemic mycoses represent a growing public health challenge in North America. We describe the epidemiology of 1,392 microbiology laboratory–confirmed cases of blastomycosis, histoplasmosis, and coccidioidomycosis in Ontario during 1990–2015. Blastomycosis was the most common infection (1,092 cases; incidence of 0.41 cases/100,000 population), followed by histoplasmosis (211 cases) and coccidioidomycosis (89 cases). Incidence of blastomycosis increased from 1995 to 2001 and has remained elevated, especially in the northwest region, incorporating several localized hotspots where disease incidence (10.9 cases/100,000 population) is 12.6 times greater than in any other region of the province. This retrospective study substantially increases the number of known endemic fungal infections reported in Canada, confirms Ontario as an important region of endemicity for blastomycosis and histoplasmosis, and provides an epidemiologic baseline for future disease surveillance. Clinicians should include blastomycosis and histoplasmosis in the differential diagnosis of antibiotic-refractory pneumonia in patients traveling to or residing in Ontario.
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Abstract
OBJECTIVE The objective of our study was to characterize and update the radiologic patterns of pediatric pulmonary blastomycosis, and correlate the radiologic patterns with patient age. MATERIALS AND METHODS Patients 0-18 years old with pulmonary blastomycosis who underwent chest imaging from 2005 to 2016 were included in this study. The following data were collected: age, sex, clinical information, and imaging findings including presence of extrapulmonary involvement and scarring on follow-up examinations. Concordance between radiography and CT was analyzed. RESULTS Thirty-six patients (28 boys and eight girls) ranging in age from 3 months to 17 years (mean, 10.5 years) were identified. Consolidation was found in 94.4% of patients and was unilateral in 76.5% of cases and bilateral in 23.5%. Upper (70.6%) and middle (47.1%) lobes were more frequently involved. Air bronchograms were identified in 76.5% of patients with consolidations, masslike consolidation was found in 55.9%, cavitation in 38.2%, and bubbly pattern (i.e., multiple small cavities) in 32.4%. In all patients younger than 5 years, consolidations involved multiple lobes. In 67.6% of patients, consolidations were associated with the following additional pulmonary or pleural abnormalities: pulmonary nodules (50% of patients), diffuse patchy opacification (26.5%), reticulonodular pattern (41.2%), atelectasis (5.9%), pleural effusion (20.6%), and hilar lymphadenopathy (23.5%). Pulmonary scarring was found in 70.4% of patients. Five patients had extrapulmonary involvement. The concordance between radiography and CT was excellent for location and extension of consolidation and diagnosis of cavitation, bubbly pattern, and nodules. CONCLUSION The most common pattern of lung involvement from pulmonary blastomycosis in our series was a combination of consolidations with bilateral lung nodules and reticulonodular opacification.
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Lohrenz S, Minion J, Pandey M, Karunakaran K. Blastomycosis in Southern Saskatchewan 2000-2015: Unique presentations and disease characteristics. Med Mycol 2018; 56:787-795. [PMID: 29924358 DOI: 10.1093/mmy/myx131] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 10/28/2017] [Indexed: 11/14/2022] Open
Abstract
In the literature, cases of blastomycosis in Canada have been documented in provinces bordering the Great Lakes, including Ontario and Quebec, as well as Manitoba. This is the first study to our knowledge reporting cases of mycosis seen in southern Saskatchewan suggesting a broader area of endemicity. We searched the Regina Qu'Appelle Health Region (RQHR) Microbiology Laboratory for all culture-confirmed cases of Blastomyces from January 2000 to December 2015 and identified 15 cases. Thirteen cases were reviewed, identifying common presenting symptoms, misdiagnosis, comorbidities, travel history, time from presentation to diagnosis, diagnostic specimen, treatment, and clinical outcome. Nine patients had no travel to areas known to be endemic to environmental blastomycosis. Eight patients presented with respiratory symptoms, four with skin lesions, four with constitutional symptoms, and one presented with chest pain after a fall. Initial misdiagnosis occurred in nine (69%) of the 13 cases, and all six patients that died of the disease were misdiagnosed. These six patients (46%) were acutely ill with refractory disseminated disease, leading to respiratory failure. It is probable that Blastomyces is present as an endemic fungus in the soil of southern Saskatchewan. Possibly due to a lack of awareness of this pathogen in the area, initial misdiagnoses were common and likely contributed to significant morbidity and mortality.
