Current Medical Mycology 2021, 7(1): 63-70 Epidemiology of fungal diseases in Africa: A review of diagnostic drivers Felix Bongomin1*, Samuel Adetona Fayemiwo2, 3 1 Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda 2 Department of Medical Microbiology and Parasitology, College of Medicine, University of Ibadan, University Hospital Ibadan, Ibadan, Nigeria 3 Division of Infection, Immunity and Respiratory Medicine, Faculty of Biological Sciences, University of Manchester, Manchester, UK Article Info A B S T R A C T Article type: Background and Purpose: There has been a significant increase in the burden of fungal Review article diseases in the last few decades which has imposed a global threat to the health of humans, animals, and plants. Epidemiology of fungal diseases is not completely understood in Africa. Most of these diseases are under-reported or not reported at all mainly due to the challenges related to the availability of and access to fungal Article History: diagnostics and the lack of human resources in clinical and diagnostic mycology across Received: 08 September 2020 the continent. Therefore, it is imperative to highlight the epidemiology of the endemic Revised: 22 November 2020 and epidemic of emerging and re-emerging fungal diseases as well as their diagnostic Accepted: 18 January 2021 challenges in Africa based on the available data. Moreover, it is important to underline the existing gaps in this regard as well. Materials and Methods: For the purposes of the study, Medline and Google Scholar were searched to retrieve articles on these prominent fungal diseases, as well as their * Corresponding author: etiologies and available diagnostics. Felix Bongomin Results: It was found that histoplasmosis and other AIDS-associated mycoses have been Department of Medical Microbiology reported in Africa, including blastomycosis, coccidioidomycosis, and paracocci- and Immunology, Faculty of Medicine, dioidomycosis. Other reported infections were fungal neglected tropical diseases, Gulu University, Gulu, Uganda. especially sporotrichosis, dermatophytosis, mycetoma, and chromoblastomycosis as well Email: [email protected] as emerging fungal diseases, such as Emergomyces africanus, Candida auris, and Blastomyces emzantsi. In Africa, the major drivers of fungal diseases include human immunodeficiency infection, tuberculosis, and poverty. Conclusion: Serious fungal diseases are common in Africa; however, the true burden remains unknown. Keywords: Aspergillosis, Candidiasis, Cryptococcosis, Emergomycosis, Fungal disease, Mycetoma How to cite this paper Bongomin F, Adetona Fayemiwo S. Epidemiology of fungal diseases in Africa: A review of diagnostic drivers. Curr Med Mycol. 2021; 7(1): 63-70. DOI: 10.18502/cmm.7.1.6246 Introduction n the last few decades, there has been a cancer, asthma, and diabetes mellitus. It is noteworthy significant increase in the burden of fungal that > 25 million (~70%) out of the estimated 37.9 I diseases which continues to pose a global threat million people living with HIV (PLHIV) worldwide to the health of humans, plants, and animals are in Africa [4]. [1]. More than a billion fungal diseases with variable Despite the popularity of antiretroviral therapy severity occur every year worldwide [2]. These fungal (ART), cryptococcosis, pneumocystosis, histoplasmosis, infections include dermatophytosis, vulvovaginal and other opportunistic fungal infections continue to candidiasis, allergic diseases, subcutaneous infections, threaten the lives of PLHIV, particularly those who and life-threatening invasive systemic diseases [2]. present with advanced HIV disease or failed their ART Over 300 fungal species cause human diseases, mainly [4, 5]. Moreover, the fungal neglected tropical diseases in the immunocompromised individuals and those with (FNTD), notably mycetoma, chromoblastomycosis, a competent immune system, especially people who sporotrichosis, and dermatophytosis occur in areas with have underlying chronic respiratory diseases and co- poverty. morbidities or live in poverty [3]. The spectrum of fungal diseases has posed a heavy Main drivers of fungal diseases in Africa include burden on Africa which differs in one way or the other the human immunodeficiency (HIV) and tuberculosis from the global statistics. However, the epidemiology (TB) syndemic, poverty, and the growing number of of fungal diseases in Africa is not understood individuals with non-communicable diseases, notably completely. This is mainly due to the challenges Copyright© 2021, Published by Mazandaran University of Medical Sciences on behalf of Iranian Society of Medical Mycology and Invasive Fungi Research