Deadly Fungus Infections Rising Even as Doctors Keep Missing Them

We are running this post as a public service announcement of sorts. The short version is if you have an infection that does not respond to antibiotics, immediately and loudly insist your doctor look into fungal infections.

A very good Wall Street Journal story tonight describes how dangerous and often fatal fungal infections have been increasing and describes some examples. This piece is much broader than some other mainstream media pieces on the rise of Candida auris in hospitals in recent years. Those stories depicted it as mainly a problem of stubborn pathogen which has gotten itself into more and more hospitals meets inadequate infection control and immune-weakened patients. But these pieces stressed that Candida auris wasn’t hazardous to those in rude good health. For instance, from Time in March:

The U.S. Centers for Disease Control and Prevention (CDC) is tracking the rise of a deadly, treatment-resistant fungus that’s causing outbreaks in a growing number of health care facilities across the country.

New data compiled by a CDC research team, published Mar. 21 in Annals of Internal Medicine, show that Candida auris infections have increased dramatically in the U.S. in recent years. In 2021, national cases reported by health care facilities increased by 95%, and from 2019 to 2021, 17 states reported their first case. With infections recorded in a total of 28 states and the District of Columbia, these numbers suggest that current disinfection and safety measures at care facilities may not be sufficient.

Experts do not currently view C. auris as much of a threat to the wider population, since most healthy people are not at risk for severe infections, which tend to spread in hospital settings. But there are fears that it could someday evolve to become one.

So the general public is told they don’t have to worry about a fungal infection witha a 30% to 60% fatality rate unless they wind up in a hospital, rehab center or a nursing home. Oddly, none of these articles I read on Candida auris mentioned Covid as taxing immune systems and potentially (more like probably) accelerating this bad trend. By contrast, a new article by CIDRAP fingers Covid as playing a significant rate in the recent rise in fungal infections:

New data from a US hospital database show a significant increase in hospitalizations involving fungal infections from 2019 through 2021, driven primarily by COVID-19–associated infections, US researchers reported yesterday in Emerging Infectious Diseases.

Using data from the Premier Healthcare Database, Special COVID-19 Release, researchers from the Centers for Disease Control and Prevention (CDC) identified 59,212 fungal hospitalizations over the 3-year period. Rates of fungal hospitalizations (per 10,000 hospitalizations) increased from 22.3 in 2019 to 25.0 in 2020 and 26.8 in 2021, for an average annual change of 8.5%. Among the specific fungal pathogens that saw increases were Candida, Aspergillus, Coccidioides, and Histoplasma.

The lack of inquisitiveness in mainstream accounts about Covid increasing vulnerability to fungal nasties seems even more odd after worldwide coverage of mucormycosis (“black fungus”) outbreaks in India in 2021. It was directly linked to Covid, with victims becoming symptomatic typically two weeks after recovering from Covid. And those patients usually had taken immune-system weakening steroids to reduce lung inflammation. Mucormycosis has a 50% mortality rate.

Back to the more general alarm sounded in the Wall Street Journal story, Deadly Fungal Infections Confound Doctors—‘It’s Going to Get Worse’. The article buries what strikes me as a particularly important concern for patients, since these ailments can go undiagnosed until dangerously late, since prompt treatment is crucial: ” Delaying treatment of some fungal disease by just a day can double the risk of death, research shows.” It’s that there aren’t good tests for many of them… and on top of that, the tests are too often not run:

A lack of good tests makes identifying fungal disease more difficult. Some blood and urine tests for some yeasts and molds are accurate only half the time. Many molds need to be identified by specialists using microscopes. Misidentification is common, infectious-disease experts said.

The fungal disease Valley Fever causes one in three pneumonia cases contracted outside of hospitals in Arizona, yet patients with pneumonia symptoms are rarely tested for it, said Dr. Fariba Donovan, an associate professor of internal medicine at the University of Arizona. “We are telling patients to ask their doctor, ‘Do you think this could be Valley Fever?’ ” Donovan said.

The article also describes how some dangerous fungal infections are not uncommon. It start with the case study of a woman who died of an initially not-named fungal infection, which they later reveal to be C. auris and then follows with one who was diagnosed late for Histoplasma, eventually was treated for it, but still has not cleared it and may lose an eye to it. As the Journal notes:

Between about 250,000 and 500,000 Americans are infected with Histoplasma each year. An estimated 10% of them suffer from serious disease and need antifungal treatment. Many struggle to pinpoint the source of their sickness. A study of insurance data last year by researchers at the University of Iowa, University of California, Davis and the University of Maryland concluded that more than 80% of the roughly 2,800 patients were misdiagnosed before their infections were identified as Histoplasma.

And this lurid example:

The CDC warned in May of a suspected fungal meningitis outbreak among people who underwent cosmetic procedures, including liposuction and breast augmentation, at two clinics in Mexico. Almost three dozen people in the U.S. are thought to have been sickened and hundreds were at risk of infection after receiving epidural anesthesia during procedures at the clinics near the Texas border, the CDC said.

Four people have died. One, an otherwise healthy woman in her 30s, was hospitalized in Texas with a fever and meningitis symptoms shortly after visiting one of the clinics in March, according to the CDC’s Chiller. Tests for bacteria were negative, which should have prompted doctors to consider fungi, said Chiller, who reviewed her case.

She was given antibiotics, briefly improved, then deteriorated, Chiller said. She wasn’t diagnosed with fungal meningitis until after her death.

The article warns these pathogens, which like mold and yeasts, are all around us, even the hazardous ones, but are normally not a danger to the healthy. That is shifting due to climate change increasing their geographic spread and increasing their infectiousness, and some fungi becoming more treatment-resistant. To its credit, this article does cite Covid as increasing susceptibility to fungal diseases. But it points out one of the biggest dangers is doctor ignorance:

A 2022 survey of 500 infectious-disease doctors by researchers at the University of Iowa and University of California, San Francisco, identified fungal infections as among the diseases most frequently diagnosed late. Failure to consider fungal disease was most often to blame, the doctors said.

Almost half of some 270 patients in Arizona with the fungal disease Valley Fever weren’t correctly diagnosed for a month or more, a 2019 paper showed. A 2020 study found that one in four patients hospitalized with symptoms of the fungus Cryptococcus were first misdiagnosed….

Many medical schools aren’t adequately training aspiring doctors to identify and treat fungal disease, infectious-disease experts said. Some schools dedicate a couple of hours to the topic, those experts said. “Most fungal diseases are taught in medical school as being rare or unusual or some even regional, but we see these on a daily basis,” said Dr. George R. Thompson, an infectious-disease specialist at the UC Davis Medical Center in Sacramento.

The CDC said it is funding fungal-disease education for doctors across specialties. Some hospitals are training emergency-room staff to consider fungal infection, particularly in high-risk patients and people returning to the hospital after treatments haven’t worked.

“If you give someone antibiotics and they come back and aren’t feeling better, don’t just give them more antibiotics,” said Dr. Patrick Mazi, an infectious-disease doctor at Washington University in St. Louis. Antibiotics can exacerbate some fungal infections because they eradicate bacteria that compete with fungi, he said.

And one of those really bad fungi that really benefits from having antibiotics wipe out bacteria is the aforementioned deadly C. auris.

Given how comparatively few doctors consider fungal infections when making diagnoses, versus the acute danger of missing a deadly one, patients yet again need to be aggressive in advocating for themselves and family members. Do not be shy about demanding test and retests (given the poor reliability of some fungal tests) and precautionary treatments. The stakes could be high.