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Affiliation(s)
- Sarah Lohrenz
- College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Jessica Minion
- Dept of Laboratory Medicine, Regina Qu'Appelle Health Region, Regina, SK, Canada.,Dept of Pathology and Laboratory Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Mamata Pandey
- Dept of Research and Performance Support, Regina Qu'Appelle Health Region, Regina, SK, Canada
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Baumgardner DJ. Use of Urine Antigen Testing for Blastomyces in an Integrated Health System. J Patient Cent Res Rev 2018; 5:176-182. [PMID: 31414001 DOI: 10.17294/2330-0698.1452] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Purpose Blastomycosis, an endemic fungal infection, mimics many other diseases. We explored the use of Blastomyces urine antigen (BuAg), reportedly the most sensitive noninvasive test, in clinical practice and compared it to other noninvasive tests. Methods A total of 836 BuAg tests performed on unique patients (first test only) at one large integrated health system from June 2013 to May 2016 were retrospectively reviewed to examine test characteristics and demographic features. Of these, 100 cases from 2015, a year containing a large local blastomycosis outbreak, were randomly selected for detailed analysis. Results Demographics for the BuAg-tested population: mean age 54.9 years, 55.0% male, 78.9% white, 213 zip codes represented. Test results were positive in 49 of 836 (5.9%, across 43 zip codes); 16 of the 49 (32.7%) stemmed from the 2015 outbreak. BuAg-positive patients were younger than those who tested negative, even with outbreak subjects removed (48.1 vs 56.7 years, P=0.008); and Asians and males were overrepresented. Sensitivity/specificity/positive predictive value of BuAg test was 87.9%/97.9%/76.3%, respectively, based on 33 culture-positive cases. Only 2 of 20 culture-positive cases were found positive by Blastomyces antibody (Ab) immunodiffusion (ID) test and 0 of the other 18 by Ab complement fixation (CF). Of those with positive BuAg who were co-tested, 16.1% were positive by Ab ID and 3.9% by Ab CF. Histoplasma urine antigen was co-performed with BuAg in 578 patients (69.1%) and positive in 25 (4.3%); 16 of these 25 (64.0%) also were BuAg-positive (ie, known cross-reactivity). Of the 100 patients examined for index illness details, 7 (6 BuAg-positive) were ultimately diagnosed with blastomycosis, 7 other fungal disease, 26 noninfectious lung disease, 22 pneumonia, 5 skin lesions, 6 malignancies, 3 mycobacteria, 11 other, and 1 unknown. Of 100, 12 were tested by BuAg based on symptoms. Conclusions Blastomyces urine antigen is commonly used for work-up of broad differential diagnoses or known exposures. Not adding Ab ID/CF diagnostic tests ($80 each) to the BuAg test saves money without losing sensitivity.
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Affiliation(s)
- Dennis J Baumgardner
- Aurora UW Medical Group, Aurora Health Care, Milwaukee WI; Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI; Center for Urban Population Health, Milwaukee, WI
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Benedict K, Richardson M, Vallabhaneni S, Jackson BR, Chiller T. Emerging issues, challenges, and changing epidemiology of fungal disease outbreaks. THE LANCET. INFECTIOUS DISEASES 2017; 17:e403-e411. [PMID: 28774697 DOI: 10.1016/s1473-3099(17)30443-7] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 10/12/2016] [Accepted: 02/09/2017] [Indexed: 12/14/2022]
Abstract
Several high-profile outbreaks have drawn attention to invasive fungal infections (IFIs) as an increasingly important public health problem. IFI outbreaks are caused by many different fungal pathogens and are associated with numerous settings and sources. In the community, IFI outbreaks often occur among people without predisposing medical conditions and are frequently precipitated by environmental disruption. Health-care-associated IFI outbreaks have been linked to suboptimal hospital environmental conditions, transmission via health-care workers' hands, contaminated medical products, and transplantation of infected organs. Outbreak investigations provide important insights into the epidemiology of IFIs, uncover risk factors for infection, and identify opportunities for preventing similar events in the future. Well recognised challenges with IFI outbreak recognition, response, and prevention include the need for improved rapid diagnostic methods, the absence of routine surveillance for most IFIs, adherence to infection control practices, and health-care provider awareness. Additionally, IFI outbreak investigations have revealed several emerging issues, including new populations at risk because of travel or relocation, occupation, or immunosuppression; fungal pathogens appearing in geographical areas in which they have not been previously recognised; and contaminated compounded medications. This report highlights notable IFI outbreaks in the past decade, with an emphasis on these emerging challenges in the USA.
