Introduction
The endemic mycoses are caused by a diverse group of fungi that share characteristics: each fungus occupies a specific ecological niche in the environment and is able to cause disease in healthy and immunocompromised hosts. There are numerous species of dimorphic fungi; however, Blastomyces, Coccidioides, Emergomyces, Histoplasma, Paracoccidioides, Sporothrix spp, and Talaromyces marneffei (formerly Penicillium marneffei) represent the most commonly encountered causes of infections in clinical care. Biosafety is an important consideration when handling these organisms, and laboratories should incorporate national guidance and regulations into their processes and practices to ensure the safety of laboratory staff. There are substantial differences in the geographical distribution, clinical presentation, radiographic manifestations, diagnostic approach, and therapeutic interventions among these mycoses. Management requires recognition of risk factors (eg, environmental exposure in an endemic region) and appropriate use of diagnostic and therapeutic interventions. Readily available guidance is important to ensure efficient diagnosis and treatment, and to optimise patient outcomes.
This Review contains comprehensive guidance to facilitate clinical decision making and to provide an overview of the areas of uncertainty in the field. We aim to address limitations of previous recommendations, by engaging physicians and scientists involved in various aspects of the endemic mycoses, representing the fields of dermatology, haematology, infectious diseases, intensive care, microbiology, paediatrics, pathology, pharmacology, radiology, and surgery. Additionally, the guideline group, which comprises experts from all parts of the world, updates current knowledge in the field via a strict methodology consistent with a previous guideline document.1 The evidence and a full description of the methodology and literature supporting each recommendation can be found in the appendix (pp 1–147). The general approach applied in the European Confederation of Medical Mycology guideline programme has been described previously.1 We invited experts to participate in this specific guideline in February, 2018. Our selection of experts was determined by their publication activity in the field of the endemic mycoses, their personal involvement in patient management, and their distribution over the world regions defined by the UN as previously described.1 Further information on guideline development, systematic approach, authors, and work flow is provided in the panel. 33 scientific societies focusing on infectious diseases reviewed and endorsed this guidance document (appendix p 147).
Key messages
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The endemic mycoses cause disease in both immunocompetent and immunocompromised hosts.
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The geographical range of the endemic mycoses continues to expand, following their recognition in non-traditional regions.
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Several novel species have been recently described in the endemic mycoses.
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Advances in laboratory techniques and non-invasive testing have improved diagnostic test specificity and sensitivity.
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Radiographic imaging is generally warranted only if concern for infection at a particular site exists—routine radiography is not typically indicated.
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Treatment options continue to expand, and our understanding of agent selection as well as dose and duration of therapy continues to evolve.