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[Malia] Hi, I'm Dr. Malia Ireland. I'm the fungal disease epidemiologist at the Minnesota
Department of Health. I'm here today with Dr. Jonathan Sellman, an occupational
medicine and infectious disease doctor with HealthPartners here in the Twin
Cities. We're going to talk about endemic fungal diseases in Minnesota. For an
infectious disease doctor thinking about infections as a differential diagnosis
is a day-to-day part of patient care. Can you talk a little bit about why
providers in Minnesota should be aware of fungal diseases? [Jonathan] So Minnesota has two
endemic fungal infections. These are dimorphic fungi that live in
the environment as molds and when they infect people they occur as spores.
People are generally infected breathing the spores in, where they cause
pneumonia or lung infection and then they may spread to other parts of the
body. These are fascinating infections and though not common they can cause
severe disease and life-threatening disease. [Malia] So, is there a typical patient
for blastomycosis or histoplasmosis? [Jonathan] So in Minnesota the majority of cases are
white men. [Silence]
[Jonathan] The patients may not have any exposure history although in some cases there can
be a historical exposure either occupationally or avocationally. [Malia] Are
there any patients that might be at more risk than others? [Jonathan] Immunocompromised
patients are especially at risk for histoplasmosis. So patients with HIV or
AIDS, organ transplantation, taking immuno- compromising medications, or even
diabetes are at increased risk. [Malia] In the cases that are reported to me at MDH,
about 70% of people with blastomycosis are actually hospitalized,
which is a pretty high number, and 60% aren't tested until they're actually in
the hospital. Why might it take a long time to reach a diagnosis of a fungal
infection? [Jonathan] Both of these infections, histoplasmosis and blastomycosis, present
initially just as influenza or a routine bacterial pneumonia might present, so
with cough, fevers, night sweats, joint pains, muscle pains. Initially, it can be
hard to diagnose a fungal infection, it's not considered in the differential. It's
only as that infection becomes more severe that someone might consider it or
if they've received multiple courses of antibiotics without effect. [Malia] So what can
providers do to check for fungal infections earlier? Are there diagnostic
tests that can be helpful for patients who don't need to be hospitalized, yet
but aren't responding to antibiotics? [Jonathan] There are a number of different tests
for these fungal infections. One of the simplest and easiest is a fungal stain
and culture of the patient sputum along with a bacterial stain and culture. That
tests if the fungal organisms are seen in the sputum it's diagnostic although it's
of low sensitivity. Culturing the organism may take up to six weeks.
Antigen testing can be performed but depending on the lab it may take days
and serology can be performed although that takes weeks. [Malia] So from my perspective
antigen testing seems really helpful because it is an easy sample to get and
it comes back pretty quickly. There can be some cross reactivity between
blastomyces and histoplasma in that test. But is that still a good
one for even family practice providers to think about using? [Jonathan] That is a test that
a family practice provider or a primary care provider should be
thinking about. Especially in settings where a routine bacterial pneumonia
doesn't explain all of the patient's symptoms and the severity of their
illness. [Malia] In the data that's reported to me,
47% of blastomycosis patients have had three or more courses of antibiotics
before they're diagnosed with a fungal infection. When should providers be
thinking about fungal diseases? [Jonathan] Certainly the patient with severe pneumonia, the
patient was hospitalized with pneumonia, patients with immunocompromise, and a
patient who's not responding as you would expect to antibiotics. A patient
should not be getting three and four courses of antibiotics for the same set
of symptoms. [Malia] My surveillance data shows that people who are immunocompromised or
have more severe illness like diabetes are five times more likely to die of
blastomycosis than previously healthy patients. Have you seen this in your
career. [Jonathan] As an anecdote, one middle-aged patient I saw, who had rheumatoid
arthritis and was on a biologic agent, had no clear exposure. She had
histoplasmosis that was disseminated and the only exposure she had was she had
walked through a park, which many Minnesotans do every day without
incident. The diagnosis just needs to be thought of in the differential in these
cases with more severe infections or immunocompromised status. [Malia] We find that
1/3 of patients with blastomycosis cases reported to us are exposed in a county
other than where they live. Are there questions that providers should be
asking of their patients that might help them consider fungal diseases sooner? [Jonathan] So
a travel history is always important and travel history includes not only travel
overseas, but travel within the state. Many Minnesotans go to a cabin up north
or go to the Boundary Waters to canoe and the northern counties in both
Minnesota and Wisconsin are higher risk for blastomycosis.
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