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Affiliation(s)
- Kaitlin Benedict
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Malcolm Richardson
- Mycology Reference Centre, University Hospital of South Manchester and University of Manchester, Manchester, UK
| | - Snigdha Vallabhaneni
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Brendan R Jackson
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Tom Chiller
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA.
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Abstract
The causal agents of blastomycosis, Blastomyces dermatitidis and Blastomyces gilchristii, belong to a group of thermally dimorphic fungi that can infect healthy and immunocompromised individuals. Following inhalation of mycelial fragments and spores into the lungs, Blastomyces spp convert into pathogenic yeast and evade host immune defenses to cause pneumonia and disseminated disease. The clinical spectrum of pulmonary blastomycosis is diverse. The diagnosis of blastomycosis requires a high degree of clinical suspicion and involves culture-based and non-culture-based fungal diagnostic tests. The site and severity of infection, and the presence of underlying immunosuppression or pregnancy, influence the selection of antifungal therapy.
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Affiliation(s)
- Joseph A McBride
- Division of Infectious Disease, Department of Medicine, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI 53792, USA; Division of Infectious Disease, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, 1675 Highland Avenue, Madison, WI 53792, USA
| | - Gregory M Gauthier
- Division of Infectious Disease, Department of Medicine, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI 53792, USA.
| | - Bruce S Klein
- Division of Infectious Disease, Department of Medicine, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI 53792, USA; Division of Infectious Disease, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, 1675 Highland Avenue, Madison, WI 53792, USA; Department of Medical Microbiology and Immunology, University of Wisconsin School of Medicine and Public Health, 1550 Linden Drive, Madison, WI 53706, USA.
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Batzlaff CM, Limper AH. When to Consider the Possibility of a Fungal Infection: An Overview of Clinical Diagnosis and Laboratory Approaches. Clin Chest Med 2017; 38:385-391. [PMID: 28797483 DOI: 10.1016/j.ccm.2017.04.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Fungal infections are an important and increasingly prevalent cause of disease in certain patient populations. These infections can occur both in immune-compromised and immune-competent individuals. Because the number of patients who are immunocompromised is steadily growing, it is vital for clinicians to consider fungal disease in the differential diagnosis of these patients. This article reviews the epidemiology and approach to diagnosis of a variety of fungal infections.
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Affiliation(s)
- Cassandra M Batzlaff
- Thoracic Diseases Research Unit, Division of Pulmonary Critical Care and Internal Medicine, Department of Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | - Andrew H Limper
- Thoracic Diseases Research Unit, Division of Pulmonary Critical Care and Internal Medicine, Department of Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA.
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Thompson K, Sterkel AK, Brooks EG. Blastomycosis in Wisconsin: Beyond the Outbreaks. Acad Forensic Pathol 2017; 7:119-129. [PMID: 31239964 DOI: 10.23907/2017.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 12/20/2016] [Indexed: 11/12/2022]
Abstract
In the summer of 2015, many individuals visiting the Little Wolf River in Waupaca County were exposed to the pathogenic fungus, Blastomyces. Over time, 59 confirmed and 39 probable cases were reported to the Wisconsin Department of Health Services (W-DHS), making this one of the largest outbreaks in recent state history. Though most instances of blastomycosis are not associated with common source outbreaks, cases such as this highlight the need for vigilance regarding this preventable cause of death. In the state of Wisconsin, an average of 118.6 cases (range, 84-174) of confirmed blastomycosis are diagnosed annually; the majority of these cases are sporadic rather than outbreak-associated. In the current study, we review characteristics of blastomycosis cases diagnosed at our academic medical center, as well as examine statewide W-DHS data, in order to familiarize pathologists with the epidemiologic and histologic characteristics of this disease.