Center. This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International (CC BY) License (http://creativecommons.org/) which permits unrestricted use, distribution and reproduction in any medium, provided appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. A review of fungal disease drivers in Africa Bongomin F and Adetona Fayemiwo S. related to the availability of and access to fungal Intradermal histoplasmin skin test (HST) is required diagnostics and the lack of human resources in clinical for the determination of prior subclinical infections. In and diagnostic mycology across the continent. Africa, the prevalence rate of positive HST is within the Definitive diagnosis of fungal disease requires range of 0-35% [7]. Almost 40% of cases of confirmation of the causative pathogen through culture histoplasmosis in Africa occur in PLHIV with very high and microscopy, histopathology, immunodiagnostics, case fatality rates [8]. Diagnosis of acute disseminated biomarkers, molecular assays, and advanced molecular histoplasmosis requires urinary Histoplasma antigen detection, alone or in combination. In many parts of tests, histological examination, and cultures of the Africa, this is practically hampering accurate appropriate specimens, such as bone marrow and tissues evaluation of the incidence of fungal infections. from organs [9]. As practicing mycologists in Africa, we are faced There has been no report of paracoccidioidomycosis with several endemic, epidemic, emerging, and or its causative agents, Paracoccidioides braziliensis/ re-emerging fungal diseases requiring correct lutzii, in Africa [6]. Several cases of blastomycosis, identification and appropriate treatment. This article two cases of talaromycoses, and five cases of aimed to highlight the key fungal diseases, their coccidiodomycosis have been documented across methods of diagnosis, and the challenges in Africa. Africa, in West Africa, and in Uganda, respectively [6, 10]. These endemic mycoses were diagnosed by culture Materials and Methods and histopathological examinations [6, 10]. Literature review The related literature was found in Medline Fungal neglected tropical diseases (through PubMed) and Google Scholar. In total, four The FNTDs consist of a diverse group of search strategies were used to retrieve the articles: 1) implantation mycoses which usually present much later each of the fungal diseases was searched, such as after the initial infection. These diseases include “cryptococcosis”, “emergomyces”, “chronic sporotrichosis, mycetoma (Madura foot), chromoblasto- pulmonary aspergillosis”, and “Madura foot” plus mycosis (chromomycosis), lacaziosis (lobomycosis), and “Africa”, 2) etiologic fungal genus or species were entomophthoromycosis (subcutaneous zygomycosis). searched, namely “Aspergillus”, “Emergomyces The causative organisms primarily affect the cutaneous africanus”, and “Histoplasma capsulatum” plus and subcutaneous tissues; however, in most cases, they “Africa”, 3) “Africa” was also replaced with each of also involve adjacent structures, such as the lymphatic, the individual 54 countries of Africa, and 4) the words cartilage, fascia, joints, and bones [11]. used in the first three strategies were combined with Mycetoma may be caused by a fungus the word “diagnostics”. Alternative names or (eumycetoma), a filamentous bacterium (actinomy- syndromes of each of the disease entities were used as cetoma), or both. It is a chronic, progressive, and well, such as cryptococcosis, cryptococcal meningitis, destructive inflammatory disease usually of the or asymptomatic cryptococcaemia. subcutaneous tissues, mostly caused by a fungus called The related literature in English was reviewed and Madurella mycetomatis. It is not a modifiable disease; there was no restriction on the year of publication. therefore, the global burden of the disease is poorly References of the retrieved studies were scrutinized to defined [12, 13]. find additional articles that might not have been Mycetoma has been found in many African included in the results of these search strategies. The countries within the “mycetoma belt”, like Sudan, University Ethics Committee code was not applicable Senegal, Nigeria, Mauritania, Kenya, Cameroon, in this article. Somalia, Tunisia, Niger, and Ethiopia [14,15]. Diagnosis is usually made by both histological and Results and Discussion cultural methods. It is estimated that over 10,000 cases Endemic mycoses of mycetoma annually occur in Africa with the Primary “endemic” mycoses majority of documented cases being taken care of at Fungal mycoses cause disease in susceptible the Mycetoma Research Centre in Khartoum, Sudan individuals irrespective of their immune