key: cord-0028237-ikebw1ra authors: Bongomin, Felix; Kibone, Winnie; Okot, Jerom; Nsenga, Lauryn; Olum, Ronald; Baluku, Joseph Baruch title: Fungal diseases in Africa: epidemiologic, diagnostic and therapeutic advances date: 2022-03-04 journal: Ther Adv Infect Dis DOI: 10.1177/20499361221081441 sha: b11c41774e0309f258f9b56017495039031ea9c9 doc_id: 28237 cord_uid: ikebw1ra nan The overarching aim of the special collection was to provide a state-of-the-art overview of our current understanding of various aspects of fungal diseases in Africa. It was overwhelmingly successful with a total of 14 high-quality submissions summarized below. In this issue, two articles further highlighted the burden of histoplasmosis in Africa. Kuate et al. 12 bring new insights into the burden of triple coinfection with histoplasmosis, TB and HIV in sub-Saharan Africa (SSA). Pulmonary histoplasmosis is often misdiagnosed as smear negative pulmonary TB due to similarities in their clinical and radiological presentations. 11 On the contrary, HIV, which is highly prevalent in SSA, is the most important risk factor for both disseminated histoplasmosis and TB. Ekeng et al. 13 summarized 44 cases of histoplasmosis among African children. Despite close to 55% of the cases being disseminated histoplasmosis, HIV was only reported in 6.8% of these children and most of the cases were due to Histoplasma capsulatum var. duboisii, the aetiologic agent of African histoplasmosis. These two articles therefore shine a light on the need for awareness among clinicians and the need to enhance laboratory diagnostic capacity for invasive fungal diseases in SSA and a need for a unified algorithm for pulmonary infections with similar presentation. In line with the above, Osaigbovo and Bongomin 14 discussed the available point-of-care tests (POCTs) for invasive fungal infections (IFIs) which are designed to detect their respective fungal antigens or antibodies and barriers to their uptake, including cost, lack of evidence to back up policy recommendations and lack of awareness among health care providers. The authors suggested a blueprint strategy to increase availability and accessibility in SSA, including increasing awareness about IFIs and corresponding POCTs, research, integrating the diagnosis of IFIs into existing vertical disease programmes, country adoption of the World Health Organization's Essential Diagnostics List, advocacy and improving POC diagnostics and supply chains. Bongomin and Otu 15 showed that a deterioration in the symptoms component of the St. George's Respiratory Questionnaire (SGRQ) and worsening of patients' self-assessment domain may be associated with clinical recurrence of chronic pulmonary aspergillosis (CPA). However, they recommended diagnosis of recurrent CPA using a combination of clinical history, SGRQ scores, chest imaging and a workup to exclude other causes of the patients' symptoms. Also regarding CPA, Oladele et al. 16 highlighted the need to standardize Aspergillus-specific IgG diagnostic cut-off values to enhance diagnosis of CPA among Nigerians. The authors reported a lower optimal diagnostic cut-off value (0.821) than the manufacturer's recommended cut-off value (1.0) for the Bordier Aspergillus IgG antibody test, highlighting the ethnic differences in antibody response in CPA. In Uganda, Kwizera et al. 17 found a high prevalence (60%) of Aspergillus fumigatus skin positivity in apparently healthy non-atopic individuals in Uganda with skin positivity being more in younger individuals. They proposed a revised definition of a suitable cut-off wheal size in healthy adults and not to use skin prick testing (SPT) alone to diagnose A. fumigatus sensitivity. Again in Uganda, Njovu et al. 18 established that approximately 71% of patients with clinical signs of pulmonary TB were positive for pulmonary fungal pathogens (PFPs) and about 4% had a co-infection of PFPs and Mycobacterium tuberculosis. PFPs and M. tuberculosis were isolated in people with HIV. The findings re-emphasize the need to have routine mycoses diagnostic tests in patients with suspected TB infection. In Nigeria, Campbell et al. 19 found that A. fumigatus constituted only 4.3% of the 117 isolates of Aspergillus species in the 168 soil samples tested contrary to other studies done in Nigeria and in other parts of the world. Importantly, all the isolates did not exhibit triazole resistance. In Tanzania, Mushi et al. 20 identified Candida albicans as the most predominant Candida species isolated from 325 oral swabs from HIV-uninfected children aged between 