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Affiliation(s)
- Katrina Thompson
- University of Wisconsin Hospital and Clinics - Department of Pathology and Laboratory Medicine
| | - Alana K Sterkel
- University of Wisconsin Hospital and Clinics - Department of Pathology and Laboratory Medicine
| | - Erin G Brooks
- University of Wisconsin Hospital and Clinics - Department of Pathology and Laboratory Medicine
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Frost HM, Anderson J, Ivacic L, Meece J. Blastomycosis in Children: An Analysis of Clinical, Epidemiologic, and Genetic Features. J Pediatric Infect Dis Soc 2017; 6:49-56. [PMID: 26703241 DOI: 10.1093/jpids/piv081] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 11/10/2015] [Indexed: 11/14/2022]
Abstract
BACKGROUND Blastomyces spp. are endemic in regions of the United States and result in blastomycosis, a serious and potentially fatal infection. Little is known about the presentation, clinic course, epidemiology, and genetics of blastomycosis in children. METHODS A retrospective review of children with blastomycosis confirmed by culture or cytopathology between 1999 and 2014 was completed. Blastomyces sp. isolates were genotyped by using microsatellite typing, and species were typed by sequencing of internal transcribed spacer 2 (its2). RESULTS Of the 114 children with blastomycosis identified, 79% had isolated pulmonary involvement and 21% had extrapulmonary disease. There were more systemic findings, including fever (P = .01), poor intake (P = .01), elevated white blood cell count (P < .01), and elevated C-reactive protein level (P < .01), in children with isolated pulmonary disease than in children with extrapulmonary disease. Children with extrapulmonary disease had more surgeries (P = .01) and delays in diagnosis (P < .01) than those with isolated pulmonary infection. Of 52 samples genotyped, 48 (92%) were Blastomyces gilchristii and 4 (8%) were Blastomyces dermatitidis. CONCLUSION This is the first large-scale study of the clinical, epidemiologic, and genetic features of blastomycosis in children. The majority of the children had isolated pulmonary disease with systemic findings. Patients with extrapulmonary disease were less likely to have systemic symptoms or additional laboratory evidence of infection, which made delays in diagnosis more common. More than 90% of the pediatric cases were caused by B gilchristii.
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Affiliation(s)
- Holly M Frost
- Department of Pediatrics, Marshfield Clinic, Minocqua.,Marshfield Clinic Research Foundation, Marshfield, Wisconsin
| | | | - Lynn Ivacic
- Marshfield Clinic Research Foundation, Marshfield, Wisconsin
| | - Jennifer Meece
- Marshfield Clinic Research Foundation, Marshfield, Wisconsin
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Enoch DA, Yang H, Aliyu SH, Micallef C. The Changing Epidemiology of Invasive Fungal Infections. Methods Mol Biol 2017; 1508:17-65. [PMID: 27837497 DOI: 10.1007/978-1-4939-6515-1_2] [Citation(s) in RCA: 238] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
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.
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Affiliation(s)
- David A Enoch
- National Infection Service, Public Health England, Cambridge Microbiology and Public Health Laboratory, Addenbrooke's Hospital, Box 236, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QW, UK.
| | - Huina Yang
- National Infection Service, Public Health England, Cambridge Microbiology and Public Health Laboratory, Addenbrooke's Hospital, Box 236, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QW, UK
| | - Sani H Aliyu
- National Infection Service, Public Health England, Cambridge Microbiology and Public Health Laboratory, Addenbrooke's Hospital, Box 236, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QW, UK
| | - Christianne Micallef
- National Infection Service, Public Health England, Cambridge Microbiology and Public Health Laboratory, Addenbrooke's Hospital, Box 236, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QW, UK
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Duong TN, Waldman SE. Importance of a Travel History in Evaluation of Respiratory Infections. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2016; 4:141-152. [PMID: 32226655 PMCID: PMC7100244 DOI: 10.1007/s40138-016-0109-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW International travel has increased at a fast pace and will continue to rapidly rise. Concomitantly, with this increase in travel is the increase in post travel-related diseases, such as respiratory illnesses. Identifying the cause of the posttravel respiratory illness is a complex challenge for many healthcare professionals because similar presentations occur for both infectious and noninfectious causes. Not only is diagnosis important but also transmission prevention. In the last two decades, there have been several severe infectious respiratory syndromes that have spread through international travel causing epidemics in many countries. RECENT FINDINGS A detailed travel history with the chronology of symptoms paired with the patient's medical risk factors and exposures along with some basic knowledge of infectious respiratory illnesses will help facilitate clinical decision making. This framework will help create a broad, but appropriate differential diagnosis to guide clinical workup, prevent delays in diagnosis, and implement the appropriate precautions to prevent transmission if appropriate. SUMMARY The foundation to diagnosing a travel-related respiratory illness lies within integrating the patient's travel history, comorbid conditions, clinical presentation, exposures, and mode of transmission. A timely and accurate diagnosis benefits not only the patient but also the surrounding community to prevent further individual transmission, epidemics, and pandemics.
