Better diagnosis and reporting is required

MycosisAnd the Coccidioidomycosis (Valley Fever), W histoplasmosis It is the most common endemic fungal disease (mycosis) in North America. The authors of a Opinion article in Annals of Internal Medicine They argue that we need to improve the diagnosis and reporting of these infections to better serve patients and understand the scope of the problem.

Traditionally, these infections have had known areas of endemicity, allowing for targeted education of clinicians and community members. Unfortunately, the borders of these regions seem to be shifting due to climate change.

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

Underdiagnosis and reporting

Because this environmentally acquired fungus is present in the form of Community acquired pneumonia (CAP) or with other non-specific symptoms such as night sweats, fever, chills, cough, or fatigue, providers often mistakenly treat patients for a bacterial or viral disease, not suspecting the presence of a fungal pathogen. Tolerating mycosis leads to delayed treatment, multiple unnecessary and potentially harmful courses of antibiotics, not to mention excess healthcare expenditure and healthcare utilization.

Even in areas where mycosis is known to be endemic, Fungal diseases It’s often overlooked, says Fariba Donovan, MD, PhD, assistant clinical professor of medicine at the University of Arizona. Valley Fever Center of Excellence (VFCE), in Tucson. (Donovan was not involved annals Article) Tucson is in an area considered hyperendemic for Valley fever. In highly endemic areas of Arizona and California, valley fever is thought to be the causative agent in about 20% of CAP cases.

Even with this heightened regional awareness, Donovan Research showed that 43% of Valley Fever patients at Banner University Medical Center in Tucson had delays in diagnosis of more than one month, with the average delay being 23 days. “The most important aspect of early diagnosis of Valley Fever is awareness among the medical communities,” she said. Medscape Medical News. The VFCE provides regular Valley Fever education to medical staff and community members.

In addition to a general lack of awareness, the annals The authors point out that endemic mycoses are not included in common laboratory diagnostic panels used for patients with pneumonia. Blood antibody and urine antigen tests for endemic fungi are usually only available from certain laboratories, so providers need to be trained to order them.

Endemic mycosis is also not specifically addressed in the professional guidelines for physicians to follow about CAP. For example, file 2019 joint guideline For community-acquired pneumonia from the American Thoracic Society and the Infectious Diseases Society of America do not directly address the question of when to suspect endemic mycoses.

Epidemiology of endemic fungi

Temperatures and precipitation patterns in an area are important to the ecology of mycosis, so climate changes can lead to geographic shifts in endemism. Forest fires It may also play a role in the dissemination of some of these organisms. For the sake of human and non-human patients, the authors argue that current mapping should be redrawn.

In the last years, The researchers found out Valley fever among non-travelers in Nebraska, much further east than the historic hot spots of Arizona and California. Similarly, researchers and clinicians found histoplasmosis and blastomyces Infection in areas outside what was previously thought to be endemic areas.

If the county, state and federal Public health authorities do not specifically mandate reporting of a particular pathogen, and epidemiological data will not be collected continuously from providers and diagnostic laboratories. Lack of data means lack of awareness among caregivers that they may fail to consider mycoses in the differential diagnosis.

These fungi often infect endemic non-human animals Also, the authors recommend increased monitoring and reporting of veterinary infections, arguing that this can help define current boundaries for endemism maps. “The greater number of animals and their higher environmental exposure increases their vulnerability to this infection,” Thompson explained.

Five suggestions to help improve diagnosis and reporting

The authors have five suggestions for improving the diagnosis and reporting rates of endemic mycoses:

1. National surveillance and reporting of endemic fungal diseases in human and veterinary patients

2. Education for service providers and patients

3. Inclusion of endemic mycoses in future CAP guidelines

4. Develop point-of-care diagnostics to reduce the time from patient presentation to diagnosis and effective treatment

5. Exploration of endemic mycoses vaccine to prevent infection

Thompson recommends: “In areas where these fungal diseases thrive, clinicians need to consider diagnosing and screening for mycosis in all patients with suggestive disease.”

Ann is a med trainee. Posted Online November 22, 2022. Summary. doi: 10.7326/M22-2371.

This research received financial support from the National Institutes of Health (5U19AI166798-02) and the University of California, Davis Family Gift Fund for Coccidioidomycosis research. Thompson and Donovan did not report any related financial relationships.

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

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