2 and 15 months with low resistance to fluconazole. However, some C. albicans isolates were resistant to fluconazole, voriconazole and posaconazole; hence, continuous monitoring of susceptibility is required for effective management of oral candidiasis in children. In Senegal, Deh et al. 21 foregrounded the possibility of a highly inflammatory tinea capitis due to Microsporum audouinii as they described a case of a nine-year-old HIV negative schoolgirl who was diagnosed with a severe form of kerion celsi. The infection completely regressed after 2 months following evacuation of 50 ml of pus and treatment with oral terbinafine 125 mg per day and ketoconazole-based shampoo. As part of the ongoing effort of the Global Action for Fungal Infections (GAFFI) to estimate the burden of serious fungal infections in each country, we received two submissions. Lakoh et al. 22 found that serious fungal infections affect a total 24 from Senegal pointed out that despite the low frequency of IFIs for which more than half is cryptococcosis, the risk factors for IFIs are prevalent across Senegal. However, it was reported that fluconazole is the only systemic antifungal available in the country, yet it has no activity on many fungi such as Aspergillus spp. responsible for IFIs in Senegal. Finally, Otu et al. 25 spotlight the importance and reliability of digital platforms and the case-based learning approach in fostering clinical reasoning skills and cascading knowledge to health professionals on clinical mycology based on their experience with online clinical mycology case competition amid the COVID-19 social distance restrictions hosted by the Medical Mycology Society of Nigeria. In conclusion, these articles provide new insights into the burden and challenges with diagnosis and treatment of fungal diseases in Africa. There is a need to put emphasis on fungal diseases and channelling of more resources towards their prevention, diagnosis and management to improve outcomes. ART, anti-retroviral therapy, CPA, chronic pulmonary aspergillosis; HIV, human immunodeficiency virus; PCP, pneumocystis pneumonia; TB, tuberculosis. Fungal infection: Diagnosis and management SARS-CoV-2, uncontrolled diabetes and corticosteroids -an unholy trinity in invasive fungal infections of the maxillofacial region? A retrospective, multicentric analysis The current state of clinical mycology in Africa: a European Confederation of Medical Mycology and International Society for Human and Animal Mycology survey. The Lancet Microbe. Epub ahead of print 18 Epidemiology of fungal diseases in Africa: a review of diagnostic drivers Burden of pneumocystis pneumonia in HIV-infected adults in sub-Saharan Africa: a systematic review and meta-analysis Prevalence of HIV-associated esophageal candidiasis in sub-Saharan Africa: a systematic review and metaanalysis Estimation of the burden of tinea capitis among children in Africa Global burden of disease of HIV-associated cryptococcal meningitis: an updated analysis Burden of fungal asthma in Africa: a systematic review and meta-analysis Mapping of chronic pulmonary aspergillosis in Africa Histoplasmosis in Africa: an emerging or a neglected disease? Histoplasmosis overlapping with HIV and tuberculosis in sub-Saharan Africa: challenges and research priorities Histoplasmosis in African children: clinical features, diagnosis and treatment Point of care tests for invasive fungal infections: a blueprint for increasing availability in Africa George's Respiratory Questionnaire in predicting clinical recurrence in chronic pulmonary aspergillosis Standardization of Aspergillus IgG diagnostic cutoff in Nigerians Prevalence of Aspergillus fumigatus skin positivity F Bongomin Status of pulmonary fungal pathogens among individuals with clinical features of pulmonary tuberculosis at Mbarara University Teaching Hospital in Southwestern Uganda Triazole susceptibility of Aspergillus species: environmental survey in Lagos, Nigeria and review of the rest of Africa Oral candidiasis in HIV-uninfected pediatric population in areas with limited fungal diagnosis: a case study from a tertiary hospital Kerion celsi due to Microsporum audouinii: a severe form in an immunocompetent girl The burden of serious fungal infections in Sierra Leone: a national estimate The burden of serious fungal infections in Azerbaijan The evidence for unavailability of systemic antifungals in Senegal Closing the knowledge gap in mycology in Nigeria by leveraging e-learning: perspectives from the field Visit SAGE journals online journals.sagepub.com/ home/tai