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Affiliation(s)
- Theresa N. Duong
- Division of Hospital Medicine, Department of Internal Medicine, University of California, Davis Medical Center, Sacramento, CA USA
| | - Sarah E. Waldman
- Division of Infectious Diseases, Department of Internal Medicine, University of California, Davis Medical Center, Sacramento, CA USA
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Glatman-Freedman A, Kaufman Z, Kopel E, Bassal R, Taran D, Valinsky L, Agmon V, Shpriz M, Cohen D, Anis E, Shohat T. Near real-time space-time cluster analysis for detection of enteric disease outbreaks in a community setting. J Infect 2016; 73:99-106. [PMID: 27311747 DOI: 10.1016/j.jinf.2016.04.038] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 04/19/2016] [Accepted: 04/20/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To enhance timely surveillance of bacterial enteric pathogens, space-time cluster analysis was introduced in Israel in May 2013. METHODS Stool isolation data of Salmonella, Shigella, and Campylobacter from patients of a large Health Maintenance Organization were analyzed weekly by ArcGIS and SaTScan, and cluster results were sent promptly to local departments of health (LDOHs). RESULTS During eighteen months, we identified 52 Shigella sonnei clusters, two Salmonella clusters, and no Campylobacter clusters. S. sonnei clusters lasted from one to 33 days and included three to 30 individuals. Thirty-one (60%) of the S. sonnei clusters were known to LDOHs prior to cluster analysis. Clusters not previously known by the LDOHs prompted epidemiologic investigations. In 31 of the 37 (84%) confirmed clusters, educational institutes (nursery schools, kindergartens, and a primary school) were involved. CONCLUSIONS Cluster analysis demonstrated capability to complement enteric disease surveillance. Scaling up the system can further enhance timely detection and control of outbreaks.
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Affiliation(s)
- Aharona Glatman-Freedman
- Infectious Diseases Unit, Israel Center for Disease Control, Tel-Hashomer, Israel; Department of Pediatrics, New York Medical College, Valhalla, NY, USA; Department of Family and Community Medicine, New York Medical College, Valhalla, NY, USA.
| | - Zalman Kaufman
- Infectious Diseases Unit, Israel Center for Disease Control, Tel-Hashomer, Israel
| | - Eran Kopel
- Division of Epidemiology, Ministry of Health, Jerusalem, Israel
| | - Ravit Bassal
- Infectious Diseases Unit, Israel Center for Disease Control, Tel-Hashomer, Israel
| | - Diana Taran
- Maccabi Healthcare Services, Tel-Aviv, Israel
| | - Lea Valinsky
- Government Central Laboratories, Ministry of Health, Jerusalem, Israel
| | - Vered Agmon
- Government Central Laboratories, Ministry of Health, Jerusalem, Israel
| | - Manor Shpriz
- Division of Epidemiology, Ministry of Health, Jerusalem, Israel
| | - Daniel Cohen
- School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Emilia Anis
- Division of Epidemiology, Ministry of Health, Jerusalem, Israel
| | - Tamy Shohat
- Infectious Diseases Unit, Israel Center for Disease Control, Tel-Hashomer, Israel; School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
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Smith CM, Le Comber SC, Fry H, Bull M, Leach S, Hayward AC. Spatial methods for infectious disease outbreak investigations: systematic literature review. ACTA ACUST UNITED AC 2016; 20:30026. [PMID: 26536896 DOI: 10.2807/1560-7917.es.2015.20.39.30026] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 09/02/2015] [Indexed: 12/28/2022]
Abstract
Investigations of infectious disease outbreaks are conventionally framed in terms of person, time and place. Although geographic information systems have increased the range of tools available, spatial analyses are used relatively infrequently. We conducted a systematic review of published reports of outbreak investigations worldwide to estimate the prevalence of spatial methods, describe the techniques applied and explore their utility. We identified 80 reports using spatial methods published between 1979 and 2013, ca 0.4% of the total number of published outbreaks. Environmental or waterborne infections were the most commonly investigated, and most reports were from the United Kingdom. A range of techniques were used, including simple dot maps, cluster analyses and modelling approaches. Spatial tools were usefully applied throughout investigations, from initial confirmation of the outbreak to describing and analysing cases and communicating findings. They provided valuable insights that led to public health actions, but there is scope for much wider implementation and development of new methods.
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Affiliation(s)
- Catherine M Smith
- UCL Department of Infectious Disease Informatics, Farr Institute of Health Informatics Research, University College London, London, United Kingdom
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43
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Azar MM, Assi R, Relich RF, Schmitt BH, Norris S, Wheat LJ, Hage CA. Blastomycosis in Indiana: Clinical and Epidemiologic Patterns of Disease Gleaned from a Multicenter Retrospective Study. Chest 2016; 148:1276-1284. [PMID: 26020566 DOI: 10.1378/chest.15-0289] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND To better understand clinical and epidemiologic patterns of blastomycosis, we report on a large series of blastomycosis in Indiana. METHODS All microbiologically and histopathologically confirmed cases of blastomycosis from four hospitals serving Central Indiana from 1985 to 2014 were identified. Available data were collected. Data on population estimates, annual precipitation, and construction in Indiana were evaluated for correlations with incidence rates of blastomycosis. RESULTS A total of 114 patients were identified. The mean age was 44.4 years; 27% had diabetes mellitus, and 16% were immunosuppressed. Most presented with pneumonia (90%); 48% had extrapulmonary disease (CNS involvement in 9%), and 15% developed ARDS. Cultures, cytopathology, and histopathology were positive in 86%, 27%, and 85% of the sample, respectively, and fungal antigen was positive in 76%. Amphotericin B was administered in 49%, and 87% received an azole. Total mortality was 12%. Immunosuppression (OR = 3.0), diabetes mellitus (OR = 2.9), and multilobar pneumonia (OR = 2.9) were associated with increased likelihood of ICU admission. There was a significant increase in incidence over time in Marion County. There was no correlation with amount of precipitation, but the rise in incidence coincided with a 2005 state initiative to expand Indiana's highway infrastructure. CONCLUSIONS The incidence of blastomycosis in Central Indiana may be on the rise. Physicians in endemic areas should be aware of the potentially fulminant consequences of the disease.
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Affiliation(s)
- Marwan M Azar
- Section of Infectious Disease, Yale University School of Medicine, New Haven, CT
| | - Roland Assi
- Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Ryan F Relich
- Department of Pathology and Laboratory Medicine (Drs Relich and Schmitt), Thoracic Transplantation Program, Indiana University School of Medicine, Indianapolis, IN
| | - Bryan H Schmitt
- Department of Pathology and Laboratory Medicine (Drs Relich and Schmitt), Thoracic Transplantation Program, Indiana University School of Medicine, Indianapolis, IN
| | | | | | - Chadi A Hage
- Department of Pulmonary-Critical Care Medicine, Thoracic Transplantation Program, Indiana University School of Medicine, Indianapolis, IN.
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Abstract
Blastomycosis is an endemic fungal infection due to Blastomyces dermatitidis that most commonly causes pneumonia; but the organism can disseminate to any organ system, most commonly the skin, bones/joints, and genitourinary tract. Both immunocompetent and immunocompromised persons can be infected, but more severe disease occurs in the immunocompromised. Blastomycosis can be diagnosed by culture, direct visualization of the yeast in affected tissue, and/or antigen testing. Treatment course and duration depend on severity of illness. For mild to moderate pulmonary disease the treatment is itraconazole. For severe blastomycosis, lipid formulation amphotericin B is given, followed by step-down therapy with itraconazole.
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Affiliation(s)
- Caroline G Castillo
- Division of Infectious Diseases, University of Michigan Health System, 3119 Taubman Center, Ann Arbor, MI 48109, USA
| | - Carol A Kauffman
- Division of Infectious Diseases, University of Michigan Health System, 3119 Taubman Center, Ann Arbor, MI 48109, USA; Division of Infectious Diseases, Veterans Affairs Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, USA
| | - Marisa H Miceli
- Division of Infectious Diseases, University of Michigan Health System, 3119 Taubman Center, Ann Arbor, MI 48109, USA.
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Abstract
Risks for illness and death caused by the Blastomyces dermatitidis fungus are affected by demographic, geographic, and behavioral factors. Blastomycosis is a potentially fatal fungal infection endemic to parts of North America. We used national multiple-cause-of-death data and census population estimates for 1990–2010 to calculate age-adjusted mortality rates and rate ratios (RRs). We modeled trends over time using Poisson regression. Death occurred more often among older persons (RR 2.11, 95% confidence limit [CL] 1.76, 2.53 for those 75–84 years of age vs. 55–64 years), men (RR 2.43, 95% CL 2.19, 2.70), Native Americans (RR 4.13, 95% CL 3.86, 4.42 vs. whites), and blacks (RR 1.86, 95% CL 1.73, 2.01 vs. whites), in notably younger persons of Asian origin (mean = 41.6 years vs. 64.2 years for whites); and in the South (RR 18.15, 95% CL 11.63, 28.34 vs. West) and Midwest (RR 23.10, 95% CL14.78, 36.12 vs. West). In regions where blastomycosis is endemic, we recommend that the diagnosis be considered in patients with pulmonary disease and that it be a reportable disease.
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Polvi EJ, Li X, O’Meara TR, Leach MD, Cowen LE. Opportunistic yeast pathogens: reservoirs, virulence mechanisms, and therapeutic strategies. Cell Mol Life Sci 2015; 72:2261-87. [PMID: 25700837 PMCID: PMC11113693 DOI: 10.1007/s00018-015-1860-z] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Revised: 02/06/2015] [Accepted: 02/11/2015] [Indexed: 12/21/2022]
Abstract
Life-threatening invasive fungal infections are becoming increasingly common, at least in part due to the prevalence of medical interventions resulting in immunosuppression. Opportunistic fungal pathogens of humans exploit hosts that are immunocompromised, whether by immunosuppression or genetic predisposition, with infections originating from either commensal or environmental sources. Fungal pathogens are armed with an arsenal of traits that promote pathogenesis, including the ability to survive host physiological conditions and to switch between different morphological states. Despite the profound impact of fungal pathogens on human health worldwide, diagnostic strategies remain crude and treatment options are limited, with resistance to antifungal drugs on the rise. This review will focus on the global burden of fungal infections, the reservoirs of these pathogens, the traits of opportunistic yeast that lead to pathogenesis, host genetic susceptibilities, and the challenges that must be overcome to combat antifungal drug resistance and improve clinical outcome.
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Affiliation(s)
- Elizabeth J. Polvi
- Department of Molecular Genetics, University of Toronto, 1 King’s College Circle, Medical Sciences Building, Room 4368, Toronto, ON M5S 1A8 Canada
| | - Xinliu Li
- Department of Molecular Genetics, University of Toronto, 1 King’s College Circle, Medical Sciences Building, Room 4368, Toronto, ON M5S 1A8 Canada
| | - Teresa R. O’Meara
- Department of Molecular Genetics, University of Toronto, 1 King’s College Circle, Medical Sciences Building, Room 4368, Toronto, ON M5S 1A8 Canada
| | - Michelle D. Leach
- Department of Molecular Genetics, University of Toronto, 1 King’s College Circle, Medical Sciences Building, Room 4368, Toronto, ON M5S 1A8 Canada
- Aberdeen Fungal Group, Institute of Medical Sciences, School of Medical Sciences, University of Aberdeen, Foresterhill, Aberdeen, UK
| | - Leah E. Cowen
- Department of Molecular Genetics, University of Toronto, 1 King’s College Circle, Medical Sciences Building, Room 4368, Toronto, ON M5S 1A8 Canada
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Seitz AE, Adjemian J, Steiner CA, Prevots DR. Spatial epidemiology of blastomycosis hospitalizations: detecting clusters and identifying environmental risk factors. Med Mycol 2015; 53:447-54. [PMID: 25908653 PMCID: PMC11037033 DOI: 10.1093/mmy/myv014] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2014] [Accepted: 01/15/2015] [Indexed: 01/30/2023] Open
Abstract
Blastomycosis is a disease caused by endemic fungi that ranges from severe pulmonary or disseminated to mild or asymptomatic. Environmental factors associated with it are not well described throughout the endemic area. We used the intramural State Inpatient Database from the Agency for Healthcare Research and Quality and ArcMap GIS to identify geographic high-risk clusters of blastomycosis hospitalizations in 13 states in the US endemic regions (AR, IA, IL, IN, KY, LA, MI, MN, MO, MS, OH, TN, and WI). We then used logistic regression to identify risk factors associated with these high-risk clusters. We describe six clusters of counties in which there was an elevated incidence of blastomycosis hospitalizations. We identified maximum mean annual temperature, percentage of persons aged ≥65 years, and mercury and copper soil content as being associated with high-risk clusters. Specifically, the odds of a county being part of a high-risk cluster was associated with increasing percentage of population over age 65, decreasing maximum temperature, increasing mercury, and decreasing copper soil content. Healthcare providers should be aware of these high-risk areas so that blastomycosis can be included, as appropriate, in a differential diagnosis for patients currently or previously residing in these areas.
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Affiliation(s)
- Amy E Seitz
- Epidemiology Unit, Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, DC
| | - Jennifer Adjemian
- Epidemiology Unit, Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Claudia A Steiner
- Healthcare Cost Utilization Project, United States Agency for Healthcare Research and Quality, Rockville, Maryland
| | - D Rebecca Prevots
- Epidemiology Unit, Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
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Hull CM, Purdy NJ, Moody SC. Mitigation of human-pathogenic fungi that exhibit resistance to medical agents: can clinical antifungal stewardship help? Future Microbiol 2015; 9:307-25. [PMID: 24762306 DOI: 10.2217/fmb.13.160] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Reducing indiscriminate antimicrobial usage to combat the expansion of multidrug-resistant human-pathogenic bacteria is fundamental to clinical antibiotic stewardship. In contrast to bacteria, fungal resistance traits are not understood to be propagated via mobile genetic elements, and it has been proposed that a global explosion of resistance to medical antifungals is therefore unlikely. Clinical antifungal stewardship has focused instead on reducing the drug toxicity and high costs associated with medical agents. Mitigating the problem of human-pathogenic fungi that exhibit resistance to antimicrobials is an emergent issue. This article addresses the extent to which clinical antifungal stewardship could influence the scale and epidemiology of resistance to medical antifungals both now and in the future. The importance of uncharted selection pressure exerted by agents outside the clinical setting (agricultural pesticides, industrial xenobiotics, biocides, pharmaceutical waste and others) on environmentally ubiquitous spore-forming molds that are lesserstudied but increasingly responsible for drug-refractory infections is considered.
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Affiliation(s)
- Claire M Hull
- Swansea University, College of Medicine, Institute of Life Science: Microbes & Immunity, SA2 8PP, Wales, UK
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Sainsbury JP, Trajtman A, Stalker AT, Embil JM, Keynan Y. Vitamin D binding protein polymorphism protects against development of blastomycosis. J Mycol Med 2014; 24:328-31. [PMID: 25459678 DOI: 10.1016/j.mycmed.2014.06.051] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 04/11/2014] [Accepted: 06/04/2014] [Indexed: 11/25/2022]
Abstract
Blastomycosis is an uncommon endemic fungal infection. It is presumed that in the endemic regions, the number of exposed individuals is significantly greater than those in whom clinical manifestations develop. We conducted a case-control study of individuals with clinical blastomycosis and controls with similar exposure but who did not develop disease. A genetic association was observed between the Gc-2 allele of vitamin D binding protein and reduced susceptibility to blastomycosis in a Canadian cohort. The Gc-2 allele can affect increased antimicrobial activity of macrophages. It may be possible to mimic this mechanism of protection by vitamin D supplementation.
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Affiliation(s)
- J P Sainsbury
- Department of Medical Microbiology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - A Trajtman
- Department of Medical Microbiology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - A T Stalker
- Department of Medical Microbiology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - J M Embil
- Department of Medical Microbiology, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Medicine, Section of Infectious Diseases, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Y Keynan
- Department of Medical Microbiology, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Medicine, Section of Infectious Diseases, University of Manitoba, Winnipeg, Manitoba, Canada.
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50
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Seitz AE, Younes N, Steiner CA, Prevots DR. Incidence and trends of blastomycosis-associated hospitalizations in the United States. PLoS One 2014; 9:e105466. [PMID: 25126839 PMCID: PMC4134307 DOI: 10.1371/journal.pone.0105466] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 07/24/2014] [Indexed: 11/18/2022] Open
Abstract
We used the State Inpatient Databases from the United States Agency for Healthcare Research and Quality to provide state-specific age-adjusted blastomycosis-associated hospitalization incidence throughout the entire United States. Among the 46 states studied, states within the Mississippi and Ohio River valleys had the highest age-adjusted hospitalization incidence. Specifically, Wisconsin had the highest age-adjusted hospitalization incidence (2.9 hospitalizations per 100,000 person-years). Trends were studied in the five highest hospitalization incidence states. From 2000 to 2011, blastomycosis-associated hospitalizations increased significantly in Illinois and Kentucky with an average annual increase of 4.4% and 8.4%, respectively. Trends varied significantly by state. Overall, 64% of blastomycosis-associated hospitalizations were among men and the median age at hospitalization was 53 years. This analysis provides a complete epidemiologic description of blastomycosis-associated hospitalizations throughout the endemic area in the United States.
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Affiliation(s)
- Amy E. Seitz
- Epidemiology Unit, Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, D.C., United States of America
| | - Naji Younes
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, D.C., United States of America
| | - Claudia A. Steiner
- Healthcare Cost Utilization Project, United States Agency for Healthcare Research and Quality, Rockville, Maryland, United States of America
| | - D. Rebecca Prevots
- Epidemiology Unit, Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
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